Palliative care is a right of all people in pain

Palliative care is a right of all people in pain

In 2017, The Lancet published a report on the international lack of palliative care. It is a tale of woe documenting the sorry state of unrelieved global suffering. Everywhere “people live and die with little or no palliative care or pain relief.” It describes the “access abyss” in which the poor live and die in extreme suffering without receiving pain-relieving medications. They describe the world in which most of humanity lives in as a world of hurt.

The report cites poor public health planning and poor physician understanding of pain relief as the major causes the multinational shortfall of palliative care:

1. International health policy investments have focused on infectious diseases. The lack of pain relief at the end of life is due to the neglect of non-communicable diseases where the need for palliative care is highest.

2. Opiophobia is the “prejudice and misinformation about the appropriate medical use of opioids.” Opiophobia worries more about the addiction of the living than the palliation of the dying.

There is an astounding maldistribution of pain relievers expressed as morphine equivalent opioids (MEOs). Of the 68,000 pounds of MEOs distributed worldwide, only 225 pounds is dispensed in low-income countries. In Haiti, only 5mg of MEOs per patient are available, leaving 99 percent of the palliative care needs unmet. In America, MEOs are a staggering 55,000 mg/patient! This meets >3000% of USA needs vs. <6% of MAO needs in Haiti which leaves almost everyone there suffering from serious health-related suffering (SHS) in pain. SHS is suffering that “cannot be relieved without medical intervention that compromises physical, social, or emotional functioning.”

It is not only the poor countries’ poor who needlessly experience SHS but also the rich countries’ poor and, frequently, the rich countries’ rich. In poorer nations, poor access to “inexpensive, essential and effective intervention” to relieve their physical torment. In America, there are frequent reports that despite the 55,000 mg/patient of MEOs many live with unrelieved SHS. For the authors, this is “a medical, public health, and moral failing.” America’s patients enduring unpalliated SHS are also in this world of hurt.

Relief of unnecessary physical pain is a right of all patients in all places. It is not a lack of drugs but a lack of appreciation that pain is an agony for the sick and their loved ones, that pain destroys the person as well as the body, and that mitigating unnecessary suffering is an ethical obligation. The global lack of pain relief is a hurtful healthcare failing on a distressingly worldwide scale.

At the center of this hurting world is the painfully skewed maldistribution of pain-relieving medications. The WHO has estimated that 80 percent of the world’s population has no meaningful access to MEOs. The International Narcotics Control Board reported that in 2014 a mere 17 percent of the world’s population consumed 92 percent of all MEOs. This disparate distribution of opioids is grimly illustrated by the fact that while over 12 million people died in pain for lack of opioids between 2016 and 2017, over 64,000 Americans died from an excess of them. In a poignant counterpoint to The Lancet report, just seven days after it was published, the U.S. declared the “opioid crisis in the USA to be a public health emergency.”

This globalization of pain is old news. In 2012, the New England Journal of Medicine published an editorial entitled “Painful Inequities – Palliative Care in Developing Countries” detailed the global burden of pain and the global initiatives to relieve. Back then, 150 countries were identified where “morphine is simply not available.” The conclusion about this human catastrophe was, “People dying in pain are generally invisible.”

The Global Access to Pain Relief (GAPRI). GAPRI has estimated that as many as 5 billion people live with “little or no access to pain medications.” This included >5 million terminal cancer patients. Their website is harrowing to peruse.

The American Cancer Association’s Treat the Pain Program has the ambitious goal “to make effective pain medicines universally available by 2020.” The ACA works with governments and international health partners to raise international awareness that the poor feel the same pain as the wealthy. Pain is everywhere on our planet, but pain medications are not.

Unrelieved global pain is not only a “medical, public health, and moral failing,” it is more disgracefully an economic failure. The cost of meeting the global need for pain-relieving opiates is approximately $145 million which is “equivalent to a very small fraction (0.002 percent) of total public health expenditure.” The money is not spent because the problem is not seen. The world-wide unrelieved suffering is appallingly invisible. The farther the problem is from our homes, the farther it is from our consciousness and consciences.

This is not merely an income or geographic problem. Many in the wealthy nations despite being awash in opiates suffer just like those in poorer countries, but the poor of the world suffer more intensely, much longer and in much greater despair. The poor often have no physicians to champion their plight. They are often so ill, in so much pain and so politically disenfranchised that they are powerless to advocate for themselves.

