FEAR

and the Problem of Access

to Essential Controlled
Medicines
in the LMICs
Katherine Pettus, PhD
International Association for Hospice and Palliative Care
More than 80! of the worlds people "5.5 billion# have
no access to strong opioids for pain control, palliative
care and dependency treatment
Morphine and methadone unavailable in most countries
Fear of addiction main barrier to prescribing and use
Presenting Problem
Result of old fear paradigm
Global distribution
morphine
Distribution of morphine consumption in 2009, as reported by the International Narcotics Control Board.
FROMTHE FOLLOWINGARTICLE:
Access to opioid analgesics and pain relief for patients with cancer
Shalini Dalal & Eduardo Bruera
Nature Reviews Clinical Oncology 10, 108%116 "February 2013#
BRIEF BACKGROUND
old paradigm
Opium, morphine, heroin, all used to be legal,
over the counter%medicines until early C20
Missionaries and social reformers, then
physicians and pharmacists wanted to
abolish/regulate
Prohibition treaties integrated into frame
international politics and relations of C20
Di&erent criminological and clinical contexts
' no treatment or recovery services.
Supply reduction considered only solution
to widespread addiction problem

Historical context: Supply Reduction
Intention of C20 drug control treaties to
reduce licit supply to only the amount
needed for medical and scientic purposes
Nobody knew how to calculate correct
amounts ' many still dont know
Political emphasis on control,
punishment, law enforcement, NOT
PROVISION for medical purposes
1988: A drug free world, we can do it
UNGASS slogan
FEAR
Of pain, of death "patient#
Of being unable to care for loved one "family#
Of vulnerability/dependence "patient and family#
Of addiction "patient and family#
Language creates us
Old Paradigm
Generated to control licit/illicit drug use
language of evil, addiction and slavery
based on 19th and 20th century religious, imperial perceptions of
Oriental, Negro, and Mexican drug use, PWUD
no evidence or scientic method to evaluate substances
pre% palliative care, HIV/AIDS, widespread IDU
Narrative of slavery
addict - To addict originally meant "to award as a slave"; an addict now is
a slave to his/her habit, from Latin addictus, which, in Roman law, meant
"a debtor awarded as a slave to his creditor.

We need to use different words.
Language in 1961 Single
Convention on Narcotic Drugs
Recognizing that addiction to narcotic drugs constitutes a
serious evil
for the individual and is fraught with social and economic
danger to mankind,

Conscious of their duty to prevent and combat this evil,

Considering that e&ective measures against abuse of narcotic
drugs require co%ordinated and
universal action
Primary Barriers to Access
Government/O(cial dimension
Fear of addiction to opioids "physicians/general#
Fear of diversion
Inadequate healthcare resources, such as facilities and
healthcare professionals
Lack of national policy or guidelines related to opioids
Poison and Dangerous
Drug


Estimated
Problem drug users 16-38 million



Injecting drug users: 16 million

Estimated 3 million are HIV infected

HIV Epidemic driven by prohibition of NPS and OST not drug use per se

People with no access to essential opioid medicines for pain,
palliative care, opioid dependency treatment: 550 billion
Who pays the price of fear?
Different perspective?
99%
0% 0%
Problem drug users
Injecting drug users
No access to opioid medinces
Reframing the debate?
Dispel the Fear
Attend to Language, Process and Outcomes


EDUCATE AT MULTIPLE LEVELS
Change expectations
slow, multi%generational process
took several generations to get here
Change the Conversation
use di&erent language
long term heavy use,, tolerance, titration, harm
reduction

PROCESS
Target Di!erent Outcomes
Institutionalise
palliative care
"2014 WHA resolution# requires EOMs
increasing NCDs and ageing populations
harm reduction services
holistic treatment
INSTITUTIONALISE KEY SERVICES
Include all a!ectedjustice
Organize
PSR
IDHDP
Physicians for Human
Rights
Physicians for the
Prevention of Nuclear War