[e-drug] Painkillers in Short Supply in Poor Countries

["E-Drug" <e-drug@healthnet.org>]

E-DRUG: Painkillers in Short Supply in Poor Countries
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[The Help the Hospices report on the shortage of opioid painkillers that
E-drug featured on 28 September was also picked up by the New York Times.
The same newspaper had also run some stories in september (also copied
below) Copied as fair use.
Report at http://www.worldday.org/documents/access_to_pain_relief.pdf
WB]

THE NEW YORK TIMES : Painkillers in Short Supply in Poor Countries 
October 9, 2007 
By DONALD G. McNEIL Jr. 

A survey of specialists in Africa, Asia and Latin America has produced a
disturbing portrait of the difficulties in offering pain relief to the dying
in poor countries. Many suffer routine shortages of painkillers, and the
majority of specialists got no training in pain relief or opioid use during
their medical education.

In Africa, the report said, 20 percent of all palliative care specialists
had no access to morphine or other strong opioids, and 25 percent never had
weak opioids like codeine.

About 40 percent in Africa, 35 percent in Latin America and 25 percent in
Asia had irregular shortages of morphine or its equivalents.

The report was prepared by Help the Hospices, a British charity that trains
hospice workers and supports hospices in poor countries, for World Hospice
and Palliative Care Day, last Saturday. 

Three hundred questionnaires were sent to all the hospices and end-of-life
specialists in poor countries that the researchers could find. Only 69 were
returned, so the results cannot be regarded as scientific, but they do show
what obstacles exist.

The chief reasons respondents gave for the shortages were restrictive
national drug laws, fear of addiction, broken-down health care systems and
lack of knowledge by doctors, patients and policy makers.

Respondents described individual problems in their countries. In Honduras
and Malawi, patients could get no more than a three-day supply. In the
Philippines, a doctor needed two licenses to prescribe morphine. 

In individual comments, respondents detailed their complaints. 
"Drug companies are not willing to import oral morphine solution as they
will not make enough profit due to spending months on legal papers," a
doctor in Ecuador wrote.

"It is simply irrational that oral morphine is not available in the country
whereas expensive fentanyl patches can be made available for the rich
patients," wrote a doctor in Bangladesh.

Dr. Willem Scholten, the World Health Organization official in charge of
advocating greater access to painkillers around the world, said his
impression was that "the situation is even worse than that found by the
survey."

"Only 10 or 15 countries have a reasonable per capita consumption," he said.
The gap between them and the rest of the world - about 175 countries - is
"very wide."

Fear of addiction, he argued, creates shortages that hurt more people than
strict laws protect. 
"Globally," he said, "several hundreds of millions of people will require
analgesia at least once in their lifetimes, while only a small fraction of
this number misuses opioids."

Copyright 2007 The New York Times Company 


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September 10, 2007
Drugs Banned, Many of World's Poor Suffer in Pain 
By DONALD G. McNEIL Jr.
WATERLOO, Sierra Leone - Although the rainy season was coming on fast,
Zainabu Sesay was in no shape to help her husband. Ditches had to be dug to
protect their cassava and peanuts, and their mud hut's palm roof was sliding
off.

But Mrs. Sesay was sick. She had breast cancer in a form that Western
doctors rarely see anymore - the tumor had burst through her skin, looking
like a putrid head of cauliflower weeping small amounts of blood at its
edges.

"It bone! It booonnnne lie de fi-yuh!" she said of the pain - it burns like
fire - in Krio, the blended language spoken in this country where British
colonizers resettled freed slaves.

No one had directly told her yet, but there was no hope - the cancer was
also in her lymph glands and ribs.

Like millions of others in the world's poorest countries, she is destined to
die in pain. She cannot get the drug she needs - one that is cheap,
effective, perfectly legal for medical uses under treaties signed by
virtually every country, made in large quantities, and has been around since
Hippocrates praised its source, the opium poppy. She cannot get morphine.

That is not merely because of her poverty, or that of Sierra Leone.
Narcotics incite fear: doctors fear addicting patients, and law enforcement
officials fear drug crime. Often, the government elite who can afford
medicine for themselves are indifferent to the sufferings of the poor.

The World Health Organization estimates that 4.8 million people a year with
moderate to severe cancer pain receive no appropriate treatment. Nor do
another 1.4 million with late-stage AIDS. For other causes of lingering pain
- burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease
and so on - it issues no estimates but believes that millions go untreated.

Figures gathered by the International Narcotics Control Board, a United
Nations agency, make it clear: citizens of rich nations suffer less. Six
countries - the United States, Canada, France, Germany, Britain and
Australia - consume 79 percent of the world's morphine, according to a 2005
estimate. The poor and middle-income countries where 80 percent of the
world's people live consumed only about 6 percent. 