If we are to preserve the dignity of the dying of our world, we must palliate their suffering. Palliative care is a right of all people in pain at home and abroad. The unrelieved pain locally and globally is unfathomable to contemplate and unspeakable to endure. This problem is “generally invisible” only because we choose not to see what The Lancet has revealed. We need to examine their revelations with our eyes wide-opened and see that many people who share our planet live in a world of hurt. Those living in this world of hurt need better pain relief. Attempting to meet these needs will not only preserve the dignity of the dying but our dignity as their fellow human beings as well.

Michael A. Salvatore is a palliative care physician.

3 Responses

  1. DEAR Jan ,
    Thank you for your reply . I will be asking my dr about this soon . I just also found out the cancer has moved into my bowels and now I will need surgery to remove the small part of my bowel that contains the cells . so yes now I definatly would be a candidate for pallative care at this point , there is only a 50 percent chance of survival long after this diagnoses . I am scared as all get out now because I know I d onot have enough pain relief . my pain has been out of control and now the last two weeks I can hardly even keep food down and sorry to be graphic but it goes right through me when I can keep it down and my back and stomach hurt horrible and on top of that I look pregnant my stomach is so bloated at this point . I also have other issue too like lupus and HS and Many many bone and tissue issues like RA and OSTEOARTHRITUS in my back and neck , bone spurs , stenosis , suicide headaches from ON and TN and the list goes on and on . I am very sick all the time . I have often thought suicide was a better option than living like this , but several months ago before the cuts I had a real life , at least it was a half life , this is no life at all . I cannot even sit for a couple hours and do my artwork on the computer , which was my bread and butter because I love it but it also helped pay bills and fill all the little holes , even a 60 dollars art edit a month was helpful being on disability and disabled , because my husband is also partcially disabled due to chronic pain but he works and refuses to take any gov help or else we would be on the streets . but him my mother and I live together just so we can make ends meet because of my health , which makes me feel like a burden anyhow . I am just at my wits ends with all this opiod crisis BS ! because it is BS ! I should never have to suffer the way I have this past 9 months . I am in hell . I know it sounds awful and desperate but I really do not like living like this and then also my other friends in the pain community having to endure the same makes me so angry and sad and depressed to the point I want to end it all or fight and I do not know how much fight I have left in me . I am not going to take another pain patient in who has been abandoned and thrown to the streets for the same reasons , no one cares about what happens to us now . She lost her mother for the same reasons , her mother was sick and lost all pallative care and her pain meds and died , they would not even let her die in peace . It is an awful world we are living in here in THE USA ! I feel like trump is hitler . I know so many would disagree with me and as much as i want him to buck up and do the right thing it seems he will only listen to people who are all out against any pain medication that helps those who need them who are not addicts ! Even though they CDC admitted the numbers were wrong quietly allbeit , there still are people everywhere suffering so bad they are dropping like flies and no one in congress seems to care enough to put a stop to all this . I feel hopeless and helpless and like I said I cry just about every single day . Every night my husband does hold me while I cry in his arms and he has cried also . He has written everyone he can about this BS going on with pain patients and the DEA AND CDC etc but no one will write him back or listen in our country . anyway thank you for the advice and I will be bringing this up to my oncologist and primary care , thank you and God bless you and everyone suffering this horrible war against us all X

  2. Dear Chaz, I am so sorry you are having to deal with this. It’s outrageous! Can’t your Dr. give you a Palliative Care diagnosis? It’s not just for end of life.

    Google: When Does Pain Treatment Become Palliative Care Treatment? By Dr. Thomas F. KLINE. Read it and take it to your Dr.

  3. It is the truth , I have lost two people this last year early on because they were dying but could had lived longer with better pain care . They also could had lived out the last months of their lives with some dignity and relief for a better life even if it was ending . No one deserves to die with no dignity or relief from their pain . I know pain meds are not a solve all , but for people who need them they mean the difference bettween life or death or a life with some dignity and having the mental power to go on with what little they have left . It breaks my heart and this does hit home for me personally . I have cancer and my meds have been not taken away totally but have been lowered so much now I have no quality of life , also honestly my cancer was in remission and subsquently as they lowered my meds because I already had been n them on and off for ten years due to chronic pain and 12 different pain related illness , guess what happened , my cancer came back full force . and then even then they are so afraid I will become an addict they will not give me the meds I need to have a quality of life to be able to function and I also have kids that depend on me . anyhow thank you for posting this . XXXX

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