In common with other natural disasters, pandemics increase demand on healthcare, including the care of people who are dying. Opioids and benzodiazepines are effective medicines for palliating symptoms at the end of life and it is our moral responsibility to ensure everyone has access to them.
In 1961 the world formally recognised that controlled substances such as opioids and benzodiazepines (often referred to as narcotic drugs) are “indispensable for the relief of pain and suffering”. Almost all UN Member States adopted The Single Convention on Narcotic Drugs, calling for adequate provision and availability of controlled substances for medical and scientific purposes. Over sixty years later and more than 80% of people in the world who need these medicines still cannot access them.
COVID has become another factor perpetuating unnecessary suffering and lost dignity at a time of greatest need.
Sadly, lack of access to controlled medicines was “usual state” at the start of the pandemic, a terrible situation to be in when faced with a pathogen that caused millions to die of acute respiratory distress syndrome, characterised by breathlessness and often agitation (Keeley et al, 2020). These distressing symptoms can be effectively managed at the end-of-life with opioids and/ or benzodiazepines (National Institute for Health and Care Excellence, 2023). This accepted, evidence-based practice was swiftly published into guidelines early in the pandemic but guidance is meaningless if the medicines recommended are unavailable. Controlled medicines have merely been added to the list of stockpile and supply-chain issues, along with PPE, vaccines, equipment, ventilators, hospital beds and an appropriately trained workforce.
… healthcare services, governments and humanitarian agencies must take a coordinated approach to implementing effective disaster planning and having adequate supplies to anticipate shortages of human and medical resources, to ensure universal access to effective end-of-life care can be realised.
END-OF-LIFE CARE IN NATURAL DISASTERS INCLUDING EPIDEMICS AND PANDEMICS: A SYSTEMATIC REVIEW, Kelly et al 2023
This is deplorable in a world which has agreed to do better.
The Sphere group of humanitarian, non-governmental organizations explicitly acknowledges the right to basic conditions for life with dignity in their Humanitarian Charter and WHO guidance Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises dedicates a chapter to the Essential Pack of Palliative Care (EP Hum), recommending medicines including morphine and diazepam. And yet, as of March 2023, palliative and end-of-life care does not appear in the text of the Zero Draft of the WHO CA+ on pandemic prevention, preparedness and response. Furthermore, there are more references to the development of new medicines in this document than making existing, evidence-based and effective ones available (3 vs 1 respectively).
Even in countries with good access to controlled medicines and palliative care, many patients dying with COVID have not felt their benefit.
People with life-threatening and chronic disease, due to their particular needs, should be included in the design of policies and plans to manage their risks before, during and after disasters, including having access to life-saving services.
sendai framework for disaster risk reduction 2015-2030,
UN office for disaster risk reduction
Despite clear guidelines and supporting policy, one multi-centre study in the UK found that opioids and/ or benzodiazepines were administered to palliate fewer than one third of breathlessness episodes in the terminal phase of COVID (Reid et al, 2021). How can this be? Local and national policy changed rapidly in the face emerging data about COVID. Staff were redeployed at short notice to unfamiliar settings, procedures altered and temporary legislation introduced – all factors relevant to prescribing, dispensing and administration of controlled medicines.
The experience of palliative care in humanitarian and emergency situations attests that none of the above is unexpected. Anticipating the inevitable increase in demand for controlled medicines in response to health emergencies is essential, as is preparing staff for the challenges they may face.
The Pandemic Accord affords the world an unmissable opportunity to finally make good the promise of the Single Convention on Narcotic Drugs agreed in 1961 and to learn lessons from all the health emergencies – including the COVID pandemic – that have gone before.