Dilkushi Poovendran, Technical Officer, WHO Expert Committee on Drug Dependence (ECDD);
Monica Ciupagea, United Nations Office on Drugs and Crime (UNODC);
Eamonn Murphy, UNAIDS Regional Director – Asia Pacific and Eastern Europe & Central Asia;
Aditia Taslim, Advocacy Officer, International Network of. People who Use Drugs (INPUD);
Sarah Evans, Division Director, Drug Policy, Open Society Foundations;
Allow us to offer our full respect and acknowledgement of the Elders of the Land of Past, Present and Emerging. It is an honour and privilege to be welcomed to your Country and home.
- I would like to thank Harm Reduction International for the invite to me to participate in this conference, and to equally thank the World Health Organization for organizing such an important side-event. As a member of the Global Commission on Drug Policy, I am delighted to be part of the 29 members working to inspire better drug policy globally: moving away from prohibition and advocating for policies based on scientific evidence, human rights, public health, and security, to effectively “leave no-one behind”.
- Currently, there is a growing recognition that prohibition has failed to achieve its goals of a “drug-free world” while having a detrimental impact on our societies. Criminalization and prohibition of drugs negatively impacts the full range of civil, cultural, economic, political, and social rights and may also entrench discrimination and marginalize populations already facing exclusion and subjugation.
CUSTODIANS OF KNOWLEDGE
The World Health Organization’s 2011 publication entitled, “Ensuring balance in national policies on controlled substances: Guidance for availability and accessibility of controlled medicines”, is laid on the table to be discussed, deliberated upon and dissected as the World Health Organization itself seeks to revise this guide for global and national policies.
In part, the World Health Organization describes itself as follows:
“leadership on global health matters; shaping the health research agenda; setting norms and standards; articulating evidence-based policy options; providing technical support to countries and monitoring and assessing health trends.”
By force of example the World Health Organization emphasises that health is a shared responsibility, involving equitable access to essential care, from government to grass roots; from NGO to the most vulnerable people in pain; from Big Pharma to Big Tech.
Admittedly so, the United Nations website on the World Health Organization, recognizes that the World Health Organization:
“operates in an increasingly complex and rapidly changing landscape… (and that) the boundaries of public health action have become blurred, extending into other sectors that influence health opportunities and outcomes.”
The 1961 UN Single Convention on Narcotic Drugs and the 1971 UN Convention on Psychotropic Substances, combined with the 1988 UN Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, not only control international trade in the substances, but also impose requirements concerning the drug laws that countries must apply domestically, thus locking into place a rigid system of prohibition and control.
As a consequence, the international drug control system contains a “deep-lying imbalance” that favours punitive approaches over ensuring access to controlled medicines, despite the fact that the 1961 Single Convention has the key objective of ensuring access to and safe use of essential medicines, while “limit[ing] exclusively to medical and scientific purposes the production, manufacture, export, import, distribution of, trade in, use and possession of drugs.”1
Allow us to take a pain inventory of the world by taking a step into the recent past and using the data available.
The Lancet Commission on Palliative Care and Pain Relief published in 2018, found that about 25.5 million out of 56.2 million people who died in 2015 experienced serious health-related suffering, and another 35.5 million experienced serious health-related suffering due to life-threatening and life-limiting conditions.
“A disproportionate number (more than 80%) of these 61 million individuals live in low-income and middle-income countries (LMICs) with severely limited access to any palliative care, even oral morphine for pain relief,” the report reads.
“Of the 298 million metric tonnes of morphine-equivalent opioids distributed in the world each year, only 0.1 metric tonnes are distributed to low-income countries and 50% of the global population (3.6 billion people who reside in the poorest countries) receive less than 1% of the morphine distributed worldwide.”
According to the UN’s International Narcotics Control Board (INCB) SUPPLEMENT TO THE ANNUAL REPORT OF THE BOARD FOR 2022 ON THE AVAILABILITY OF INTERNATIONALLY CONTROLLED SUBSTANCES, states the following:
“Analysis of the consumption of opioid analgesics, as reported by Governments to the Board, relative to the estimated number of people in need of palliative care in countries as provided in the Global Atlas of Palliative Care (2nd edition, 2020) by the Worldwide Hospice Palliative Care Alliance and the World Health Organization (WHO), confirmed the inequities.
“There is a clear need for decisive action, in particular in low- and middle-income countries. A major problem in those countries is the limited access to affordable opioid analgesics, such as morphine. One reason for this is that most of the morphine produced globally is converted into other drugs and not much is used for palliative care.
“In 2020, for example, 78 per cent of the morphine produced globally was converted into other drugs, mainly codeine, which in turn was mainly used in cough medicines, while only 11 per cent was consumed directly, mainly for palliative care. Furthermore, over 82 per cent of the global population had access to less than 17 per cent of the world’s morphine-based medicines.”
But as the pain inventory is attended to, filled out and ticked in wealthier countries, let us also recognise the other side of that coin of privilege and acknowledge the suffering of the opioid crisis in the United States, and how this unfortunate side of the coin has caused global alarm and perhaps in some countries a layer of misinformation, anxiety and an excessively cautious, knee-jerk reaction to morphine treatment.
And, in a region such as sub-Saharan Africa where many, many people who live in poverty die in agony as a result of AIDS related conditions (of which a large portion are youth), a restrained and overcautious reaction to an opioid crisis across the Atlantic, can result in the most poor and vulnerable, including children, not receiving palliative care due to misguided fear, and a lack of education and training on how to prescribe and administer morphine treatment.
