By Rick Gladstone, New York Times

While Americans are confronting an epidemic of prescription drug abuse, particularly for addictive painkillers, the reverse problem prevails in much of the world.

Many ill people with a legitimate need for drugs like oxycodone and other narcotics known as opioid analgesics cannot get them and are suffering and dying in pain, according to health officials, doctors and patients’ rights advocates.

In Russia, India and Mexico, many doctors are reluctant to prescribe these painkillers, fearful of possible prosecution or other legal problems, even if they believe the prescriptions are justified.

In Kenya, health officials only recently authorized the production of morphine, one of the most effective drugs for pain relief, after criticism that it was available in only seven of the country’s 250 public hospitals. In Morocco, the advocacy group Human Rights Watch reported in February, only a small fraction of physicians are permitted to prescribe opioid analgesics, which the country’s law on controlled substances identifies as poisons.

And in most poor and middle-income countries, these drugs are restricted and often unavailable, even for patients with terminal cancer, AIDS or grievous war wounds.

The reasons include an absence of medical training, onerous regulations, costs, a focus on eliminating illicit drug use and, in some cultures, a stoic acceptance of pain without complaint. The problem has been amplified, public health experts say, by the stigmatization of the drugs, partly from fear of what has happened in the United States, where opioid misuse is a growing cause of death.

Reinforcing this view has been publicity about high-profile users like Prince, the pop star who died last month at his Minnesota mansion as friends sought help from an addiction specialist to treat what was apparently a dependence on opioid painkillers.

“While clearly there are issues with some prescribing practices, there’s also clearly a risk to vilifying these medicines,” said Diederik Lohman, associate director of the health and human rights division at Human Rights Watch.

In some countries, Lohman said, “a clerical error in a morphine prescription” can lead to criminal inquiries. “The fear associated with prescribing a medicine under strict scrutiny makes physicians afraid,” he said.

Afsan Bhadelia, a visiting scientist and palliative care expert at the Harvard School of Public Health, said “the biggest misconception” internationally regarding opioids was the need for tighter control.

“People do not have access to pain control for basic surgery,” she said. “People are going into the operating room and not having anyone mitigate their pain. It is a great injustice.”

Liliana De Lima, executive director of the International Association for Hospice and Palliative Care, a Houston-based advocacy group, said that global publicity about the American opioid epidemic “had brought this problem to the people, and that has had an effect on the fears.”

Despite international protocols dating back decades that entitle patients to pain relief and palliative care, access remains limited or nonexistent for many.

A report published in February from the International Narcotics Control Board, a United Nations agency, showed that most growth in the use of opioid analgesics has been in North America, Central and Western Europe, and Oceania. It remains low in Africa, Asia, Central America, the Caribbean, South America, and Eastern and Southern Europe.

“Many low-income and middle-income countries continue to fail to provide adequate opioid analgesic medicine for pain,” the report said.

Stefano Berterame, who leads the board’s narcotic control and estimates section, said officials in many of these countries attributed the shortages to the expense of the drugs and a lack of suppliers. He also said that in some Asian countries, pain relief through the use of opioids or other drugs was an alien concept.

“They believe you can sustain the pain, work through the pain,” he said.

The pain-relief problem was addressed by the World Health Organization in a report published in advance of a U.N. summit meeting on international drug policy in April, the first such review in nearly two decades.

“Ensuring the adequate availability of controlled substances for medical and scientific purposes,” the WHO said, was a commitment made by member states that had “yet to be universally achieved.”

It estimated that 5.5 billion people live in countries with “low or nonexistent access to controlled medicines for the treatment of moderate to severe pain.”

Dr. Dingle Spence, an oncology and palliative medicine physician in Jamaica, said that although opioids are available in her country, the supply is disrupted by so-called stockouts — demand exceeding supply — because of bureaucracy.

“There’s not enough understanding about timely ordering,” she said. “The amount of permits needed to bring them into the country slows down the timely flow.”

Still, Spence said Jamaica was fortunate compared with other countries in the region. In Trinidad, for example, she said officials refused to allow “the simplest type of morphine” for pain relief. “It seems to be they are bound by the opiate-phobia problem,” she said. "Here we are in 2016, all the advocates are still trying, and nothing has happened.”

Morphine consumption data from the International Narcotics Control Board, she said, tells part of the story. In 2013, the global average for 139 nations was 6.27 milligrams per capita. The only Caribbean nation above the mean was Barbados. In Jamaica, consumption was 1.63 milligrams; in the Bahamas, 0.24 milligram.

“That means there’s a ton of people in pain,” Spence said.

Felicia M. Knaul, an international health economist and expert in Latin American health systems, criticized what she described as a widespread overemphasis on the addictive risks associated with opioids. Although fear of opioids may be fed by American tragedies like Prince’s death, she said, strict regulations also are responsible for the pain-relief crisis elsewhere.

“It’s not that we shouldn’t be concerned about addiction,” she said, but “we basically have zero access in most countries around the world. You don’t go from zero to the situation in the United States.”

Knaul, a breast cancer survivor and global advocate of cancer patients, is chairwoman of the Lancet Commission on Global Access to Pain Control and Palliative Care, a group of experts created in 2014, in part to help integrate pain relief into health systems around the world. A major concern of the commission is the disparity between patients in rich and poor nations who have access to painkillers, which it called “an ongoing crisis that plays out almost entirely to the detriment of poor people."

In Mexico, a 2009 amendment to its health law that required hospitals to offer palliative care to terminally ill people was basically ignored for years, prompting Human Rights Watch to issue a scathing report in October 2014 asserting that “tens of thousands” of Mexican patients entitled to pain relief were not getting it.

Knaul, who has worked extensively in Mexico, said that there had been “huge improvements” there more recently, but that drugs for palliative care remained difficult to obtain in many remote areas. She said Mexico’s war on drug cartels had actually increased illicit use of opioids.

“The irony for a pediatric oncologist is that it’s much easier to buy on the street than go to a hospital,” she said. “That’s what people turn to when they don’t have the appropriate means available.”

To Learn More:

U.S.: 5% of World Population; 80% of Opioid Consumption (by Steve Straehley, AllGov)

U.S. Doctors Prescribe Opiate Painkillers at Twice the Rate of any other Country…and 500,000 Veterans are Dependent (by Steve Straehley, AllGov)