Allaying fear of addiction: the main barrier to access to pain medicine in the world

Fear

As preparations begin for the United Nations General Assembly Special Session on Drugs, I address fear-driven opioid policy and calls for integrated education on pain and dependence, and improved clinical practice for both.

Fear of diversion, abuse, and addiction actively conditions the scarcity of medical opioids in most countries.

Palliative care advocates often choose to distance themselves from ‘drug policy reform’ debates about national and global efforts to control and reduce the harm of illicit drugs. Indeed, many see people who use illicit drugs as ‘the problem’ that hinders legitimate access to opioids for pain relief.

Yet the challenge of improving access to opioids for palliative care is joined at the hip with drug policy reform and law enforcement. Fear of diversion, abuse and addiction actively conditions the scarcity of medical opioids in most countries. The same fear or – more accurately – phobia, has a chilling effect on medical education and results in stigmatisation and negative public health outcomes for both palliative care patients and people who use drugs who need to access treatment.

According to the International Narcotics Control Board (INCB) survey of countries where access to controlled medicines such as morphine and methadone is low-to-inadequate, fear of addiction is the main barrier to access. The scream Munch depicts in his famous painting can be seen to aggregate the screams of the millions of people whose doctors cannot or will not prescribe morphine or other painkillers because decades of fear have configured systems of law, education, medicine and culture, wherein fear of diversion, ‘abuse’ and addiction trump the ethical duty to relieve avoidable pain and suffering.

The fear-driven paradigm deprives more than 80% of the world’s population (5.6 billion out of 7 billion) of access to opioid medicines for pain, palliative care and dependency treatment. These people literally pay the price of this socially and politically generated fear with their lives, the quality of their lives, and their families’ and communities’ copathetic pain and suffering.

This fear-based approach to pain relieving medicines derived from ‘narcotic drugs’ – read opium poppies that have been used as medicine for millennia – is based on the 19th and early 20th century experience of European and US missionaries in China and the Far East who witnessed the deliberately induced ‘epidemic’ of dependence created or supported by their own governments (Great Britain and the US for the most part). Opinion leaders feared that the corrupting effect of ‘oriental’ opium ‘addiction’ would spread to the respectable middle classes in their home countries. There is a prolific literature on this, and many primary sources are archived at the World Council of Churches Ecumenical Centre in Geneva, where I have spent many happy hours of research.

But that was then, when there was no evidence-based addiction medicine as we know it today. Concepts such as ‘prevention’, ‘treatment’, ‘tolerance’, or the titration that is intrinsic to palliative care were unknown. Any and all use was stigmatised as ‘addiction’. That day and age was pre-HIV/AIDS, pre-injection drug use, and pre-palliative medicine. The only remedy at hand, to the social reformers who wanted to abolish the scourge, or ‘evil’ of addiction as they called it – since it hampered their missionary activities in the far reaches of the Empire – was what is now known as ‘supply control’. Supply control means literally eliminating all sources of narcotic drugs on the planet, except for the amount needed (an imaginary number in the early 20th century) “for medical and scientific purposes.” Resulting policies generated the model of forced crop eradication, punishment, and military policing that is popularly known as ‘the war on drugs’, creating large black markets, violent trafficking cartels, overflowing prisons and so on.

Three decades after the international treaty regulating narcotics was drawn up at the United Nations, we have relatively accurate data: The World Drug Report, published every year by the United Nations Office on Drugs and Crime (UNODC) estimates the number of people who have used an illicit drug in the past year is 243 million. The number of ‘problem drug users’, people who need opioid dependence treatment, is estimated at (an annually stable) 27 million, out of a world population of more than 7 billion. And globally, the number of people needing treatment for dependence disorder relative to availability mirrors the unmet need for palliative care: at least one in ten.

There is no need to fear the prospect of generalised dependence disorder as did previous generations. There is wide-ranging agreement about what causes it, how to identify it, and how to prevent it. However, the policies are severely lacking. We now know how to alleviate severe pain and symptoms resulting from cancer, terminal AIDS and other disorders. Again, appropriate policy lags behind palliative medicine’s rapid development as a recognised specialty. Morphine is cheap, easy to produce, and scarce. Yet countries like Uganda and Indian states like Kerala manage to subsidise it and teach their pharmacists to reconstitute morphine powder for the needs of their citizens.

Institutionalizing palliative care knowledge and practices more widely, alongside evidence-based prevention and dependency treatment, will dissipate and displace the fear generated by the old paradigm of the ‘evils of addiction’. Expanding clinical education about pain and dependence, and integrating both practices into primary healthcare are pragmatic first steps.

