Opioids and chronic pain

MacDonald and colleagues1 rightly identify the need to scale up clinics for treatment of chronic pain and improve the availability of quality care for pain to Canadians in need. The proposed approach provides a rough framework to improve Canadians’ access to relief from pain. In the global context, however, the undertreatment of pain remains a health tragedy,2 and improving access to even basic treatment is far less straightforward than scaling up existing services.

Morphine — one of the most basic analgesics for treating moderate-to-severe pain — is almost wholly unavailable in many parts of the world, despite being listed as an essential medicine by the World Health Organization.3 The underlying rationale for this is complex and varies among nations, but has its origins in international treaties that have a dual mandate of ensuring access while simultaneously curtailing diversion from licit to illicit markets.4 Overwhelmingly, the emphasis has been placed on prohibition rather than access, resulting in over 80% of the world’s population having no functional access to controlled narcotics.5

Improving the management of both acute and chronic pain care in the global context necessitates more than scaling-up services. Rather, it requires a paradigm shift in the way controlled narcotics are viewed, so as to prioritize access for medical purposes rather than the prohibition of illicit narcotics. Education of health professionals must follow suit; however, first we must ensure that basic supplies are made legally accessible to patients and providers.