September 19th, 2008

(A non-campaign post but may contain traces of ground-up wingnuts)

The world needs a massive expansion of opium production.


Credit Wikimedia, hi-res version available

Rachel Nowak, a New Scientist staff writer, 3 September, paywall:

Drug addiction and the ramifications of the illegal drug trade need to be dealt with. But there is another drug problem that arguably causes far more suffering but gets only a fraction of the attention: the chronic underuse of opiate-based painkillers in poor countries … Global consumption of these drugs has more than doubled in the last two decades as the alleviation of pain has come to be taken more seriously. Yet in the developing world they are hardly ever used. … M.R. Rajagopal, a palliative care expert .. [from] the south Indian state of Kerala, told the World Congress on Pain in Glasgow [in August] … that morphine reaches fewer than 1 per cent of Indians who need it.

Also in August, the 2008 World Cancer Summit in Geneva said the same:

Underuse of opioids condemns millions of cancer patients to suffer unnecessary pain. In many low-and middle-income countries access to opioid analgesics is extremely low or non-existent.

More along the same lines here.

The standard opioid for treating moderate to severe pain is morphine. In the form of laudanum, it was for 400 years the only drug in the physician’s bag that really worked. It is is still our friend when treatment fails, as it does at some point for all of us.

What are the numbers? Nowak, relying on data from the International Narcotics Control Board (INCB), reports that 80 per cent of the world’s population consume just 6 per cent of its morphine. The INCB, under a tough UN convention, administers a socialist, centrally-planned world market for medical opioids with rigid quotas for everything.

Run the thought experiment: what would demand be if every patient in pain in the world had the same access to morphine as patients in rich countries? I’ve just taken this year’s numbers for Britain and the USA from an INCB technical report and population data from Wikipedia:


Is American consumption extravagant? I doubt it. From the Big Pharma point of view, morphine is an uninteresting low-margin generic, that hardly deserves a marketing budget to boost sales. On the other side, there are a lot of factors making for under-prescription: legal red tape; the overblown fear that patients will become addicted (for dying patients and chronic sufferers, so what?); hostility to borderline euthanasia; the low prestige of palliative care; and simple lack of empathy. Does every post-surgical recovery room in these two countries automatically provide patients with self-controlled morphine pumps? I would guess that the lower British figure is down to lack of patient choice. Anyway we’ll take the two as defining a range of acceptable, if not ideal, practice.

Applied across the world, British and American standards of pain relief would require an increase in world morphine production of five to seven times. It takes about ten kilos of raw opium to produce a kilo of morphine. So world annual production of legitimate opium should grow from the current less than 3,000 tons to between 16,000 and 23,000 tons. Hence my 20,000 tons of opium headline.

Afghan production of opium – all illicit – is around 4,000 tons. What this creates is a huge policy opportunity: pain relief for the poor, an economic way forward for Afghan poppy farmers, and a good blow at the Taliban’s support.

The USA would not have to pay for all of this. India and China say could pay for their own shares. Rich countries would however have to pay for most of the supply boost in sub-Saharan Africa. The rough production and delivery cost of morphine delivered to the bedside is 1c per mg, so $10m per tonne. A programme donating 500 tonnes a year to Africa would only cost $5bn a year – plus probably larger costs in training and security. The problem isn’t finding the money, it’s getting all the policy ducks in a row. There are many ways a scheme like this could go wrong.

Licit opium growing is carried on today in well-policed countries like India, Turkey and Australia. If you were a Kurdish peasant In Anatolia with a valuable opium quota, would you think it a clever idea to grow a bit extra to sell on the side to drug dealers? Me neither. The ideal in Afghanistan would be a similarly watertight setup, with flinty Turkish MPs in every village. At the other end of the security scale, you could just send in agents with bags of money and armed guards to buy up the crop. Whether that would cut or increase illicit production depends on the elasticity of supply, a number I don’t have. Somewhere in between is the least leaky scheme actually attainable. I would fly village elders, imams, and go-ahead farmers (see an African model here) to visit Indian and Turkish villages to see how it’s done. I’m sure Afghans, like us, would rather earn a secure living honourably than live dangerously off criminals.

The risk of leakage from expanded medical production into illicit channels raises a moral issue as well as practical ones. How far are we prepared to ignore the pain of millions of people dying from cancer in order to reduce a smallish plague of drug addiction in rich countries? I think you would need very strong evidence that crop-burning reduces addiction before even considering this trade-off; and the evidence isn’t there.

The Obama administration should take a close look at this complex of issues. I’ve one practical suggestion: give the lead to the public health people and counter-terrorist development guys, sidelining the blinkered drug warriors.

PS: Campaign check

Obama website:

Barack Obama would increase U.S. non-military aid to Afghanistan to $3 billion. This aid would fund reconstruction, police and army training, embassy operations, and local projects including efforts to impact the lives of ordinary Afghans and to give farmers alternatives to growing opium poppies.

Not bad but still thinking inside the old box.

McCain website: you must be joking.

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