Page 334 Guide to Pain Management in Low-Resource Settings

322 David E. Joranson

drugs simply did not have any stock to sell … a direct of pain and suff ering and that they also have a potential
result of low and unpredictable demand. During these for abuse. Th e principle recognizes that eff orts to pre-
times, morphine stocks … would run out. In these emer- vent illegal activities and abuse should not interfere with
gencies, the clinic would resort to otherwise unethical the adequate availability of opioid analgesics to relieve
and unacceptable cutback measures, implemented in pain and suff ering. International agreements that are
such a way so as to minimize the eff ect on patients and binding on governments have recognized for decades
families. … When these alternative treatments failed to that narcotic drugs, i.e. opioids, are indispensable for
achieve adequate pain relief, as was usually the case, the the relief of pain and suff ering and that governments are
staff would share in the helplessness, anger, and frustra- obligated to ensure their adequate availability for medi-
tion of the patients and their families. To communicate cal and scientifi c purposes.
the intensity of the dread felt by staff and patients when
a morphine shipment was delayed, and the joy when the What is the world situation
morphine fi nally arrived, is not possible. [Rajagopal et regarding the availability of
al. 2001]
opioids such as oral morphine

What do these cases illustrate? for people in pain?

Th roughout the world every day, millions of people
Th ese cases demonstrate some of the causes and the hu-
including older adults and children experience pain
man impact of unrelieved severe pain when access to
from surgery, trauma, cancer, AIDS, sickle cell ane-
opioid analgesics is blocked. Such situations are tragic
mia, and a range of other diseases that may include
and never should be allowed to happen, but they do set
severe pain. Th e incidence of cancer and HIV/AIDS is
the stage for this chapter that will describe a number of
shifting to low- and middle-income countries. Clini-
resources that can be used by health professionals and
cians understand only too well how unrelieved severe
government in low-resource settings, or anywhere else,
pain can destroy quality of life and sometimes even
to improve availability and patient access to opioid anal-
the will to live.
gesics such as oral morphine.
Some—but not all—of the wealthier countries
Th is chapter is based on the international studies
have fairly good opioid availability, and therefore pa-
and experience of the University of Wisconsin Pain and
tients have access to opioid analgesics. However, the
Policy Studies Group (PPSG) and many collaborators.
reality is that most of the world’s population lacks ac-
Since 1996, the PPSG has been a World Health Orga-
cess to these indispensable medicines. Lack of access
nization Collaborating Center (WHOCC) with terms of
is especially serious in settings with limited resources
reference to develop methods and resources that can be
and an inadequate health care infrastructure. A num-
used to improve availability and access to essential opi-
ber of organizations with an interest in pain, palliative
oid pain medicines.
care, cancer, and HIV/AIDS are working to address
Th e following questions and responses are intend-
these problems.
ed to assist clinicians and advocates in their eff orts to
improve patient access to pain relief. Readers are en-
couraged to consult the resource materials referenced Why are controlled drugs such as
in the text and at the end, refer to other chapters in oral morphine important?
this book, and seek expert professional guidance on
specifi c questions relating to clinical pharmacology, While other chapters address this question in more de-
medicine, and law. tail, it is important to note that a variety of drug and
nondrug therapies, including surgical procedures, radia-

What is the principle of balance? tion, and behavioral techniques, can be useful in treat-
ing pain and providing palliative care. Pain is treated
Eff orts to improve opioid availability should be guided with a combination of drug and nondrug measures. Th e
by the drug regulatory principle of “balance.” Balance is WHO has determined that pharmacological treatment,
an internationally accepted medical, ethical, and legal including opioids and nonopioids, is the mainstay for
principle stating that opioids are indispensable for relief relieving pain due to cancer and HIV/AIDS.