Saturday, March 5, 2011

Pain relief and opiates--or the lack thereof

Opiates like morphine or fentanyl are in short supply here in rural Indonesia. Our clinic treats patients who suffer from acute or chronic pain with a mixture of ibuprofen, acetaminophen (paracetamol), and occasionally codeine. Friends who have worked in Uganda and other developing countries tell me the situation is similar there. The lack of opiates condemns many end-stage cancer patients to a nightmare existence.

The International Narcotics Control Board, a United Nations drug organization, recently issued a report decrying the lack of availability of narcotic pain medications in many parts of the world, and argued correctly that such drugs should be considered indispensable in medical practice. Inadequate policies and regulatory constraints are among the reasons why many countries have made pain relief a low priority. One of my American colleagues once opined that that's because some cultures believe in the sanctity of suffering. I don't know enough about Islam to know if that's the case here, but Mother Theresa seems to have believed that, at least when it came to other people's.

But  the relief of suffering is at the heart of medicine. If prevention and cure fail, or when there's a delay before a treatment takes effect, there is palliation. At the very least, a health care worker ought to make a patient comfortable. I've never been as glad to have morphine in my toolbox as I was when I took care of a little kid in my ER in the US who had been severely burned and needed to be transferred to a burn center. He was fully conscious, suffering pain few of us can imagine, but we pulled him out of the depths of hell with large and repeated doses of morphine. His agony subsided even as he remained awake, and watching his transformation from tortured to calm made me feel a near-religious sense of gratitude to have been able to do that for him. I think about him from time to time and hope he enjoyed his helicopter ride, at least a little.

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