This link is expired unfortunately. Is there anything CEA/the forum could do to collate existing translations?
Lee_Sharkey
Increasing Access to Pain Relief in Developing Countries—An EA Perspective
Thanks Austen!
Yes, it’s actually very large. So large, in fact, that it seems to be taken for granted by many people in those countries with low access.
I’ve withheld strong judgement on whether it should be a cause area that other EAs should act on. I think it could be a particularly attractive area for EAs with certain ethical preferences.
Before funding programmes such as PPSG’s, further analyses of the cause and the programme(s) are warranted. I’d be open to suggestions on how to carry those out from anyone with experience, or I’d be happy to discuss the matter with anyone interested in taking it forward themselves.
Thanks Julia! Glad to have the chance to share
Hi Elizabeth,
I focus on opioid medications for the same reasons that I don’t focus on cannabinoids:
There isn’t strong expert consensus on the effectiveness of cannabinoids. This may change as the search for alternative drugs, particularly for chronic pain, intensifies. While there are some areas that will likely see their use increase (you justly highlight neuropathic pain), my understanding is that current evidence doesn’t reliably indicate their effectiveness for severe pain. All this said, there are good reasons to believe they are understudied, both as single interventions and as adjuvants. I should perhaps have elaborated on this and similar research avenues in the article. Thank you for bringing attention to this issue.
Opioid medications, although controlled and functionally inaccessible, are legal medicines in all countries. With few, well-evidence cannabinoid medications approved for use, and only in a handful of countries, it’s unlikely that fighting to approve members of a controversial drug class of questionable efficacy for many medical indications is the best way to bring pain relief to patients in developing countries (It could be incredibly effective if generating widespread acceptance of cannabinoid medications, through a long causal chain, ended up driving more rational controlled substances policies. But this is far from a neglected and tractable cause).
For the above two reasons, the movement to increase access to opioid medications has historical precedent on its side and solid expert consensus on their efficacy (even if their dangers are debated). It seems that they comprise an essential component of the best solution (however imperfect) to the gross deficiency of analgesia in the majority of contexts globally. But you’re correct to highlight what may be the least explored part of the analysis.
Hi Austen,
Thanks for all your interest!
I would have to disagree on your point about corporate influence. Pharma has been implicated heavily in the current opioid epidemic in the States and elsewhere. See the John Oliver expose for a light introduction (link above). In this area, if anything, there is even more reason to be wary of pharma influence because the product is so addictive when misused. Pharma does do some positive work—I’m aware of a BMS-funded training hospice in Romania (Casa Sperantei). I’ve only heard good things about it.
You’ve hit on an accepted strategy for promoting pain relief access/palliative care. One only knows one has succeeded in making a MoH care about the area when it does something about it, such as developing a policy. The ‘public health approach’ to increasing access to pain relief/palliative care, supported by WHO, recognizes policy as the foundation on which other progress can be built. Without it, success in other areas of the approach (namely medicine availability, education, and implementation) is much less likely. Kathy Foley and colleagues introduce the public health approach here http://www.jpsmjournal.com/article/S0885-3924(07)00122-4/pdf
Regarding tractability:
The issue is likely to be more tractable in some countries than in others, and so it’s hard for me to give anything but a range.
I’m adding retrospective justification for my choice of low-moderate tractability here, but compare this cause to similar ones assessed by 80k. The scores given to them according to their scoring matrix are: Smoking in the Developing World − 3⁄6; Health in poor countries − 5⁄6; Land Use Reform − 3⁄6;
(Where 3 is “Some possible ways to make progress, with significant controversy; Significant uncertainty about how to approach, solution at least a decade off; many relevant people don’t care, or some supportive but significant opposition from status quo.”)
Judging by the rest of the scoring matrix I think a range of 2 − 3.5 in most countries is appropriate, which roughly correlates to low-moderate in my book.
