Felicia Knaul woke up from a mastectomy several years ago. She still remembers the horror of the pain, pain so severe she felt she couldn’t breathe. Yet because she lives in the U.S., she, like many other Americans, had access almost immediately to pain relief that allowed her to push through her recovery much more easily.

Knaul is a professor at the University of Miami school of medicine. She also chaired The Lancet Commission on Global Access to Palliative Care and Pain Relief. The results of the study shocked even the researchers.

Among the findings: Nearly 26 million people around the world suffer intense pain without painkillers. Eighty-three percent of these people live in low- and middle-income countries where access to low-cost morphine is rare or unavailable.

Only 3.6 percent of the world’s morphine supply goes to low- and middle-income countries, and these countries pay far more for it than rich countries do. In the U.S., a pain-relieving dose costs 3 cents. In low-income nations, it costs 16 cents, if it is available.

Knaul said it would cost $145 million to make the pricing the same for all countries, a fraction of the cost of running a medium-sized U.S. hospital for a year.

‘Massive’ emergency

“The pain gap is a massive global health emergency, which has been ignored, except in rich countries,” said Knaul. “This global pain crisis can be remedied quickly and effectively. We have the right tools and knowledge, and the cost of the solution is minimal. Denying this intervention is a moral failing, especially for children and patients at the end of life.”

In a comprehensive global analysis, The Lancet Commission measured the need for palliative care in 172 countries. Palliative care seeks to make a patient comfortable, whether it is end-of-life care or whether the patient is expected to recover.

Out of those 172 countries, 25 had almost no morphine. Another 15 had less than 1 percent what was needed. One hundred countries had only enough morphine for less than 30 percent of their patients in severe pain.

In countries with the largest global populations, China has enough opioid pain reliever to meet the needs of only 16 percent of those needing it; India, 4.0 percent; Indonesia, 4.2 percent; Pakistan, 1.5 percent; Nigeria, 0.2 percent; Bangladesh, 3.9 percent; Russia, 8.0 percent, and Mexico, 36.0 percent.

Solutions found

Yet, some low-income countries have found ways to provide pain relief to those who need it. This includes Costa Rica, Uganda and Nepal, among others, because governments, doctors and others made it a goal. Knaul said this proves that low-income countries can provide pain management.

Costa Rica and Uganda have universal health care.

The study reports that in Nepal, where morphine was virtually unavailable, a local doctor convinced a Nepalese pharmaceutical company to produce oral morphine locally and to distribute it at cost to hospitals as a humanitarian gesture.

Knaul and the other researchers are in discussions with the World Bank on how to address the pain gap.

Part of the answer lies in providing more morphine and training doctors in how to administer it and monitor their patients. The other part of the problem lies in improving health systems in poor countries.

Dr. Jim Yong Kim, World Bank president, said that “we can and will change both these dire situations.”

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