By Lukas Radbruch, IAHPC Chair of the Board
IAHPC, together with other reputable organizations, is very concerned about the public perception that medical professionals have been compromised by pharmaceutical companies.
This perception has already led to a damaging backlash, a backlash that could further jeopardize access to opioid analgesics desperately needed in many low- and middle-income countries. One example is the rather biased report by two U.S. congress persons on the alleged influence of Purdue Pharma on two World Health Organization guidelines (Ensuring Balance in National Policies on Controlled Substances and Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses). WHO reacted by retracting these guidelines, which has been mistakenly interpreted as an admission of guilt, as the WHO “now effectively declaring that they were never valid.”1
The crisis in developing countries is not opioid overuse, but lack of access to morphine as an essential medicine for palliative care patients.2
The criticism in the U.S. report, the withdrawal of the guidelines, and the re-emerging discussion on the perils of opioids has frustrated me deeply, not only as Chair of the Board of Directors of IAHPC, but also personally.
I was involved in the development of the Ensuring Balance guideline,3 as I was coordinator of the European Union-funded research project that included the guideline’s development as one of its work packages.4 We followed a rigorous scientific consensus process for the development of the guideline,5 and I certainly felt that we endeavored to be as scientifically sound as possible, without undue influence from pharma companies.
Admittedly, the opioid crisis in the United States and some other countries is still in full flow, with 47,600 deaths in 2017 in the U.S. (67.8% of all drug overdose deaths) involving opioids.6 However, opioid-related deaths involve illicit opioids much more often than prescription opioids, and recent research has highlighted the contribution of socioeconomic factors — such as social capital and workforce participation — to opioid-overdose deaths.7 Yet persistent public perception is that the opioid crisis is predominantly linked to ruthless pharmaceutical companies seeking higher profits, abetted by physicians influenced by the companies.
Recently, there have been warning calls that these companies are now pushing for increased opioid use in other countries, risking a global opioid crisis.
This issue of potential bias from pharmaceutical companies has become increasingly prominent. Earlier in my research career, I did a lot of pharma-sponsored lectures, participated on some advisory boards, and performed some studies funded by the companies. I have also been uninvited by these companies — or not booked for subsequent lectures. Perhaps it was because I was too critical of messages the companies wanted to promote. Other speakers, advisory board members, and I frequently discussed whether the honoraria or travel cost reimbursements would have an undue, albeit subtle, influence on our opinions.
I decided to break free of all pharmaceutical companies in 2010 when I moved to my new position as Chair of Palliative Medicine at the University of Bonn in Germany. Since then, I have rejected any offers from companies for lectures, research funding, or other paid activities. When I attend a congress, I even buy my own coffee so as not to accept it from a pharma company booth. I am not the only one doing this. Here in Germany, we have an association called MEZIS (mein Essen zahle ich selbst), which means, “I will pay for my own lunch.” It is part of an international No Free Lunch Movement.
I can report that ceasing to work in any way with pharma companies did make a difference in my perspective. I have become more critical when reading research papers of pharma-funded studies, or when listening to a someone from a pharma company’s speakers bureau. IAHPC publications have been very critical of pharma companies as well: for example, we have highlighted problems with subsidized fentanyl patches in some developing countries instead of promoting cheap generic morphine as the standard of care.8
Having no conflict of interest, I hope that I can participate in redrafting the WHO guideline, making sure that it maintains the principle of balance, with adequate prevention of nonmedical use, but also adequate access to opioids for all patients who need them. It is possible for a country to have high opioid consumption without the U.S. problems: Germany is an example.9 We should try to learn from those countries, and not return to a time when pain and suffering were inevitable for severely ill people.
We have come too far in the global development of hospice and palliative care to risk that!
1. Dyer O. WHO Retracts Opioid Guidelines after Accepting That Industry Had an Influence. BMJ 2020; 368: m105.
2. Pettus K, De Lima L, Maurer M, Husain A, Connor S, Torode J, Ling J, Downing J, Rajagopal MR, Radbruch L, Pastrana T, Luyirika EB, Goh C, Marston J, Cleary J. Ensuring and Restoring Balance on Access to Controlled Substances for Medical and Scientific Purposes: Joint statement from palliative care organizations. J Pain Palliat Care Pharmacother 2018; (2-3): 124-128.
3. World Health Organization. Ensuring Balance in National Policies on Controlled Substances — Guidance for availability and accessibility of controlled medicines. Geneva: WHO Press, 2011.
4. Radbruch L, Jünger S, Payne S, Scholten W. Access to Opioid Medication in Europe (ATOME): Final report and recommendations to the Ministries of Health. 2014.
5. Junger S, Brearley S, Payne S, Mantel-Teeuwisse AK, Lynch T, Scholten W, Radbruch L. Consensus Building on Access to Controlled Medicines: A four-stage Delphi consensus procedure. J Pain Symptom Manage 2013; 46(6): 897-910.
6. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths — United States, 2013-2017. MMWR Morb Mortal Wkly Rep 2018; 67(5152): 1419-1427.
7. Heyman GM, McVicar N, Brownell H. Evidence That Social-Economic Factors Play an Important Role in Drug Overdose Deaths. Int J Drug Policy 2019; 74: 274-284.
8. De Lima L, Arias Casais N, Wenk R, Radbruch L, Pastrana T. Opioid Medications in Expensive Formulations Are Sold at a Lower Price Than Immediate-Release Morphine in Countries throughout the World: Third phase of Opioid Price Watch cross-sectional study. J Palliat Med 2018; 21(10): 1458-1465.
9. Radbruch L. Rising Opioid Prescriptions May Not Be a Crisis. BMJ 2019; 367: l6452.