Some countries imported virtually none. "Even if the president gets cancer
pain, he will get no analgesia," said Willem Scholten, a World Health
Organization official who studies the issue. 

In 2004, consumption of morphine per person in the United States was about
17,000 times that in Sierra Leone.

At pain conferences, doctors from Africa describe patients whose pain is so
bad that they have chosen other remedies: hanging themselves or throwing
themselves in front of trucks.

Westerners tend to assume that most people in tropical countries die of
malaria, AIDS, worm diseases and unpronounceable ills. But as vaccines,
antibiotics and AIDS drugs become more common, more and more are surviving
past measles, infections, birth complications and other sources of a quick
death. They grow old enough to die slowly of cancer.

About half the six million cancer deaths in the world last year were in poor
countries, and most diagnoses were made late, when death was inevitable. But
first, there was agony. About 80 percent of all cancer victims suffer severe
pain, the W.H.O. estimates, as do half of those dying of AIDS.

Morphine's raw ingredient - opium - is not in short supply. Poppies are
grown for heroin, of course, in Afghanistan and elsewhere. But vast fields
for morphine and codeine are also grown in India, Turkey, France, Australia
and other countries.

Nor is it expensive, even by the standards of developing nations. One
hospice in Uganda, for example, mixes its own liquid morphine so cheaply
that a three-week supply costs less than a loaf of bread.

Nonetheless, it is still routinely denied in many poor countries.

"It's the intense fear of addiction, which is often misunderstood," said
David E. Joranson, director of the Pain Policy Study Group at the University
of Wisconsin's medical school, who has worked to change drugs laws around
the world. "Pain relief hasn't been given as much attention as the war on
drugs has."

Doctors in developing countries, he explained, often have beliefs about
narcotics that prevailed in Western medical schools decades ago - that they
are inevitably addictive, carry high risks of killing patients and must be
used sparingly, even if patients suffer. 

Pain experts argue that it is cruel to deny them to the dying and that
patients who recover from pain can usually be weaned off. Withdrawal
symptoms are inevitable, they say - as they are if a diabetic stops insulin.
But the benefits outweigh the risks. 

Too Poor for Medicine

In Mrs. Sesay's case, Alfred Lewis, a nurse from Shepherd's Hospice, is
doing what he can to ease her last days.

When he first saw her, her tumor was wrapped with clay and leaves prescribed
by a local healer. The smell of her rotting skin made her feel ashamed. 

She had seen a doctor at one of many low-cost "Indian clinics" who pulled at
the breast with forceps so hard that she screamed, misdiagnosed her tumor as
an infected boil, and gave her an injection in her buttocks that abscessed,
adding to her misery.

Nothing can be done about the tumor, Mr. Lewis explained quietly. "All the
bleeders are open," he said. "Her risk now is hemorrhage. Only a knife-crazy
surgeon would attend to her." 

Earlier diagnosis would probably not have changed her fate. Sierra Leone has
no CAT scanners, and only one private hospital offers chemotherapy drug
treatment. The Sesays are sharecroppers; they have no money. 

So Mr. Lewis was making a daily 10-mile trip from Freetown, the capital, to
change her dressing, sprinkle on antibiotics, and talk to her. He asked a
neighbor to plait her hair for her, so she would look pretty. Mrs. Sesay
said she could not be bothered.

"It's necessary for to cope," he said. "For to strive for be happy."

"I 'fraid for my life," she said.

"Are you 'fraid for die?"

"No, I not 'fraid. I ready."

"So what is your relationship to God? You good with God?"

"I pray me one."

He asked her, half-jokingly, if she still had sex with her husband.

No, she said, since the illness, he stayed in his room and she stayed in
hers. She, too, was joking. In their hut, there is only the one room.

Life has become hard, she added, and her husband is getting too old for farm
labor. She, too, is getting old, she said - she is somewhere in her 40s.

"We are really being punish."

For her pain, Mr. Lewis gave her generic Tylenol and tramadol, a relative of
codeine that is only 10 percent as potent as morphine. It was all he could
offer. "I would consider putting her on morphine now, if we had morphine,"
Mr. Lewis said.

In New York, she would have already started on it, or an equivalent like
oxycodone or fentanyl. 

Even if his hospice could get it, Mr. Lewis could not give it to her.

Under Sierra Leone law, morphine may be handled only by a pharmacist or
doctor, explained Gabriel Madiye, the hospice's founder. But in all Sierra
Leone there are only about 100 doctors - one for every 54,000 people,
compared with one for every 350 in the United States.

In only a few places - in Uganda, for example - does the law allow trained
nurses to prescribe morphine.

And pharmacists will not stock it. 

