Pain and lack of opioids, a hidden reality

At his short 8 years of age, Toño could describe how it is the most excruciating pain that anyone can imagine. A cancer that started in his intestines spread to his bones and throughout his body; his lower limbs no longer responded but they did hurt unbearably. He said it was like a hammer drilling inside him. He stopped walking and being already a very advanced metastatic cancer there was no hope of being able to recover. At the National Institute of Pediatrics, where he practically lived for months, the doctors spoke with his parents and estimated that he would have 1 to 2 months to live. They recommended taking him to his house -they are from the mountains of Puebla- so that he could enjoy the last weeks of his life with his family.

They gave him a strong opioid for only one month and the next they had to return for a new dose that would help Toño with his pain and have at least some quality of life.

In the hospital’s pain clinic, he was lucky enough to be treated by the anesthesiologist Jenny Alexandra González Santander who, as a pain interventionist, is clear that in principle you have to believe the patient, and resort to everything that is needed to alleviate their pain. She decided to give him fentanyl, an opioid that is the most used by drug traffickers but that in the form of medicine is most useful for severe pain. Parents’ biggest fear is usually that their child will become addicted. In this case there was no such concern because the most important thing was that Toñito have a certain quality of life in his last days. The good thing was that this time he was in the hospital, because it is common for these drugs to not be available, and family members often have to buy them.

The problem is that the regulation does not allow these controlled medications to be given for more than a month. For Toño’s parents it was impossible to return to Mexico City. They were given the child’s medical history to try to get the fentanyl from the health center. But the same doctors know that in these cases it is easier to get it among drug dealers. A reality that many people face living with pain.

Another problem is that in Mexico there are no authorized opioid drug molecules for pediatric patients. “If we want to give a fentanyl tablet to a minor, we have to break it down in a rudimentary way or if it is morphine, we have to dilute it and sometimes there are inaccuracies in the doses,” says Dr. González Santander, who for Toño diluted the morphine by means of craft maneuvers with good results.

Opioid treatment can cost between 2,000 and 4,000 pesos a month, an amount that not all families can cover. The recommendation of experts is to cover the need as much as possible with immediate reaction oral and injectable morphine that is off-patent and, therefore, cheaper. This removes the incentives of big pharmaceutical profits. But for this, order and strategy are needed in public purchases. Generic morphine in 30-milligram tablets in Mexico can be had for 160 pesos. Of course, for very severe pain there are much more powerful versions of opioids.

Another problem, according to specialists consulted, is that in the current regulation there is no balance: there is greater concern for controlling opioids than for guaranteeing their availability for therapeutic purposes. Opioids represent so much the daily violence caused by crime and drug trafficking, that the fear of consuming these drugs has been exalted too much to the point that it is forgotten that there are narcotics indicated for pain treatment. It is true that they are highly addictive and can cause undesirable side effects, but when used properly they give patients quality of life.

Chronic pain affects between 25 and 29% of the world population, motivating 15 to 20% of medical consultations. The World Health Organization (WHO) recognizes it as a public health problem. In Mexico we lack statistical information that allows knowing the impact of chronic pain in the general population. The segment that suffers the most pain is that of adults over 50 years of age; there are estimates that 4 out of 10 report pain, and it is more frequent in women.

For those who live with pain, the consequences are innumerable, among others: it affects their mobility, their ability to eat, concentrate, sleep, and interact. One in 3 people with serious ailments cannot have a normal life. Chronic pain is a leading cause of absenteeism from work and disability, generating enormous costs for any economy.

In addition, the pain generates psychological consequences that can be quite profound. The WHO has reported that those who live with chronic pain are 4 times more likely to suffer from depression and anxiety. Most adults who need pain medication have chronic diseases such as cardiovascular, cancer, respiratory, and HIV. Hence, palliative care aims to relieve suffering and improve quality of life for patients.

More Papists than the Pope

In this framework, however, it seems that the problem of pain is ignored and that it hides behind the door. The lack of opioid medications for severe pain in Mexico has been historical in the vast majority of Latin American countries. Faced with the reality of abuse and increasing deaths from overdoses in the United States and Canada, Latin American countries have become more papist than the pope, and we defend the fight against illegal drugs and addictions to such a degree that we end up limiting drug coverage too much effective legal services for patients who suffer pain and end up dying without adequate palliative care.

