Tractability

A major obstacle in many countries is the existence of Kafkaesque regulations that severely limit the ability of doctors to prescribe and of patients to acquire sufficient quantities of morphine. Each country has its own unique hurdles, in some cases clearly identified, in others less so. Invariably, political will to resolve the issue and establish effective strategies is key to achieving a comprehensive, sustainable solution. In some countries, local efforts to educate doctors in prescribing and administering morphine and, more generally, in palliative care can also lead to increased levels of use. However, in all countries with regulations that severely curtail the ability to prescribe or to obtain morphine, a change in government regulations is a necessary condition for significant scale up.

Persuading governments to change policies is possible, but it requires the right approach and some luck, which may also include good contacts in the government. It therefore remains a risky endeavour. However, the importance of the problem means that even, say, a 10% success rate of advocacy campaigns in several countries would still have high impact.

General awareness of this issue remains low among the general public worldwide. Awareness campaigns including social media and outreach to journalists have the possibility to raise interest.

It is also important to note that impact in this cause area is systemic and sustainable, as it changes the operating rules and capacity of the medical system, thereby ensuring the alleviation of suffering of patients in the future as well (on the assumption that the cost of medicine is covered). This is the case even for changes that may require a few years to be implemented and rolled out, such as the establishment of new education and training programs.

Again, the actual cost of the morphine itself is not a significant obstacle. Morphine is relatively cheap, and although lower income countries typically pay 4 times the lowest international bulk prices, the cost of a 30-day, 100 mg/day treatment would be about $36 at current prices (ca. $0.0120/mg; $9 at the lowest international price of ca. $0.0030/mg; calculated from Lancet Commission report figures). Furthermore, as regulations are relaxed and prescriptions are increased, it will also be easier to justify international health spending to help cover the cost of morphine, such as a World Bank-led fund, as proposed by the Lancet Commission. The report estimated the total cost of meeting the global shortfall of morphine for palliative care at $145 million at the lowest international prices – more than 99% of this in LMICs, and representing only 0.009% of healthcare expenditures in these countries.

It is entirely plausible that a focused, multi-pronged campaign in any one country, especially in collaboration with an ambitious local partner, could help to persuade a government to seriously address the issue of morphine access, revise regulations and legislation, and promote medical training. These kinds of advocacy projects appear to be rare and would represent not just an increase in resources but the use of resources for neglected activities. A doubling of resources in any one country for a period of several months might therefore be expected to solve 1-10% of the problem in that country, giving a tractability rating of about 4 or 5 according to the 80’000 Hours scale, or low.