Last month, the World Health Organization published Left Behind in Pain, a report on the extent and causes of global variations in access to morphine for medical use and actions to improve safe access. This month, we asked Kiusiang Tay-Teo, WHO's Technical Officer in the Department of Essential Medicines and Health Products, to give us a more personal glimpse.
1. What was the WHO's impetus for this report?
The WHO is committed to improving safe access to essential opioids for medical use and, as the report states, “morphine is considered the most basic essential medicine for managing acute or chronic, moderate to severe pain, particularly in palliative care. It is also less expensive than other derivative and synthetic opioids, such as oxycodone and fentanyl, which have been associated with the 'opioid overdose epidemic' in a few high-income countries.”
As noted by the Assistant Director General, “Leaving people in pain when effective medicines are available for pain management, especially in the context of end-of-life care, should be a cause of serious concern for policy-makers.” We think that the global community must come together to provide timely and safe access to morphine for those in medical need through balanced policy, everywhere.
2. Were any of the conclusions a surprise to you?
I’m shocked by how persistent the lack of safe access to morphine is in many parts of the world, despite morphine’s well- and long-established clinical place for managing severe pain and the fact that severe pain is a human experience beyond cultures and borders.
I’m surprised by the degree of variations in the consumption pattern across countries, especially among countries that seem comparable.
The sad reality is that people do recognize that this lack of safe access and the preventable suffering don't make sense, and yet we let it happen repeatedly. The report has described a range of barriers and enablers that could explain why someone has safe access to morphine while others not. But we must scrutinize the relevance of these factors individually and carefully so that we could fine-tune or revamp policy responses accordingly, rather than using these factors as false justifications for inaction.
3. Was there a response (or one respondent) to the WHO survey of stakeholders that illustrated the importance of a report on this topic at this time?
All responses in the WHO survey of stakeholders contributed to our understanding of the global status on access to morphine. I can recall many responses that illustrate the importance of this report. As an example, a comment noted that the problems associated with opioid misuse and overprescription in some high-income countries were having a strong influence on access policies in other countries, including those with little access.
The report recognizes that concerns about the potential harmful effects of opioids are valid. It also stressed that “such concerns should not undermine the benefits of opioid use when clinically indicated and when used safely by trained professionals.” To find a balanced policy response through a well-informed policy dialogue is the aim of this report.
4. In your practice as a pharmacist, have you had a direct experience with the lack of access?
I practiced as a pharmacist in an urban setting in Australia where access was not a problem, but at the time I did see individual cases of harms due to overprescription and misuse.
In my personal capacity, I witnessed individuals who experienced preventable pain because of a lack of access, reluctance to seek help for fear of financial burden to the family, or due to inappropriate prescribing (e.g., inadequate dose, lower potency opioids). Seeing the impacts of lack of access on the well-being of these individuals has shaped my understanding and professional responsibility about ensuring safe access through balanced policy.
5. How is the WHO gearing up to help enact changes to disseminate the report and improve access?
This month, WHO is hosting three webinars with leading experts globally to discuss issues and country experiences pertaining to safe access to morphine. These webinars will coincide with Pain Awareness Month, which we hope will bring attention to this public health problem too.
To improve access, WHO will continue to work with member states, other UN agencies, and key stakeholders to coordinate various work, including on how to improve supply chain efficiency, and build capacity of the health care workforce to ensure safe use of morphine and other opioids.
WHO is also finalizing a guideline on ensuring balanced national policies for access and safe use of controlled medicines, which will help countries in formulating policy.
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