In this regard, we interviewed Felicia Marie Knaul, Ph.D. in economics, lead author of the Lancet Commission Report issued in 2018 “Closing the gap in access to palliative care and pain relief, an imperative for universal health coverage”, rated as a historical report that, among other things, revealed that almost half of the deaths that occur in the world do so in situations of extreme pain, something that could be preventable.

In that report in the British scientific journal where special emphasis is given to the issue of inequality and inequity, it was calculated that in 2015 the legally imported opiate for medical purposes in Mexico was enough to satisfy only 35% of the need for palliatives alone. That without considering other needs such as pain related to surgeries and trauma, and without being sure that they really reached the patient. Dr. Knaul shares with us that they are already working on a new updated report on the subject and what they are detecting is that instead of improving the situation, it is getting worse: the Mexican demand for medicinal opioids would have been reduced from 35 to a level of 20% of what is really needed.

We are going from bad to worse

As part of this phenomenon is the decrease in permits for medical and scientific use that the country requests from the International Narcotics Control Board (INCB). It must be said that as part of the international controls to combat drug trafficking, the management of these drugs is very sui generis, since each country requests permission from this United Nations unit to legally import a certain amount of drugs for controlled drugs; It should be based on medical demand but it is not. The point is that each year the quantities requested would have to increase, given that the growing demand is natural due to the epidemiological transition itself and the incidence of certain diseases that cause pain, such as cancer. And instead, the petitions from Mexico and other countries before the INCB have been decreasing. I mean, we’re going from bad to worse.

In the INCB there is already awareness that in LA there are countries like Mexico that have had a lack of opiates for years and groups of experts have been formed -in which Dr. Knaul participates- trying to think about how to help the INCB achieve a balance.

In the past six-year term, work was done with the health regulator Cofepris to promote electronic prescriptions as a way to encourage doctors not to be afraid to prescribe opiates and other controlled drugs, and at the same time have traceability of prescriptions to control that no doctor abuses of the prescription. It was said then that it was the best way to increase access but without excess.

In the current administration, this program has not been continued and, moreover, there have been setbacks in the national production of morphine. The Grupo Pisa laboratory in Jalisco was the only one that imported the drug, recombined it and produced medicinal morphine to supply the public system at affordable prices, but in the midst of the declared fight against corruption, the company was disqualified. The authority had the idea that they would be able to buy it easily in another part of the world, but this has not been the case and since 2020 it has been one of the molecules with supply problems.

Expenditure for pain, in a tailspin

Consequently, not only is there not enough to cover the need, but the supply of these drugs is declining. According to the Pharmaceutical Institute of Mexico (INEFAM), in public purchases of medicines, the therapeutic group of palliative care and pain had a strong contraction between 2016 and 2021. In amounts, it was reduced by 45%, going from 4,046 million pesos that added the purchase of this group in 2016 to 2,789 million for 2021. And in the most important thing, which is the number of pieces, the drop was 40% in 5 years; from 1,539 million pieces purchased in 2017 it dropped to 1,003 million pieces in 2021.

Enrique Martínez, general director of Inefam, specifies that the pain segment represents 5.28% of the total public purchases of medicines, but it should rise to 7% of the total, this implies investing at least 1,000 million additional pesos in acquisition of these medicines. to fight the pain for years to come.

The origin of everything is that there is not the demand as it should be due to opiophobia: there is prejudice and fear of the doctors themselves to prescribe opiates. For there to be greater sensitivity and awareness, there is a need for more training on pain management among doctors and nurses. Dr. Silvia Allende, from the Palliative Care Clinic of the National Cancer Institute (Incan), says that there should be no graduate doctor or nurse without at least one course in palliative medicine and pain control. “In the genesis of the doctor and nurse there is no vision of how to diagnose and treat your patient’s pain, and they arrive at hospitals of lineage using tamizol and paracetamol, they are not interested in treating pain as a starting point to approach the patient with quality”, he warns.

The president of the Mexican Association for the Study and Treatment of Pain (AMETD), Dr. Rocío Guillén, agrees, commenting that all doctors are well trained to attend to the beginning of life but not the end. They know how to attend a birth, but in the face of death there is no awareness of avoiding the patient suffering at all costs.

Another lack is that Cofepris authorizes a broader range of pain medications according to the type of our population. But for this, greater demand is required; Here, greater participation of patient associations is necessary.

Pain management is a very sensitive issue, but due to its complexity and lack of understanding, we end up setting it aside. The saying goes that you don’t die of pain. What is a fact is that uncontrolled pain sure takes away many lives.

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