"It's opioid phobia," Mr. Madiye said. "We are coming out of a war where a
lot of human rights violations were caused by drug abuse."

During the war, the rebel assault on the capital was called Operation No
Living Thing. Child soldiers were hardened with mysterious drugs with names
like gunpowder and brown-brown, along with glue and alcohol.

Esther Walker, a British nurse who sometimes works with Mr. Lewis, said she
once gave a lecture on palliative care at the national medical school.

There were 28 students, and she asked them, "Who has seen someone die
peacefully in Sierra Leone?" 

"Not one had," she said.

The Burden on the Young

In the poorest countries like this one, even babies suffer.

Momoh Sesay, 2, (no relation to Zainabu) is a pretty lucky little guy - for
someone who tumbled into a cooking pot of boiling water.

He lost much of the skin on his thighs, and his belly is speckled with burns
as if he had been sloshed with pink paint.

But he was fortunate enough to live close to Ola During Children's Hospital,
the leading pediatric institution.

No doctor was in. There was not even any electricity. At night, nurses
thread IV lines into babies' tiny limbs by candlelight. "And our eyes are
not magnets," one of them, Josephine Maajenneh Sillah, complained.

But they knew Momoh would die of shock and pumped in intravenous fluids and
antibiotics. 

If he had been born in New York, Momoh would have had skin grafts. Here,
that is unthinkable.

Momoh was given saline washes, and his dead skin was scrubbed off with
debridement, a painful procedure. In New York, he would have had morphine.

So probably would Abdulaziz Sankoh, 7, in another bed, who has sickle cell
disease. He moans at night when twisted blood cells clump together and jam
the arteries in his spindly legs, slowly killing his bone marrow.

As would Musa Shariff, an 8-month-old boy whose scalp is so swollen by
meningitis that his eyelids cannot close. Dr. Muctar Jalloh, the hospital
director, said he would not prescribe morphine to babies or toddlers if he
had it. Only in the case of third-degree burns, like Momoh's, did he say: "I
would consider it - maybe."

That flies in the face of Western medicine, which allows careful use even in
premature infants.

The strongest painkiller that Momoh, Abdulaziz and Musa can take, if their
parents can afford $1.65 per vial, is tramadol. It is impossible to know
what morphine would cost if it were here, but it is sold in India at 1.7
cents a pill by the same company that makes tramadol. 

The nurses know the prices because they sell the drugs that are available.
They have not been paid for three years, they say, so they support
themselves in part by filling the prescriptions that the doctors write. Kind
as they are - they do extend credit, and are sometimes moved to charity by
the children - it is a business.

That is the other reason Dr. Jalloh said he would not order morphine. "I
wouldn't want to leave my staff in charge of morphine," he said. "The
potential for abuse is so high."

Worries About Abuse

If morphine were to be imported to Sierra Leone, it would be overseen by two
agencies: the National Pharmacy Board and the National Drugs Control Agency.

Kande Bangura, the rangy, sharp-eyed former police commander who runs the
drug control agency, said the country had a serious drug-abuse problem,
especially among former child soldiers. 

It also is a smuggling route. He spread out pictures of an autopsy on a
British citizen with Nigerian roots who had dropped dead in line at
Freetown's airport. His intestines were found to be packed with condoms full
of cocaine, one of which had burst.

Mr. Bangura said he had no objections to morphine, however, "as long as it's
for medical use and is strictly controlled by the country's chief
pharmacist."

Wiltshire C. N. Johnson, the chief of the enforcement arm of the National
Pharmacy Board, explained why painkillers were not imported.

Scarce funds must go to the top five causes of death, he said: diarrhea,
pneumonia, tuberculosis, malaria and sexually transmitted diseases. "I'm not
saying that palliative care doesn't top the list, too," he said. "But it's
officially a very small percentage of the requirement."

He also had fears like those of Dr. Jalloh. "There's no way we're going to
put morphine in the hands of a pharmacy technician," he said. "In the wrong
hands, drugs, like guns, are a greater evil than a cure." 

Mr. Madiye, who predicted exactly those answers before the interviews
started, vented his frustration later.

He founded Shepherd's Hospice in 1995, saw it destroyed in the civil war and
rebuilt it. But he cannot get the one drug that would let him give people
like Zainabu Sesay the dignified deaths that in the West would be their
birthright.

"How can they say there is no demand when they don't allow it?" he asked.
"How can they be so sure that it will get out of control when they haven't
even tried it?"

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NY Times 2

 
 


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September 10, 2007
Japanese Slowly Shedding Their Misgivings About the Use of Painkilling Drugs

By DONALD G. McNEIL Jr.
OKAYAMA, Japan - If any nation ought to lead the world in the consumption of
painkillers, it is Japan.

Its population is aging, and cancer is the leading cause of death.

