Fear of Addiction as a Barrier to Access to Opioid Medications in the LMICs
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Transcript of Fear of Addiction as a Barrier to Access to Opioid Medications in the LMICs
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FEAR… and the Problem of Access
to Essential Controlled Medicines
in the LMICs
Katherine Pettus, PhD
International Association for Hospice and Palliative Care
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More than 80% of the world’s 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
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Result of old fear paradigm
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Global distribution morphine
Distribution of morphine consumption in 2009, as reported by the International Narcotics Control Board.$FROM THE FOLLOWING ARTICLE:$
Access to opioid analgesics and pain relief for patients with cancer$Shalini Dalal & Eduardo Bruera$
Nature Reviews Clinical Oncology 10, 108-116 (February 2013)
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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$
• Different criminological and clinical contexts — no treatment or recovery services. $
• Supply reduction considered only solution to widespread “addiction” problem$
!
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Historical context: Supply Reduction
• Intention of C20 drug control treaties to reduce licit supply to only the amount needed for medical and scientific purposes!
• Nobody knew how to calculate correct amounts — many still don’t know$
• Political emphasis on control, punishment, law enforcement, NOT PROVISION for medical purposes$
• 1988: “A drug free world, we can do it” UNGASS slogan!
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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)$
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Language creates usOld 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 scientific method to evaluate substances$
• pre- palliative care, HIV/AIDS, widespread IDU
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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.
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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 effective measures against abuse of narcotic
drugs require co-ordinated and$universal action
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Primary Barriers to Access
Government/Official dimension$
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
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“Poison” and “Dangerous Drug”
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!!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?
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Different perspective?
99%
0%0%Problem drug usersInjecting drug usersNo access to opioid medinces
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Reframing the debate?
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Dispel the Fear
Attend to Language, Process and Outcomes$!!
EDUCATE AT MULTIPLE LEVELS
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Change expectations $
• slow, multi-generational process$
• took several generations to get here$
Change the Conversation $
• use different language $
• “long term heavy use”,, tolerance, titration, harm reduction
!
PROCESS
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Target Different Outcomes
Institutionalise $• palliative care$
• (2014 WHA resolution) requires EOMs$• increasing NCDs and ageing populations$
• harm reduction services$• holistic treatment$
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INSTITUTIONALISE KEY SERVICES Include all affected…justice
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OrganizePSR$
IDHDP$Physicians for Human
Rights$Physicians for the
Prevention of Nuclear War$
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