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Editorial

Untreated Pain a ‘Scandal of Global Proportions’

Doherty M

When a child is diagnosed with cancer in
Bangladesh, it is likely that he or she will not
receive any pain medications stronger than
paracetamol. Globally more than 5 billion
people live in countries where access to opi-
oids is extremely limited or not available at
all. In many cases, drug regulations intended
to prevent misuse leave many patients without
access to essential opioid analgesia. Currently
low and middle-income countries account for
only 7% of global opioid consumption despite
having 80% of the world’s population.
The recent results of the Global Opioid Policy
Initiative (GOPI) survey by the European
Society for Medical Oncology (ESMO) found
that in the most countries, multiple barriers
prevent the routine use of inexpensive and
effective opioid pain medications, such as
morphine. Pain relief is widely accepted as a
patient right and a human right. The Global
Action Plan for the Prevention and Control of
Non-Communicable Diseases (NCD) pub-
lished by the World Health Organization
(WHO) in 2013 calls for the integration of
palliative care and pain relief into the care of
all patients with NCD and strongly urges all
developing country governments to improve
access to these medications. 
Although it is important to prevent misuse of
opioids, many developing countries, includ-
ing Bangladesh, have extremely strict opioid
control policies that significantly limit the
supply, distribution, and consumption of opi-
oids, and prevent most patients with severe
pain from accessing these essential medica-
tions. The International Association for
Hospice and Palliative Care (IAHPC), recom-
mends 7 essential opioids be available in all
countries. These include codeine, oral oxy-
codone, transdermal fentanyl, immediate and

slow release oral morphine, injectable mor-
phine, and oral methadone. In Bangladesh
only 3 of these medications are on the nation-
al formulary and none are actually available
more than half of the time according to the
GOPI survey published in Annals of

Oncology1.
Many physicians in Bangladesh are hesitant
to prescribe opioids due to widespread fears
and misconceptions about the risk of addic-
tion and respiratory depression. Many clini-
cians incorrectly believe that opioids should
only be used in patients who are dying. All
physicians will encounter patients who need
palliative care and pain management in the
course of their career. Thus, training and edu-
cation in these areas should be included in
standard medical curriculum at the undergrad-
uate and postgraduate levels. Unnecessarily
stringent opioid control policies continue to
significantly impede clinicians’ ability to pre-
scribe opioids in this country. These regula-
tions must change, empowering properly
trained clinicians to prescribe opioids based
on individual patients’ needs.
Patient and public misconceptions about the
safety of opioids compound the issues facing
physicians when prescribing opioids. Patients
are often unaware that opioids are a safe and
effective option to treat their pain and fear
addiction. Complicated registration proce-
dures for patients and difficulty obtaining
medications discourage many from accessing
appropriate opioid analgesia. 
What are the next steps as moving forward?
The solutions must be adapted to the local
context. Lessons can be learned from devel-
oping countries who have improved opioid
access dramatically, including: Uganda,
Vietnam, Nepal, and Ukraine. In each of these

Corresponds to: Megan Doherty, Practicing in Pediatric Palliative Care, Children's Hospital of Eastern
Ontario/Roger's House, Canada, Email: mdoherty@cheo.on.ca

Bangladesh Journal of Medical Science Vol. 13 No. 03 July’14

249

DOI: http://dx.doi.org/10.3329/bjms.v13i3.17694
Bangladesh Journal of Medical Science Vol. 13 No. 03 July '14. Page: 249-250 



countries, an essential early step was reform of
national drug control and public health policies,
which were preventing medical access to opioids.
Ensuring that pain relief policies are developed as

part of the National Cancer Control Plan is also an
important step. Lastly, physicians must engage with
their paitents, civil society, and health advocates to
create a movement for change. 

Untreated Pain a ‘Scandal of Global Proportions’

250

References:
1. Cleary J, Radbruch L, Torode J, Cherny NI.

Formulary availability and regulatory barriers to
accessibility of opioids for cancer pain in Asia: a

report from the Global Opioid Policy Initiative
(GOPI). Ann Oncol
2013;24(11):1124–1132.[cited 2014 Jan 17 ]