BY: ISABEL PEREIRA*
Lea la versión en español aquí.
In the world of medicine, what is essential and whom do we deem deserving of it?
There are two situations in which people need essential medicines such as opioids for therapeutic reasons, and yet they are largely unable to access such medicines. For palliative care, patients are facing severe or chronic pain, caused by chronic illness, end-of-life decline, or accidents. For Medication Assisted Therapies (MAT), patients are suffering from heroin addiction, searching for treatment to reduce the problematic use of this substance and the side effects of withdrawal syndrome, which causes pain and suffering. The first patient is suited to be prescribed morphine, fentanyl, or hydromorphone, accompanied with a series of interventions from other palliative care practitioners: nurses, social workers, psychologists, etc. The second patient would usually be prescribed methadone or buprenorphine, as part of a broader treatment which should encompass counseling, social and housing advice. Opioids used in both these medical approaches are inexpensive and effective. In both cases, these essential medicines are not the complete solution, but they are at the core of holistic treatment to alleviate pain.
But despite the urgent need of pain relief and the proven efficacy of these medicines, according to the World Health Organization (WHO) only 14% of people in need of palliative care are receiving such treatment, and taken from 2008 data, only 30% of countries have availability of treatments to addiction with use of medicines.
These two scenarios are situations of pain, and one could think that the terminally ill and the person who uses drugs are worlds apart, given that the reasons and structural causes to the pain are different, but they both need their health systems to ensure access to the same thing: opioids and professionals who know how and when to administer them, along with psychosocial services.
Most of the specific opioids that these patients need are part of the WHO Model list of essential medicines. For palliative care, this list has a specific section devoted to the medicines that should be a part of every country’s essential health care, such as codeine, fentanyl and morphine in various forms. For the case of MAT, not many therapeutic options appear in the WHO list. Methadone is included, but only as part of the complementary list of palliative care, and specifically suggested for the management of cancer pain.
This division that makes us perceive these two patients as completely different is caused by criminalization. Addiction has been, for the past 50 years, treated by public policymakers as a crime rather than an illness. In practice, this has ethical and practical impacts. On the ethical side, clinicians, families, law enforcement and the general public refer to addicts with stigmatizing language, deeming them as people who lack will, are morally flawed, and are, in general, undeserving. On the practical side, criminalization and stigmatization create barriers to access treatment that are almost impossible to overcome. How is someone supposed to get treatment when, once she comes in contact with the State is sent to jail rather than to health facilities?
To overcome these barriers, advocacy has become the tool through which patients, families and practitioners have placed their needs in the public debate. In the past decade, the palliative care movement has won some important political battles. In 2014, the World Health Assembly (WHA) approved a resolution specifically addressing this topic. The United Nations General Assembly Special Session on the World Drug Problem (UNGASS 2016) outcome document has a section devoted to it and the list of essential medicines continues to include them. Nonetheless, there is a long way ahead, as the differences in availability and access to opioid pain relief continues to be dramatically low in the Global South. Countries like Pakistan and Sri Lanka report consumption below 1 mg/per capita, compared to the global average at 61 mg/per capita, which inevitably means that severe pain is undermanaged.
For the second group of patients, advocacy movements for drug policy reform and harm reduction continuously place them at the forefront, reminding the public and politicians alike that these are people who need and deserve evidence-based treatment, and not punishment or oblivion. Last year’s triumph was to get harm reduction language included in the UNGASS 2016 outcome document. But these advancements continue to be secluded within the drug policy world. In other fora where these patients should be recognized, the silence is deafening. UN language in a number of treaty bodies and special mechanisms has recognized increasingly that the failure to provide controlled medicines such as opioids for palliative care constitutes a number of human rights violations. But such language has failed to include those who need those same medications for substitution therapy to overcome heroin addiction.
The Committee on Economic and Social Rights (CESR), in General Comment No. 14 on the right to the Highest Attainable Standard of Health, has said that “Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity.” Governments and the public alike must sincerely believe that every human being counts and every human being deserves the option to receive treatment to their ailments, if they choose to take it.
As a society, we have come to believe that people who become addicted live at the margins, unworthy of choices. This emanates from a certain moral position that presumes people choose drugs over life, and as such, no State resources should be devoted to this population, but today we know far more about addiction so we must dismantle the stigma. As a society, we must remember that our Constitutions and the international legal standards we adhere to speak of every human being, regardless of whether or not we agree with their choices or paths.
We need to unite these two worlds and find a common ground, understanding that the person battling addiction is facing an illness that needs public health policies just as much as those facing the end of life. The experience of pain, whether we experience it ourselves or we watch a loved one suffer, should remind us of the fragility of life and the need for compassion and empathy. Public health policy must be guided by the ethical and political commitment to guarantee that professionals and services are available for both patients, so that both worlds can find relief and live a life of dignity.
* Isabel is a researcher at the Center for Law, Justice and Society (Dejusticia).
Featured photo: ep_jhu