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Poppies for Pain Relief

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Millions of individuals worldwide suffer from acute or chronic pain without adequate access to pain medication. The problem is particularly acute in the developing world, as Time Magazine chronicled last year:

Whether you will have access to pain treatment depends largely upon where you live. Africa, which has most of the world’s AIDS victims, is a painkiller wasteland. In India, more than a million cancer and AIDS sufferers die each year in extreme pain as cumbersome regulations and paperwork make it nearly impossible to get prescription painkillers. (India produces much of the world’s legal opium, yet nearly all of it is exported to Western pharmaceutical companies.)

The geography of pain relief is so skewed that the seven richest countries consume 84% of the world’s supply of legal opiates, according to the International Narcotics Control Board, an independent agency that enforces U.N. conventions. For the estimated 10 million people who are suffering from untreated pain, relief is often found only on the black market, or in death

This gaping unmet need and global inequity is becoming the subject of various calls for change, by pain experts, by cancer treatment advocates, by international organizations, and by the human rights community. As Brent Foster explains in this podcast, the reasons behind the inequitable global distribution of pain medication are complex – like many intractable global social problems that get too little attention by policymakers.

However, a significant (and solvable) aspect of the problem is simply the relationship of supply to demand: the need for analgesics like morphine far outweighs the available supply. In part, this is due to the fact that such analgesics are produced from opium, the sap of the poppy. Since the same plant extract can also be used to produce heroin, a significant amount of political effort is now being expended worldwide to actually inhibit, rather than encourage, opioid production. This fuels shortages of analgesics.

Writing in the Journal of Epidemiology and Community Health, Amir Attaran and Andrew Boozary suggest a seldom-mentioned way to increase supply: re-framing Afghanistan’s poppy problem as “an opportunity for global public health.” In short, the authors suggest pro-government forces abandon efforts to eradicate Afghan poppy cultivation and instead redirect them toward the production of licit opiods for analgesic pain medication.

Opium can be extracted to produce morphine at a conservative ratio of 10:1, and morphine in turn can be synthesised into other medical analgesics (eg, codeine or dihydromorphine) with little loss. As such, Afghanistan’s available poppy crop is sufficient to supply about 690 tons of morphine: enough to nearly triple the current global supply of that medicine, and to narrow substantially the analgesia gap between rich- and poor-country patients having terminal cancer or HIV/AIDS pain.

No other country comes remotely close to producing enough. As such, the ‘problem’ of Afghanistan’s opium poppy, which is now wasted on manufacturing illicit drugs, is potentially the solution for millions of suffering pain patients, who desperately need proper analgesic medicines.

Of course, increasing supply would ultimately be only one important step in resolving the global distribution problem, which is partly a result of a grossly inequitable quota system operated by the UN International Narcotics Board, as well as cultural factors.

But given the staggering human need for opiod analgesics worldwide, it is remarkable that policy discourse on Afghan poppy production has been so focused on eradication, reduction or poppy-free zones to the exclusion of regulation for the purpose of filling medical need. Foreign Policy’s recent “Think Again” piece on Afghan’s poppy crop, for example, ignores this option completely, suggesting only marginal shifts in status quo policies that treat poppies as the problem (like “focusing alternative-development efforts on more stable parts of the country” or “fund drug treatment in Afghanistan.”)

Producing licit opiods for export would link Afghanistan to the global trading system and provide a legal and lucrative pathway toward economic development. Instead, poppy crops are being literally destroyed in Afghanistan as part of the “war on drugs.”

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  • Michael Drew

    Literally destroyed? No; it can’t be. Surely you jest.

  • xaaronx

    And even in the US, it can be hard for patients who need these drugs to get them, thanks to the pressure on doctors about prescribing them and limits on how much individual doctors can get their hands on. When my father was dying of cancer he and my stepmother had to make a huge deal and go to multiple doctors to get enough of the painkillers to make a dent in the pain he was feeling–and this was for a man with a particularly high pain tolerance.

    It wasn’t until the last weeks when he was in hospice care that this stopped being an issue. My stepmother told me a story this week of returning some of the drugs to their favorite of the doctors he saw and how grateful the doctor was because he had trouble getting sufficient supplies of painkillers. Relaxing the “War” on Some Drugs at both ends of the supply chain will help not just those involved at some point in the illicit trade, but doctors and patients as well.

    • xaaronx

      I forgot to include, even doctors and patients in the countries that get more than their fair share of the opiates already.

  • The possibility of diverting the poppy crop towards morphine has been raised. However, given the size of the Afghan crop, it would threaten those farmers/countries already producing such stuff. So, it has been considered, but I think met resistance due to the harm it would pose to existing producers.
    This is not a good argument for the status quo but merely perhaps a political explanation for the road not chosen.

    • BigSid

      You are exactly correct, Big Pharma worldwide is screwing any chance of indigenous pharmaceutical production in Afghanistan.

  • Welome to the club.
    For the record, Mark Kleiman, the Jefe and actual drugs expert on my group blog, disagrees on the benefits in Afghanistan.

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  • Anonymous

    Absolutely right. I’m about to get a lawyer after Kaiser. The pharmacist called my doctor ordering him to lesson my opiate drugs. Anyone want to help?

  • Dorothy Knable

    Anonymous wanting to go after Kaiser: [email protected], 916-451-2045.

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