No Opiates for the Masses: Untreated Pain, International Narcotics Control, and the Bureaucratic Production of Ignorance

One morning in July 2013, a young man presented to a public hospital in the southern African nation of Malawi with a fracture of the femur. The patient, a manual laborer, had been digging the foundation of a new building at a nearby mission when an earthen wall collapsed onto his leg. Though the standard of care for such fractures in the United States involves opioid analgesics, the Malawian nurse who treated this patient used only acetaminophen for pain relief.¹ The young man complained of excruciating pain, but was given no other analgesic medicine.²

This patient’s case is not anomalous. While hospitals in the United States and Europe usually prescribe opioids for terminal cancer, bone fractures, sickle-cell crises, burns, and surgical procedures, patients in much of the rest of the world are frequently unable to obtain analgesics stronger than acetaminophen.³ According to statistics published in 2010 by the International Narcotics Control Board (INCB), a body created by an international treaty regime and based at the United Nations, the United States accounted for less than 5 percent of global population but more than 99 percent of the world’s consumption of hydrocodone, 80 percent of its oxycodone, and 55 percent of its morphine.⁴ To take a specific yet typical comparison between rich nations and poor, between 2007 and 2009 legal per-capita morphine consumption in the United States was approximately 412 times greater than in Malawi.⁵

What explains these vast disparities? The publications of the INCB posit a link between the lack of opioids in poor countries and their poverty. This statement, from a 2010 publication, is typical: “The level of consumption of opioid analgesics in a country is generally correlated with its level of socioeconomic development.”⁶ But while there is a strong correlation between national income and aggregate national consumption of opioids, it is misleading to suggest that poor countries either cannot afford to obtain or have inadequate health infrastructure to use these drugs. A 2007 article in the New York Times observed that a hospice in Uganda obtained a three-week supply of morphine for less than the cost of a loaf of bread.⁷

In other writings, the members of the INCB offer more reasons for the disparities; in their accounts, all fault lies within the countries with low consumption. A 2008 publication by former INCB President Hamid Ghodse attributed insufficient use of opioids for pain relief in poor countries to “lack of financial resources, inadequate infrastructure, the low priority given to health care, weak government authority, inadequate education and professional training, and outdated knowledge, which together affect the availability of not only controlled drugs but all medicines.” Ghodse chided “a considerable number of countries” that “continue to show no appreciation of the problem itself or of the relative ease with which efficient treatment may be provided.” In these statements and others, Ghodse located the problem in irrationally fearful physicians and overzealous national officials, all while discounting the unique nature of narcotic drug policy.

But narcotics are special; their absence in clinical settings is not solely attributable to problems with the availability of “all medicines.” The “misguided fears” and “outdated restrictive regulations” Ghodse lamented are in large part a legacy of the international narcotics-control treaty regime. Operating within discourses forged by late-nineteenth-century missionaries and Cold War propagandists, international agencies and the national legislators they influenced focused almost entirely on ending the illicit traffic in opiates, neglecting to ensure access to licit, medicinal derivatives of opium.

To be sure, the lack of opiate analgesics in hospitals and clinics in poor countries today is the result of a complex of pathologies, including a dearth of medical professionals and epidemiologists, fears of addiction, and regulations on importation and licensing.⁸ But this article will focus on the rise of the international narcotics-control regime at the United Nations because it is a fundamental and inadequately recognized cause of each of these problems. The history that follows does not chronicle deliberate acts designed to deny access...