It has universal health insurance, and few restrictions on prescription
narcotics.

And it is a heavily medicated society; it consumes half the world's Tamiflu,
the anti-flu drug.

Yet, on charts detailing the per capita consumption of narcotic painkillers
throughout the world - routinely topped by the world's richest countries -
Japan is down in the neighborhood of Bulgaria and South Africa. It consumes
one-twelfth as much per capita as the United States.

The leading reason for that, said Dr. Fumikazu Takeda, a retired
neurosurgeon who leads the fight for better pain control, is patients' fear.

Until recently, morphine was used only in hospitals, and near the end.

"People hate morphine because they think, 'As soon as the doctor injected
morphine, my father died,' " Dr. Takeda said.

Also, until recently medical schools taught that narcotics should be used
only briefly at low doses. 

And some national sense of "gaman" - that suffering in silence is a virtue -
persists even in hedonistic modern Japan. 

"Long ago, a samurai who complained about pain was considered a very weak
samurai," he said. Young people have other ideas, but with life expectancies
over 80, the typical cancer patient is from another generation.

"Patients in their 70s and 80s who lived through World War II feel guilty to
have survived the war," said Atsuko Uchinuno, vice president of the Japanese
Society for Palliative Medicine. "I had one patient who told me, 'I need
some pain, because I feel bad about the people who died.' "

Some experts scoff at that but admit that the reluctance exists.

"Saying we don't take morphine because of gaman in today's Japan is a
stereotype like geishas and Mount Fuji," said Hajime Mizuno, who writes
about medical issues. "The biggest reason is that doctors think morphine is
evil because it causes addiction, and ordinary people do, too."

But those attitudes are changing. In 1980, Japan was using only 1 percent of
the morphine it uses now. And last year, Parliament adopted a new national
cancer plan. 

Historically, governments feared opium because they saw it devastate China.
After World War II, China had 40 million addicts, including the last
empress. Mao cracked down ruthlessly, burning crops and executing dealers;
by 1960, addiction was virtually gone. 

Disdain for pain control is also a byproduct of Japan's medical system.

In May 2006, a member of the Parliament disclosed that he had cancer and
said the system was so shamefully disorganized that it left thousands of
"cancer refugees" roaming the archipelago looking for care.

Care is typically led by a surgeon who oversees chemotherapy and radiation
as adjuncts and focuses less on drug management, including pain control,
experts said. 

And, until recently, patients were not even given their diagnoses. In a
scene from a decade-old documentary well known here, a surgeon shows a
family their mother's excised breast on a steel tray to point out the tumor;
but she was not even told she had cancer. 

Now disclosure is normal, and there is a government campaign urging patients
to request pain relief. "Tell Us About Your Pain!" posters decorate hospital
walls.

Drug enforcement agencies are struggling to adjust to the new reality.

Dr. Junichi Ikegaki, chief of palliative care at Hyogo Cancer Center, gave
an example. His wife runs an outpatient clinic, and 100 OxyContin tablets
disappeared from her narcotics cabinet.

In low-crime Japan, the theft of even 100 pills was such big news that
television crews showed up with the police.

One narcotics officer criticized Dr. Ikegaki's wife, he said, because the
cabinet was not bolted to the wall. 

But the officer's partner, saying the country used too few painkillers, took
her aside and asked her to prescribe more.

"Hon-ne and tatamae?" Dr. Ikegaki asked, using a Japanese expression for the
difference between one's public facade and one's real feelings. "One was a
suppressor and the other was a promoter."

Takahisa Murakami, director of drug compliance at the national Health
Ministry in Tokyo, chuckled at the story.

His office is decorated with posters warning teenagers about the dangers of
Ecstasy, but he is not worried about a crime wave, he said. Heroin use, for
example, is negligible. His department sponsors symposiums encouraging
doctors to prescribe more painkillers.

"In situations like this," he said, "narcotics officers have to change."

Kumi Takagi, 40, was initially reluctant to take morphine. Her breast cancer
has spread to her spine and pelvis, and she has endured surgery,
chemotherapy and radiation. 

Touching her shoulder blades and lower back, she parsed her pain: "Up here,
it was a stinging pain. But down here, it felt like the bones were grinding
against each other, as if they were sticking and then breaking free. I
wanted to slam my back against a wall."

She resisted until she found herself unable to get out of a chair without
help. "Its image in Japan is that you will get hallucinations, or will have
difficulties in your daily life," she said. "I was afraid I wouldn't be able
to do my work or make my son's lunch."

She now takes morphine every 12 hours and carries a "rescue dose" for the
sudden, severe pain called breakthrough pain.

"It's not all gone," she said, "but it's mild, and I can bear it. And I can
sleep. Honestly - I wish I'd started it before."

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