US attack on WHO ‘hindering morphine drive in poor countries’

Claims have hurt efforts to help people around world in acute pain, say palliative care experts

US attack on WHO 'hindering morphine drive in poor countries'

An attack on the World Health Organization (WHO) by US politicians accusing it of being corrupted by drug companies is making it even more difficult to get morphine to millions of people dying in acute pain in poor countries, say experts in the field.

Representatives of the hospice and palliative care community said they were stunned by the Congress members report, which they said made false accusations and would affect people suffering in countries where almost no opioids were available.

At least 5 billion people live in countries where there is limited or no availability of opioids for pain treatment, according to the International Association for Hospice and Palliative Care (IAHCP). More than 18 million people a year worldwide die with untreated, excruciating pain, the organisation says.

The report by the Democratic congresswoman Katherine Clark and the Republican congressman Hal Rogers, published in May, has undermined efforts to encourage governments to buy generic morphine or other appropriate opioids and doctors to prescribe them, dealing a severe blow to the struggle to help people dying in acute pain from cancer, Aids, injuries and other conditions, the IAHPC says.

The palliative care experts say low- and middle-income countries need cheap morphine, not patented opioid drugs such as OxyContin, at the centre of the US opioids crisis.

According to the UNs International Narcotics Control Board (INCB), only 10% of the worlds morphine is used for palliative care. Almost all of the remainder is converted into codeine and used in cough medicine for sale in wealthy nations. That makes it difficult for countries with fewer resources to procure any of the limited amount of morphine available for palliative care, said a 2018 INCB report on access to controlled drugs for medical use.

There is anxiety in many countries about the potential for opioid addiction, which has been heightened by events in the US.

The Congress members accused WHO and the palliative care community of being influenced by funding from Purdue Pharma, the company accused of precipitating the disaster in the US. Two sets of WHO guidelines on the prescribing of opioids wrongly claim the drugs are safe, says the report, supporting Purdues claim that dependence occurs in less than 1% of patients and talking of the need to tackle opiophobia, which stops doctors prescribing the medications.

Congresswomen Katherine Clark. Photograph: Joseph Prezioso/AFP/Getty Images

The web of influence we uncovered, combined with the WHOs recommendations, paints a picture of a public health organisation that has been manipulated by the opioid industry, says the Congress members report.

WHO and palliative care organisations have denied taking money or being influenced by Purdue Pharmas global offshoot, Mundipharma. But the decision of WHO to withdraw the guidelines immediately after the criticism dismayed the palliative care community. The move will further discourage countries from trying to buy the drugs, they say.

Dr Lukas Radbruch, the chair of the IAHPC, said the opioid crisis in the US had caused global alarm before the attack on WHO. Stakeholders are getting more reluctant to advocate for easy access to opioids, he said, citing India as one of the countries that had slowed down. He said he had seen morphine locked in a small safe labelled poisonous drugs cupboard in one of the largest hospitals in the world, in Johannesburg. In sub-Saharan Africa, people still die in agony as a result of Aids.

We were really shocked about the withdrawal of the guidelines from WHO in response to that report, said Radbruch, a professor of palliative medicine at the University of Bonn. The two sets of guidelines, from 2011 and 2012 Ensuring Balance in National Policies on Controlled Substances, and Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses provided vital information and guidance to governments and doctors on what was safe and necessary for pain relief.

This wasnt influenced by any of the pharmaceutical companies, said Radbruch, who was involved in drawing up the guidelines. The IAHPC, which was also attacked in the report, has published a detailed refutation of the allegations, saying claims it took pharma money are false. The IAHPC has never served the interests of Purdue or any other pharmaceutical company to influence WHO or any other agency, government, institution or entity, it says.

Prof Felicia Knaul of the University of Miami, chair of a recent Lancet commission on palliative care, said the Congress members report was not evidence-based. Actions that are not based in evidence will do harm, she said.

The stakes were high, she said. I believe that policies that work to deny access to necessary pain relief medication in low- and middle-income countries because of the situation in the United States are akin to denying food to people suffering from malnutrition because there is an obesity epidemic in the United States.

More than 60 million people every year require pain relief and palliative care and we know that more than 80% get virtually nothing. The vast majority of those individuals live in low- and middle-income countries. I consider it despicable from an ethical point of view and completely antithetical to the goals of global health and sustainable development to have children and adults living and dying in extreme pain when we have very inexpensive safe medications that we could offer them. Poor policies in the United States are not an excuse for allowing that to continue to happen.

Clark said in a statement that all patients deserve access to the medical care they need to live with dignity and without pain, and that includes access to medically appropriate pain medication. But opioid manufacturers including Purdue Pharma had lied about the risk of substance use disorder and their claims made their way into the WHO guidelines, she said.

Some critics, including those financed by the opioid industry, would have you believe that we face a choice between irresponsibly flooding countries with powerful opioids or leaving patients to suffer without any pain relief at all. This is simply not true, said Clark.

An electric syringe pump administering morphine in Congo-Brazzaville. Photograph: Alamy

No one disagrees that patients deserve access to medically appropriate treatment, but they also deserve factually accurate information about the care they receive and the risks that they might face. In addition, respected health authorities have a responsibility to promote appropriate access to palliative care while at the same time working to prevent the opioid crisis that we are experiencing in the United States from being replicated across the globe.

A spokesperson for Rogers said he and Clark had raised legitimate concerns with WHO in 2017 that Purdue Pharmas reckless and unsavoury marketing strategies would be employed internationally and lead to a global crisis.

Their goal has never been to restrict access to therapies for patients truly in need of palliative or other care, the spokesperson said of the Congress members. In fact, he [Rogers] agrees that WHO ought to ensure adequate access to internationally controlled essential medicines necessary for the relief of suffering, while preventing diversion and non-medical use.

However, it is clear that in the United States, we have failed to prevent vulnerable patients from [unwittingly becoming addicted] to powerful pain medications and that is due in large part to the influence of companies like Purdue Pharma that put profit above people.

Unless and until organisations like the World Health Organization do more to ensure that the pharmaceutical industry does not unduly influence their policy-making, these patients remain at risk.

Maringela Simo, a WHO assistant director general in charge of access to medicines, said: WHO pushes for a balanced approach people suffering severe pain should get the medication they need. At the same time, some pain medication, specifically opioids, needs careful handling through sound prescription practices and regulations to reduce the risk of abuse and potential harm.

WHO withdrew the 2011 and 2012 guidelines because new evidence on these risks has come out in recent years and, on examination, they were not fully aligned with revised internal procedures. We are now in the process of reviewing the guidelines for publication next year.

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