Neglecting the World’s Pain

To state the obvious: 1) most advanced cancer patients have pain and 2) We have excellent pain medications which can effectively treat more than 90% of cancer pain. Therefore, most patients with cancer receive proper prescriptions for pain.  Obvious, yes?  True? No.

In Europe, Australia and North America narcotic analgesics are widely available, and frequently prescribed.  While there is access, many patients, particularly those in certain groups such as seniors and those with limited financial means, often receive insufficient doses and amounts, which only superficially address pain needs. Nonetheless, this partial success means that high income Countries use up to 95% of the world supply of morphine.  Tragically, the remaining world population has its pain treated with the remaining 5%.

This month at the European Society for Medical Oncology (EMSO) yearly meeting, Dr. Nathan Cherny presented frightening data on the world pain pandemic. In an analysis which looked at the medical care of almost 5 billion people, it was found that very few have access to pain medications.

Of the 76 Countries studied in Africa, South America, the Middle East and the Caribbean, rarely were the seven basic pain medications (oral morphine (IR/SR), oxycodone, fentanyl, codeine, methadone, tramadol) available.  Most Countries had only one, two, or none at all.  When these drugs were available, there was limited access, short supply, high cost and tight regulation.  Thus, with cancer rates exploding in developing countries, millions of people are suffering in unrelieved pain.

The problem is a combination of cultural mores, cost and most importantly, bizarre laws which limit availability.  For example in the Ukraine narcotics are only legal in an injectable form, despite over a dozen oral forms manufactured, which makes it impractical to prescribe or use. India is the world’s largest manufacture of morphine, but the drug is almost unavailable in that country.  In much of the world archaic poorly designed laws designed to limit abuse fail to achieve that goal but instead limit access for patients in critical need.

We must remember that cancer pain is much more than physical suffering.  If we fall and break an arm, there will be pain.  That same bone may fracture from a cancer as it mines a hole deep into the marrow.  However, none of us would propose that the pain is the same.  The pain from a fall is uncomfortable and limiting.  The pain from the cancer is uncomfortable and limiting, but it also strikes deep into the spirit.  That pain means cancer, that pain means fear, that pain means death.

It is unacceptable that with inexpensive pharmaceutical solutions for pain available that we should allow this global suffering to occur.  The vast majority of narcotics prescribed to treat pain are not diverted from their therapeutic goal and do not contribute to dependence or addiction. On the other hand, ineffective, poorly designed efforts in global drug trafficking wars markedly reduce access for most patients, with cancer patients collateral victims of friendly fire.  This is a global problem and will require a world effort to stop the agony.

While the suffering of one is a story that touches our heart, the suffering of many can overwhelm and provoke apathy.  I suggest that we each focus on one … one special person that we love … and consider how we would feel if that person was in uncontrolled pain.  Then, we act, together, to relieve that pain, a billion times.



    so, who do we contact, that is always the problem, No one tells us to whom to write and complain. I read your articles every time I get them, You are a compassionate dr. rare these days. I do wish I lived in your area thanks
    • James Salwitz, MD
      Thanks very much for the comment and support. The WHO and other world organizations are beginning to recognize the need, especially as first world diseases (like heart disease and cancer) move into the third world. None-the-less without the support of Western nations the problems will spread and the suffering increase. jcs
  • A few years ago I struggled with one of the most puzzling of contemporary contradictions: a global production of illegal drugs in a global economy in which pharmaceutical companies are dominant players. Your 5% breakout underscores the problem dramatically. I want to suggest a way that the drug-industrial complex might become part of the solution but nothing comes to mind. My instinct is that any efforts to redirect what are now illegal drugs into more constructive (and legal) channels will be met with a double-whammy of opposition -- those profiting from illegal drugs as well as for-profit corporate interests regarding any such moves as a threat to business. The same politics making strange bedfellows is what produced so many "dry counties" here in the South. Making it legal to drink was/is opposed by pious religious types cuz it is immoral, while the bootleggers were against making it legal cuz it cut into the local business. I haven't done any homework lately about finding legal channels for farmers in the developing world to market those high-yielding cash crops, but it may be time for another push from somewhere along those lines. Whatever it is will need an international effort. Every year that passes sees yet another spate of losses in the so-called "war on drugs." (Which is being fed in no small part by a prison-industrial complex supporting ever longer and more strict mandatory sentences, even for non-violent drug "offenders.")
    • James Salwitz, MD
      Tragically you further outline a long list of powerful interests who are made wealthy by the suffering of their fellow man. When we look at history we tend to focus on violent conflict as the greatest curse. However, you make the point well that man is capable of waging "war" in far more devious ways. Perhaps I am naive but it is my hope that the transparency and communication which is the product of pan-electronic communication gives an opportunity to bring light to this darkness. However, I recall that the inventor of the machine gun thought that he had produced a weapon that was so horrible that it would end war ... I hope that the internet is not such a demon in disguise. Thanks for your insightful comment. jcs

Leave a Reply