Currently nobody can answer the question, "Which countries are worse off?"
• Is it those with "too few" opioids (as measured by a presumed need for relief of acute pain and chronic cancer pain), or
• Is it those awash in opioids being prescribed too readily for chronic noncancer pain and, perhaps, being overprescribed for acute pain and cancer pain and then being diverted to the illegal market?
While the available data are not adequate to measure palliative benefits of treatment and the harms associated with prescribing (including diversion), a balance must be struck.
In recent years, many international bodies have incorporated the concept of a human right of access to pain management and that this right has legal grounding in international human rights documents; this imposes obligations on signatory governments that might be enforceable in domestic courts under some circumstances.
This is a wide claim in the context of acute and chronic pain, with a focus on the regulatory challenges posed by some countries. The argument potentially implicates a right of access to non-opioid pain management alternatives, although currently they are generally of modest effectiveness.
Although admitting that opioids may play a "circumscribed role" in the treatment of chronic noncancer pain, the right to access pain treatment implies that "physicians should be able to make the clinical determination of the best treatment options — without inappropriate government interference." That claim may be too strong as a normative matter because: a) governments have a strong regulatory interest in this issue, and b) the medical profession's failure to establish effective mechanisms for self-policing is evident in the historical increases in opioid prescribing and some of the associated negative consequences.
Although many health professionals from different countries have expressed apprehension about arbitrary restrictions on prescribing (e.g., dose and time), it would be a serious mistake for magistrates to constitutionalize a right to opioid medications for any specific indication.
Diverse initiatives on pain policy question the balance in regulatory policies. They suggest that policy makers have focused too much on regulating controlled substances, preventing opioid use disorder, and modifying prescribing practices. This focus has led to a failure to formulate a coherent analgesic policy; policy makers have failed to facilitate safe and effective analgesia.
The present situation is rooted in health systems failure, and steps need to be taken on all fronts to reduce the supply of, and demand for, opioids.
Regulatory bodies must establish a proper balance between the needs of patients in pain and the prevention of opioid-related harms. Careful regulation should be rooted in a long-term cultural transformation of how pain is perceived, assessed, and treated, including efforts to develop clinical pain competencies for all health care providers.
See reference for more information.
Adapted from Medscape News & Perspective. Pain management and opioid regulation: continuing public health challenges. Available at https://www.medscape.com/viewarticle/907290_5. Internet. Accessed on January 23, 2020. To view the entire article and all other content on the Medscape News and Perspective site, a free, one-time registration is required.