Dear HIFA colleagues,
Below are the citation and extracts of a letter from Nick Stepney (former HIFA volunteer) and Nishanth Shaji, and a comment from me.
CITATION: Complicating opioid access in global health
Nick Surawy Stepney & Nishanth Kunnukattil Shaji
Lancet Global Health 2025, Volume 13, Issue 6e990 June 2025
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(25)00175-5/fulltext?dgcid=raven_jbs_etoc_email
EXTRACTS
LMICs account for 80% of what it terms serious health-related suffering. The relative absence of opioid analgesia is a key component of this problem...
Although global health efforts to increase opioid availability for palliative care are essential, we draw on our anthropological research with oncologists and palliative care specialists in India to suggest that this framing risks missing the deeper economic, historical, and social reasons opioid analgesics can go unused...
Our first point is that the language of opioid access pushes us towards a very narrow conception of the role of economic context. Morphine is an opioid drug long out of patent and so very cheap. That cost is no longer a barrier to use has therefore been suggested.3 However, what the continued low levels of morphine consumption in northern India show is that its price remains a central impediment, albeit in the opposite way to that usually imagined.
Since India's economic liberalisation in the 1990s, the health-care landscape has become highly commercialised. For corporate hospitals and pharmacies operating in a competitive and insecure environment, morphine — a drug with a low price ceiling fixed by India's National Pharmaceutical Pricing Authority—actually holds little appeal relative to more expensive alternatives such as synthetic opioid patches (often buprenorphine or fentanyl). Within this marketised system of medicine distribution, the low cost of morphine incentivises its substitution for other opioids that are more expensive and so profitable, even if their cost places them out of reach for many patients.
Second, to what extent does it therefore make sense to talk about opioid access in the singular? Opioids are a diverse group of medicines... For several senior oncologists in the public cancer hospital in which our research was situated, to prescribe morphine was to communicate that treatment would only be palliative... Morphine can therefore indicate not continuing curative care but potential medical abandonment.
Finally, as health researchers and practitioners globally, we therefore need ways of understanding the avoidance of specific opioids that do not rely on ideas of misinformation or misconception (a third thread common to discussions of access)...
COMMENT (NPW): The decision on which opioid to give in any individual context is clearly multifactorial. This letter highlights the importance of profitability in selection of opioids, which favours the prescription of the more expensive newer opioids. An additional aspect is the influence of pharamceutical marketing. Pharma companies have the greatest interest in selling expensive newer opioids, especially where these are still under patent. It would be interesting to explore their current and past marketing tactics in India, and how this has effectively contributed to misunderstanding and misconceptions among prescribers and users. For example, for morphine to be regarded as 'potential medical abandonment' could well represent a triumph of pharmaceutical marketing to sideline this inexpensive drug in favour of much more expensive formulations.
There is also a parallel here with antibiotic stewardship and the overprescription of unnecessarily expensive and broad-spectrum antibiotics contributing to antibiotic resistance.
The issues of profitability and misinformation are intertwined.
Best wishes, Neil
HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: neil@hifa.org