Page 333 Guide to Pain Management in Low-Resource Settings

Chapter 43

Resources for Ensuring Opioid Availability

David E. Joranson

Th e purpose of this chapter is to provide perspective Case 1
and tools that you can use to make opioid analgesics A patient was initially given radiotherapy for her pain,
more available and accessible for the treatment of your but it was not eff ective as the disease progressed. Next
patients’ pain. she was given a weak pain-relieving medication, but her
Th e availability of opioid analgesics depends on the pain continued to worsen. Finally, she returned to the
system of drug control laws, regulations, and distribu- doctor in excruciating pain requesting medication that
tion in your country. Unless this system is able to safely would end her life. She was given another weak pain
distribute controlled medicines according to medical medication along with antidepressants and sent home.
needs, clinicians will be unable to use opioid analgesics She committed suicide. [Pain & Policy Studies Group]
to relieve moderate to severe pain according to interna-
tional health and regulatory guidelines and standards of Case 2
modern medicine. XX is a referral hospital for cancer management. Th e an-
Th is chapter poses a number of questions that are nual requirement of morphine is approximately 10,000
relevant to a better understanding of how the system is tablets of 20 mg. But the Institute has not been able to
supposed to function, and to identify and remove impedi- procure a single tablet … primarily due to the stringent
ments to availability of opioids and patient access to pain state laws and multiplicity of licenses. After a lot of ef-
relief. Th is is of utmost importance, since pain manage- fort, the Institute had been able to obtain the licenses…
ment of postoperative, cancer, and HIV/AIDS pain is vir- and had approached a [manufacturer] for a supply
tually impossible without the availability of opioids. Th is of tablets … the [manufacturer] did not have tablets in
does not imply that opioids are indicated for every type of stock and by the time the tablets could be arranged, the
pain. Opioids can be useful to treat patients with chronic licenses had expired. Th e doctors at the Institute and the
pain from noncancer conditions, but the choice of thera- associated pain clinic have stopped prescribing morphine
pies needs to be made on an individual basis, governed by tablets because they would not be available. [Joranson et
a careful consideration of risks and benefi ts of treatment. al. 2002]

Case examples Case 3
[T]here were several occasions when no morphine was
Several real cases are off ered to focus this chapter on the available. Such situations normally arose as a result of
critical importance of availability and access to opioid the diffi culties encountered when trying to obtain the
analgesics for the relief of pain. required licences. At other times, manufacturers of the
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 321
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.