In South Africa, another factor that limits access to morphine is the fact that most nurses do not have the level of qualifications to prescribe it, in a country where many urban and rural clinics are without a medical doctor and are run by the nurses; and where nursing Sisters are the skilled practitioners who take care of patients in hospices.
Compounded on top of this complex situation, there is also the concern about the level of education on pain management that healthcare workers are receiving in South Africa. Therefore education, education, education is a key solution to improving access to palliative care for people living in poverty and, it is this access to vital information that guides health practitioners to recognise causes of pain in order to treat and manage it.
However, Programme Director,
If access to vital information is a major determinant to the access of palliative care for the poorest and most vulnerable people in the world, then the striking question that rises to the surface is:
Why withdraw and discontinue the 2011 guidance: “Ensuring balance in national policies on controlled substances: Guidance for availability and accessibility of controlled medicines”, as well as the 2012: “WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses?”
As if it was not enough to have existing layers of restricted access to essential treatment, the WHO’s withdrawal of vital information seemingly exacerbated the problem by discontinuing the availability of guidelines that healthcare workers rely on to know what was safe and necessary for pain relief.
Was the action taken to discontinue the 2011 and 2012 guidelines based on evidence?
At this World Health Organization side event at the 27th HARM REDUCTION INTERNATIONAL CONFERENCE, I would like to assert that such actions have the potential to CAUSE MORE HARM to children in developing countries who may be left abandoned in their hour of agony, to die in extreme pain.
We know that there are safe and affordable options for these children but we refuse to reduce the pain and we insist on taking actions that add to the challenges for young, innocent and fragile souls.
Professor Felicia Knaul of the University of Miami, Chair of the Lancet Commission on Palliative Care was quoted commenting:
“I believe that policies that work to deny access to necessary pain relief medication in low- and middle-income countries because of the situation in the United States are akin to denying food to people suffering from malnutrition because there is an obesity epidemic in the United States.”
- This is a violation of the universal and inalienable right to health enshrined in the International Covenant on Social, Economic and Cultural Rights.2
- The access to controlled medicines is seriously hindered by a number of key factors alongside the international drug control system, including but not limited to:
- An ineffective global estimation system;
- Burdensome domestic regulatory frameworks;
- Stigmatized societal attitudes driving a fear of prescribing opioids for pain relief (as well as for substitution treatments of opioid dependence);
- Poor knowledge of these medicines by health professionals and regulators; and
- However, the United Nations Common Position on Drug Policy3, UN agencies explicitly committed to supporting UN Member States
“in developing and implementing truly balanced, comprehensive, integrated, evidence-based, human rights-based, development-oriented and sustainable responses to the world drug problem, within the framework of the 2030 Agenda for Sustainable Development”.
- Moreover, Member States have also made commitments relevant to these issues, through ratification of international human rights treaties, as well as via specific thematic instruments on the subject: e.g. the United Nations General Assembly Special Session on Drugs – UNGASS (2016)4 , the Commission on Narcotic Drugs (CND) Ministerial Declaration (2019)5 and the recently adopted UNGA resolution (77/238) of December 20226 whereby the UNGA – inter alia – it reaffirmed “its commitment to respecting, protecting, and promoting all human rights, fundamental freedoms and the inherent dignity of all individuals, and the rule of law in the development and implementation of drug policies”.
- Evidence supports that Opioid Substitution Therapy (OST) improves public health and is cost-effective – as it decreases or eliminates injecting practice among people who use drugs, thus significantly reducing HIV and hepatitis C transmission in this group. For example, since 1988, Switzerland has seen reductions in overdose drug-related deaths and crime, when heroin-assisted treatment (HAT) became available. However, global coverage of OST remains extremely low.
- Since its inception in 2011, the Global Commission on Drug Policy advocates for five pathways of drug policy reform that fully fit in such an approach that places human rights at the centre. These pathways include:
1) Put people’s health and safety first.
2) Ensure access to essential medicines and pain control.
3) End the criminalization and incarceration of people who use drugs.
4) Refocus enforcement responses to drug trafficking and organized crime.
5) Regulate drug markets to put governments in control.
- Considering that the right to health serves as the basis of our first two priorities – namely, to put the health of people and communities first, and to ensure universal access to medicines under international control – the Global Commission stresses that governments need to establish clear plans and timelines to remove the domestic and international obstacles to the provision of essential medicines under international control.7
- The Global Commission also recommends8 that to overcome the global crisis of avoidable pain, UN drug control bodies and States must recognize that drug policies at both national and international levels are imbalanced, with the current emphasis on preventing the diversion of controlled substances which holds primacy over ensuring their access for medical use.
- We also believe that a high priority must be given to the treatment of physical and mental pain by ensuring access to controlled medicines, including opiates, for pain relief, palliative care, anaesthesia, dependency, and all other forms of suffering—especially those that are on WHO’s Model List of Essential Medicines. It is equally important to expand the spectrum of treatment for opioid dependence, while respecting human dignity and offering the possibility of prescription of controlled medicines such as methadone and buprenorphine or diamorphine.9
- While the International Narcotics Control Board (INCB) must take more assertive steps in working with countries that consistently lack adequate access to controlled medicines, ensuring they provide evidence-based estimates to document their needs, governments and UN drug control bodies should also:
- Review the 1961 and 1971 drug conventions’ schedules in light of scientific evidence; and
- Prioritize exploring the medical benefits of controlled substances, based on WHO’s Expert Committee on Drug Dependence recommendations. 10
- With an increasing number of States and UN bodies drawing attention to the lack of access to controlled medicines, we are reaching a critical juncture. The Global Commission on Drug Policy encourages all stakeholders to join forces on tackling inequitable access to controlled medicines.
We must provide tangible actions so millions of people will stop suffering unnecessarily.