Opioid crisis: A global rethinking
Krithika Muthukumaran is a postdoctoral fellow at the University Health Network, Toronto. She moved to Canada from India in 2011 to pursue a PhD in biochemistry.
The neighbors describe how anxious they would get whenever they heard Mrs. Amutha, a 70-year-old lady, as she banged her head on the walls of her apartment and screamed. She suffered from severe headache and facial pain caused by advanced stages of oral cancer, and this is how she dealt with it. Unfortunately, Amutha suffering in pain would be the memory her family would have of her for years to come. This is the state for millions of patients and families across India, as less than 1% of the patients have access to prescription opioids to treat pain even in advanced stages of cancer.
This is the reality I was aware of, growing up in Chennai, India. Through my mother, who is a palliative care physician, along with her colleagues and teachers, I have known of the various challenges faced by them with regards to increasing awareness about palliative care among the medical fraternity, availability of opioids for pain relief, and associated healthcare policies.
This situation is not limited to India alone; the World Health Organization estimates that 83% of the global population live in countries with low or no access to opioids (http://www.who.int/mediacentre/factsheets/fs402/en/). Each year 5.5 million terminally ill cancer patients and 1 million patients in the last phases of AIDS suffer without any treatment for pain, and tens of millions of people suffer with untreated moderate and severe pain (Human Rights Watch).
“Having morphine in the cupboard is not enough” says Dr. M.R. Rajagopal, pioneer of pain and palliative care in India. Even though policy reforms were made in 2014 in order to facilitate availability of opioids for pain relief, most people are still unable to get an opioid prescription when required.
Better policy reforms and regulations alone cannot help improve this situation. Equally important are awareness and education of healthcare professionals about opioids, pain, and palliative care so that doctors are able to assess the pain and prescribe appropriate medication as and when necessary. For example, in India, there is very little knowledge about opioids, pain, and palliative care, and few associated policies and regulations even among the medical fraternity. Therefore, the policy reforms made in 2014 failed to translate into an effective solution, and did not reach the people in need. Even though a postgraduate degree in palliative medicine was recently implemented in two teaching colleges, there are only four spots available per year, which is strikingly low for a country with 1.2 billion people.
When I moved to Canada to pursue higher studies, I was shocked to read about the problems due to opioid over-prescription and how the challenges related to opioids are very different here. In North America, opioid over-prescription has contributed to rising rates of opioid use disorders (in the U.S., 2.4 million people and 200,000 individuals in Canada are affected by opioid use disorder) and overdose, resulting in a huge epidemic – and the government and medical practitioners are having a hard time coming up with an effective strategy to overcome this crisis. Even though there has been a decline in over-prescription-related deaths in the U.S., most of the time the root cause for addiction is prescription opioids. In Canada, policy reforms have not been able to prevent the steady rise in the over-prescription of opioids.
Where did it start and what is the possible cause for this crisis? In 1980, a small paragraph written by Dr. Hershel Jick from Boston University Medical Centre was published in one of the most esteemed medical journals, The New England Journal of Medicine. This article suggested that opioids were safe and there was very minimal risk of addiction, and the pharmaceutical companies used this as evidence to promote the use of opioids to treat any type of pain without any side effects. The push for eradicating pain completely using opioids means that for two decades, doctors in North America were trained to prescribe opioids with the mindset that there would be no problem of addiction. However, with the opposite being true and with an epidemic in hand, it is not only time to bring in policy reforms and strict regulations, it is also necessary to urge doctors to take a different approach to pain and prescription of opioids.
Pain can have a serious impact on one’s quality of life and it takes a toll on mental health as well. It could also affect work, interaction with friends and family, and make it hard for caregivers. North American and European nations are struggling to cope with the side effects of opioid misuse, while the remaining population does not have access to opioids to alleviate pain and suffering.
I believe that the opioid crisis is not territorial, it is a global crisis. The cycle has to be broken all over the world. The next generation of doctors and residents who are in training should be taught about the side-effects as well as the benefits of opioids in improving the quality of life, say, for a cancer patient. They should learn from past mistakes and the history of opioid use; however, fear should not prevent them from alleviating suffering for patients in need. While the medical practitioners and government are busy tackling the crisis, it is time to lay out reforms in the medical education system with regards to opioids and palliative care in order to better equip the new generation of medical practitioners to take a more balanced approach to treat pain. A new strategy and possibly bringing in uniform operational guidelines worldwide for the next set of doctors will greatly help them approach pain with the right mindset and prevent the past errors.
Note: The story described in the opening paragraph is a real incident; however, the name has been changed.