Yes, sure. For patients in the end stages of terminal diseases such as cancer or AIDS who are in severe pain, dependence is clearly not an issue. For others, short-term treatment with opioids has been shown in studies to lead to dependence in only a small fraction of cases. And for those with chronic pain, dependence on medication is arguably much less of a concern than for them to suffer.
The opioid crisis in the US and the irrational response by the authorities to drastically limit opioid prescriptions have been devastating to chronic pain patients, often suddenly deprived of a medication they have used stably for years that allowed them to function. It has also created the false impression that prescribing opioids to patients in need is a significant cause of drug deaths. Although overprescribing of pain medications in the past likely contributed to overuse and dependence, most of the overdoses today are due to street heroin and illegally imported fentanyl, a powerful drug which is also used to lace heroin.
There are also means to limit the risk of prescribed morphine getting into the wrong hands, such as distributing it in diluted oral form, which is of much less use to those with drug dependence—this has been done successfully in Uganda. So although opioids need to be managed carefully and precautions taken so that only those who need it can obtain it, there is ample evidence for how morphine can be provided to patients in need without reasonable grounds for opiophobia.
16 Oct: This short article sums up the irrationality of opiophobia: https://www.cato.org/publications/commentary/opioid-crisis-not-helped-panic
Thanks a lot for your very interesting work. While I am very sympathetic to the views you expressed here, I want to play the devil’s advocate for a moment and try to explore some counter-arguments.
Like Sanjay I think it would be desirable that you explain more why fears of morphine dependence and misuse are unwarranted. The article you linked to as a response to Sanjay argues that restricting the prescription of opioids in the US is counterproductive. This article is not very strongly convincing to me, in part because of lack of sources, and in part because the intervention context is really very different. I want to note that problems with opioids are observed in some African countries, see https://www.economist.com/the-economist-explains/2018/08/23/west-africas-opioid-crisis . Also, even if the probability that this intervention turns out to be detrimental in some important way is small, the negative consequences it would have if this were the case could be rather devastating, especially if the cause is tightly associated with the EA movement. Finally, this is much more speculative, but I was also wondering how “flow-through”, more long-term effects of the intervention would compare with other interventions. (E.g. the longterm positive effects could be smaller if most people need pain relief in the last few years of their lives.)
After all that criticizing of mine, I want to end by expressing again my sincere appreciation for your work. I view my critique not as a way to discourage people to work in this direction, but as a modest attempt at trying to help adjust as best as we can what we can do there.
JC, thanks a lot for your comments. The short article I linked to summarised the situation but you’re right that it doesn’t provide additional sources. I would, however, maintain that much of the concerns about opioid misuse do come from the US, even though the context is different, which is why it is so important to show the weakness of the arguments made linking justified prescriptions and misuse. Two white papers by the Alliance for the Treatment of Intractable Pain are useful and contain many references:
Also this article by noted pain patient advocate Thomas Kline, MD:
See also this article in The Guardian:
The situation of opioid misuse in West Africa hasn’t received nearly as much scrutiny. But as is the case in the US, it’s critical to distinguish between the use of street drugs and medically appropriate prescriptions, and to be careful about drawing any putative link between them. There are already tight controls on the import of most opioids, including morphine, and government restrictions are generally stricter than necessary to prevent diversion. The Economist article refers to codeine, a weak opioid that isn’t as strictly regulated as more powerful opioids, and tramadol, which is a medically used opioid that, as far as I know, is not included in UN conventions and in many countries has not been subjected to the same domestic regulations as other opioids, making it easier to import and distribute for non-medical uses. So this is a public health issue with socioeconomic causes as well, and there are different potential strategies to address it, including more balanced regulations for the drugs in question. But there is no good reason to think that making morphine widely available within the medical system under controlled conditions would contribute in any significant way to this problem.
The fact that the lack of access to morphine in most of the world has been meticulously studied and highlighted in a major Lancet article as a huge public health problem in itself, and the lack of evidence that balanced domestic policies to make morphine available to those in need result in diversion to street use, should give sufficient cover to EAs and any others who want to help address this issue. Things are changing far too slowly, and if there were issues along the way that emerged in some countries they could be corrected. Even if the EA movement were to embrace this issue as a major cause area, I would see the risk of “devastating” consequences as being extremely low.
I am unaware of any major flow-through effects, other than allowing chronic pain patients to function and work, and reducing stress and suffering in family members and others supporting those in pain.