The new paradigm of global palliative care is responding to fear by demanding appropriate national and international institutions. You don’t have to be a Christian to subscribe to the notion that “God hath not given us the spirit of fear; but of power, and of love, and of a sound mind” (2 Timothy 1:7). You can be a humanist, an atheist, even an evolutionist to help midwife this new paradigm into being so long as you can synthesize love with a sound mind and good clinical skills.

The cosmic dance: being for and of the world as delusion

Being for the world as delusion, for love of the world: the dance as God

I wrote this essay while reading Dietrich Bonhoeffer’s (DB’s) ethics of Christian imperative of participating in the world, in the context of the my personal tantric view of the “outside” world as we perceive and act in it as a projection of our minds, delusion, ignorance, etc.

Since I totally get that perspective, why am I participating so deeply in the world, and if I am going to continue interacting with it, how can I do it better and more successfully?

Perceiving and reacting to “the outside world” as reality rather than seeing it as delusion and projection doesn’t mean that freedom from the world somehow mitigates the effects of the delusion. Our delusion persists whether we work in the world or not — the question is how much damage we do when we engage without awareness, or withdraw into a state of narcissistic awareness, another delusion.

There seem to be degrees of delusion, hierarchies, though! According to DB, to Kuan Yin certainly, the suffering of the world entails action and engagement. But how do we engage ethically with delusion? That has to be a contradiction in terms!

Just as people, usually out of ignorance, built worlds from negative, destructive delusions, people can also, from a place of awareness and intentionality, reprogram our common, perceived reality, to more closely resemble the Kingdom. First we have to reprogram ourselves, though: download the divine software so to speak.

The strong challenge is always the temptation to identify ourselves with our perception of the world as it appears in our thoughts and desires. When we do that, we miss the connection with inherent, non-dual reality, that is the source of compassion.

The pathology of consumer, market driven society is that it tempts us to disassociate from that non-dual reality. Or has it always been so? Dogen said, “how could you waste your time delighting in sparks from a flint stone?” And that was back in the 13th Century!

Neo-liberal corporate/consumer culture intentionally and relentlessly urges people to delight in the sparks, to identify with our desires. I am my desires. I burn with them.

We may perceive there is less space to make a choice to identify or not. But we still do have that choice and that space, we just have to practice awareness of our thoughts and desires…especially the very charged ones like passion and aversion.

Jesus did give the world a model of resistance to false identification, and a free choice to love God in ordinary people, in everyone, from the leper to the centurion.. And Buddha gave us the method of training the mind, the noble eightfold path.

I need both, because J’s method of Kenosis, love, metanoia, love, is a tough feedback loop for those who live in their heads! Getting into it is easier said than done, and most people in today’s world at least need to suffer a lot before they can surrender like that.

Then it is hard to see it as voluntary self-giving except by some extraordinary souls like Simone Weil, Etty Hillesum, and DB of course, just to name some recent examples, although of course the community of saints is crowded with them.

DB, like Ignatius, was convinced that God is in the world, even making the strong existential claim that God is the world. DB’s ethics was that the Christian, the church, should be fully engaged in the world in order to live the Gospel and Jesus did.

This comes back to indifference though — but indifference to ends, not to process and means. Process can be deeply passionate, can lead to martyrdom, etc. Can we be deeply passionate about the process, but not attached to the ends?

The attachment to ends contaminates the free development of the process. I’m not sure why that is, except perhaps that it diverts attention from the present moment, which is the source of all knowledge.

This doesn’t mean, of course, that we shouldn’t have an idea or a vision of what the ends should be or might look like. Jesus was very clear about the Kingdom of God being a “free for all,” with a welcoming, open door policy.

But the process is the path. Our attitude to our neighbour is the path. The ends are the means, as L said. It’s not about either “justifying” the other.

This is what the Tibetan/Indian iconography means by The Dance of Shiva/Shakti, the cosmic dance is a pretty universal symbol of non-duality. We participate in the dance passionately, erotically, with abandon — self-abandon, Kenosis, knowing that the participation in the dance of the World is The Kingdom.

That is the only way I can live and work — engaging with the delusion. Doing otherwise creates to much suffering, which unfortunately I am all too aware of, having received a visitation from Kuan Yin herself when I was nineteen. Kuan Yin’s thousand eyes and arms are always identifying and reaching out to offer what is needed to alleviate suffering.

If that is not activity for love of the world, I don’t know what is. We can envision that activity as our delusion just as we can join Jesus in envisioning the Kingdom, and thereby construct the sort of world God had in mind when S/he first created us.