So I think I would stand by my choice of low-moderate. I probably a proclivity for pessimism so perhaps I’m not being generous enough about its solvability here. The problem may be highly tractable in some countries but I feel that to recognise it in the range would misrepresent the issue. As for Wisconsin, I would hesitate to proclaim its effectiveness before more specific analysis. So even if they only spend 15% of their time on it, that may not mean much in terms of tractability or neglectedness. It does seem promising though.
Other funding: There are reasons other than politics that PEPFAR may not have chose to fund palliative care measures. Preventive measures may just be way more cost effective in the long run. I haven’t looked closely into it.
An area where palliative care is of growing interest is in multidrug resistant TB.
Hi Austen,
Just to clarify, I’m not trying to promote or demote the cause. I’m aware that the cause is of interest to some EAs, and as someone in a good position to inform them, I thought something like this would help them make their own judgement :) I’m just sharing info and trying to be impartial.
Sorry if I my comments gave the impression that I thought it was low priority and financially inefficient. To reiterate I’ve withheld strong judgement on its priority, and I said I haven’t looked into its financial efficiency compared with other interventions. Because its importance/effectiveness depends heavily on ethical value preferences, both of these question are hard for me to take strong stances on.
My apologies for seeming contrary here, but I’m not taking an anti-corporate stance either. I made those points because the way you had originally put it made it seem like you believed that access to pain relief was unique in that corporate influence didn’t carry much risk compared with other causes. Unfortunately, it isn’t so. Of course pharma involvement is essential, yet the history of this very cause illustrates the risks. I’d agree with you that lack of corporate involvement is the missing link in some aspects of increasing access, but we should both be specific about the sectors we’re talking about to avoid appearing broadly pro-corporate or anti-corporate, which we both agree is unhelpful.
I haven’t got a wide enough grasp of the palliative care movement to say if it suffers from an anti-corporate agenda. ‘Global health’ in general tends to be pretty anti-pharma, and it’s hard to argue that the short-term externalities of the existing capitalistic model of drug development and production favours the ‘Global health’ agenda over the agenda of ‘health in the developed world’. So Global health’s culture of being anti-pharma is at least understandable, even if it relies on discounting the potentially-positive long-term externalities of the capitalistic model. It’s hard to say if access to pain relief/palliative care is more antagonistic to pharma than the rest of Global health. If it is suspicious of opioid manufacturers being involved in other aspects of the movement such as policy, then, without being too SJW, I actually think they actually have good reason to be so, given the history.
Thanks for those links. It’s troubling to hear about some of the promotional techniques described, though I can’t say it’s surprising.
While US regulations have been developed decades before their equivalents in many developing countries, it’s not necessarily a mark of quality. In the article I refer to less desirable idiosyncrasies of the US health system (i.e. aspects of the consumer-based model; pain as a fifth vital sign), which have exacerbated the crisis there and will not necessarily exist in some developing countries. Yet, while I hesitate to paint all developing countries with the same skeptical brush when it comes to developing adequate regulations, I agree with you more than I disagree. I say that a small amount of adverse outcomes are almost inevitable, and it’s really difficult to judge where the positives outweigh the negatives.
I still think expanding access should be part of the strategy. The approach promoted by WHO, UNODC, INCB, is to aim for a ‘balanced in policies on controlled substances’. The trouble is that countries are all too keen to control the downsides of using narcotic drugs at the expense of the upsides. So I think that what you’re suggesting may already be the approach being taken, but the emphasis needs to compensate for states’ existing imbalance.
And what you’re doing sounds interesting! Feel free to post links
Hi Tom,
Great to hear that it’s been suggested. By the looks of it, it may be an area better suited to an Open Philanthropy Project-style approach, being primarily a question of policy and having a sparser evidence base and impact definition difficulties. I styled my analysis around OPP’s approach (with some obvious shortcomings on my part).
I could have done better in the analysis to distinguish between the various types of pain. As you say, they are not trivial distinctions, especially when it comes to treatment with opioids.
I’d be interested to hear your take on the impact of pain control on the nature of medicine and the doctor-patient dynamic. What trends are you concerned about hastening exactly?
Indeed. And essay competitions are not like examinations; plagiarism only needs to be detected in potential winners and can be achieved by googling fragments of the essays.