The ecstasy and the agony

“PLEASURE is oft a visitant; but pain clings cruelly,” wrote John Keats. Nowadays pain can often be shrugged off: opioids, a class of drugs that includes morphine and other derivatives of the opium poppy, can dramatically ease the agony of broken bones, third-degree burns or terminal cancer. But the mismanagement of these drugs has caused a pain crisis (see article). It has two faces: one in America and a few other rich countries; the other in the developing world.

In America for decades doctors prescribed too many opioids for chronic pain in the mistaken belief that the risks were manageable. Millions of patients became hooked. Nearly 20,000 Americans died from opioid overdoses in 2014. A belated crackdown is now forcing prescription-opioid addicts to endure withdrawal symptoms, buy their fix on the black market or turn to heroin—which gives a similar high (and is now popular among middle-aged Americans with back problems).

In the developing world, by contrast, even horrifying pain is often untreated. More than 7m people die yearly of cancer, HIV, accidents or war wounds with little or no pain relief. Four-fifths of humanity live in countries where opioids are hard to obtain; they use less than a tenth of the world’s morphine, the opioid most widely used for trauma and terminal pain.

Opioids are tricky. Take too much, or mix them with alcohol or sleeping pills, and you may stop breathing. Long-term patients often need more and more. But for much acute pain, and certainly for the terminally ill, they are often the best treatment. And they are cheap: enough morphine to soothe a cancer patient for a month should cost just $2-5.

In poor countries many people think of pain as inevitable, as it has been for most of human existence. So they seldom ask for pain relief, and seldom get it if they do. The drug war declared by America in the 1970s has made matters worse. It led to laws that put keeping drugs out of the wrong hands ahead of getting them into the right ones. The UN says both goals matter. But through the 1980s and 1990s, as the war on drugs raged, it preached about the menace of illegal highs with barely a whisper about the horror of unrelieved pain.

American policy has been especially misguided. By keeping cocaine and heroin illegal, drug warriors have empowered criminal gangs that torture and kill. Even as American fee-for-service doctors overprescribed opioids at home, America spread its harsh approach to illegal drugs worldwide. Poor countries, scared of getting on Uncle Sam’s wrong side for not trying hard enough to control narcotics, have written laws even more restrictive than those recommended by the UN. One passed in India in 1985 saw legitimate morphine use plunge by 97% in seven years. In Armenia morphine is only available to cancer patients, who must rush from ministry to ministry filling in forms to receive a few days’ supply.

Opioids should be more widely available. That entails risks. One is addiction: doctors need training to minimise it. Long-term use is perilous; use by the terminally ill is not. Another risk—that the drugs will leak onto the black market—is real, but less serious than America’s example might suggest. Many American buyers of street opioids were first hooked by their doctors; other countries can avoid that mistake. They can also avoid the mix of fee-for-service provision and direct-to-consumer drug advertising that aggravated America’s lax prescribing. And they should copy Britain’s centralised system for prescription records, which stops patients from doctor-hopping their way to addiction.

Biting on a stick is not good enough

Above all, the global bodies that monitor narcotics should recognise that easing suffering is as important as preventing addiction. Forcing people in great pain to jump through hoops to get relief should be recognised as an infraction of international rules. The UN has, belatedly, started to talk of unrelieved pain as a problem. As the cause of needless suffering, it should be trying harder to bring solace.