• Demand;
  • legislation;
  • morphine;
  • narcotics;
  • opioid;
  • political;
  • poppy;
  • social;
  • supply;
  • WHO

Inequity of analgesic availability is ignored politically. Governments must balance analgesic access against illicit opioid control; but ignorance and inertia leave opioids widely unavailable. Western social cravings drive illicit opioid production in developing countries, yet their citizens die with agony unrelieved. International analgesic aid could transform basic health care.

Two recent news items on opioids highlighted our conflicting societal attitudes. Massive hauls of illegal drugs were widely reported [1,2], but an important paper from the World Health Organization (WHO), ‘Ensuring balance in national policies on controlled substances’, had little publicity [3]. The drugs seizures (cocaine worth £300 million from a yacht in Britain and more than half a tonne of heroin for shipment from a car in Panama) will drive up street prices of illicit opioids in the developed world, while the toll of unrelieved pain is unchecked and ignored in the developing world.

Here is the extraordinary contrast. One half of the world, by and large the developed world, has analgesia freely available, able to take medication for the most minor pain from headache to dysmenorrhoea. For these people, severe pain will warrant opioids and the knowledge of dose titration means that even those with more chronic requirements, such as with cancer pain, are able to have analgesia. The other half of the world has so little medication available, if any, that they cannot have analgesia for the most terrible of pains; 75 000 women die in childbirth each year with no analgesia of any type having been available. Many governments in the developing world are terrified of the abuse potential of opioids. In contrast, in the developed world the abuse of substances has become so commonplace that many are arguing that recreational use should be legally allowed.

Is the insatiable demand of the addicted affluent in effect denying others in the world access to pain relief? Fear of the addictive potential and potential toxicity of opioids has resulted in tight prescribing regulations. In some health-care systems, complex regulations result in analgesia being rationed, leaving patients' pain undertreated. However, WHO considers the public health outcome of opioid availability to be at its maximum (or ‘balanced’) when the optimum is reached between maximizing access for rational medical use and minimizing substance abuse [2].

After the modern hospice movement was established in the 1980s and safe analgesic morphine titration became the norm, the consumption of medicinal morphine increased significantly in industrialized countries. Despite this knowledge, almost 80% of the world's population today has no access to morphine analgesia. An estimated 33 million people, 60% of those dying each year in the developing world, need palliative care but have no access to even basic care and symptom control [4]. This terrible lack of pain relief can be attributed to three main influences: legislative and policy blocks to access, ignorance that perpetrates opioid phobia among clinicians and society alike, and the economics of health-care delivery whereby accessing even the cheapest of preparations are simply unaffordable for most of the population [5]. Ignorance by clinicians of the safety profile of morphine and other analgesics means that even when governments are willing to rethink their approach they often receive outmoded advice, even though analgesics are very cheap to produce.

In 1961 the Single Convention on Narcotic Drugs was adopted world-wide; it stated that narcotics (opioids) are ‘indispensible for the relief of pain and suffering’, and instructed states to make adequate provision to ensure their availability. Fifty years on little has changed. Some of the world's most populous countries have very poor availability of opioids for pain relief [6]. As Human Rights Watch reports, in China, India, Indonesia, Nigeria, Russia and South Africa, at least 100 000 people die from cancer or human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) each year without access to adequate pain treatment, with about 3.5 million terminal [4]. As they say, ‘the combined suffering due to lack of opioid pain medicines worldwide is staggering’.

Perhaps this can be attributed to the insular selfishness of the developed world, or that the dying and those in severe pain are invisible or that women in childbirth are less valued than dominant men in some societies; but the developed world has a responsibility to look beyond its shores to see that unfettered consumption of opioids is damaging world stability.

It is in the poppy fields of Afghanistan that anti-West feeling foments. Across about 123 000 hectares the vast bulk of the opium is produced to be sold illicitly in the developed countries, accounting for 63% of the total global opium production area. Some disease in poppies has slightly decreased production, but there is real concern that as soon as the international troops pull out production will rise again, particularly as the country has the potential to increase production by 75%. In 2008, as Parliamentarians, we suggested that some trading should be set up with Afghan farmers to buy up their raw opium and use it to produce analgesics to be supplied at minimal cost to the developed world as a form of international analgesic aid [7]. UK and US governments reject the idea out of hand, saying that there will always be a percentage siphoned off for illegal sale and that within any contract the farmers will claim that production is down from one year to the next due to weather or pests, thereby preserving their share to sell on illegally.

However, such arguments miss the fundamental problem. Production will continue for illicit use as long as there is demand. Trying to stop opium entering the addiction market seems analogous to King Canute demonstrating the impossibility of trying to hold back the incoming tide; perhaps we are being as stupid as his onlookers were in thinking such things are possible.

Our attempts at present only scratch the surface of a more fundamental problem. In the United States prescription drugs abuse is rising; in parallel there is an increasing supply of new psychoactive chemicals on the streets. Demand for psychoactive substances continues apace. Meanwhile, in most of the world people are dying with terribly unrelieved pain, struggling to live a meagre existence without access to even basic health care. The developed world has a responsibility to radically rethink its aid policies and consider whether ‘pain-aid’ should be a strategy in the future.


  1. Top of page
  2. Declaration of interests
  3. References
  • 1
    Southampton cocaine haul ‘worth up to £300m’. BBC News, 3 August 2011. Available at: (accessed 5 September 2011; archived at
  • 2
    Panama police seize more than half a tonne of heroin. BBC News, 2 August 2011. Available at: (accessed 5 September 2011; archived at
  • 3
    Ensuring Balance in National Policies on Controlled Substances: Guidance for Availability and Accessibility of Controlled Medicines. Revised edition of ‘Narcotic and psychotropic drugs: achieving balance in national opioids control policy: guidelines for assessment’, World Health Organization, Geneva, 2000. Geneva: World Health Organization; 2011. ISBN 978 92 4 156417 5.
  • 4
    Stjernsward J., Clark D. Palliative medicine: a global perspective. In: Doyle D., Hanks G., Cherny N. I. et al., editors. Oxford Textbook of Palliative Medicine. Oxford: Oxford University Press; 2003, p. 1199222.
  • 5
    Rajagopal M. R., Joranson D. E. India: opioid availability—an update. J Pain Symptom Manage 2007; 33: 61522.
  • 6
    Human Rights Watch.Global State of Pain Treatment: Access to Medicines and Palliative Care.New York, USA: Human Rights Watch; 2011, ISBN: 1-56432-771-X.
  • 7
    Finlay I. G., Mancroft L., Field F. Opium production in Afghanistan: let's re-examine buying the Afghan poppies that are left. BMJ 2008; 336: 1325.