Political Economy and Moral Crusades in Early International Narcotics Control

At the dawn of the twentieth century, American and European observers concerned with the health of populations overseas focused not on the dearth of opiates in faraway lands, but on the colonial role in creating and feeding opiate addiction. Twice in the nineteenth century (1839–42 and 1856–60), Britain waged war against the Chinese emperor with the aim of prying open a lucrative market of opium consumers.^{Footnote 11} Within their respective Asian empires, Britain, France, Portugal, the Netherlands, and Spain each controlled monopolies on the sale of opiates.^{Footnote 12} While colonial officials claimed these monopolies were intended to control the flow of drugs, the revenues they garnered made them pillars of colonial finance.^{Footnote 13} In 1905–6, opium sales were responsible for 16 percent of tax revenues in French Indochina, 16 percent of tax revenues in the Dutch Indies, and 53 percent of tax revenues in British Malaya.^{Footnote 14}

The United States became a champion of narcotics control only after vacillating about its own inherited opium monopoly. In 1903, four years after the U.S. had taken control of the Philippines at the end of the Spanish-American War, Civil Governor William Howard Taft ordered the reinstitution of a government monopoly on the archipelago, arguing that profits could be used to finance education for Filipinos. But President Theodore Roosevelt ordered Taft to abort this plan after missionaries in Manila and the United States voiced their objections, and in 1905 the U.S. Congress ordered the prohibition of opium use in the Philippines (with a three-year grace period for non-Filipinos).^{Footnote 15}

After issuing this order, Roosevelt sought to turn the United States’ newfound prohibitionist position to its material advantage by aiding a Chinese government besieged by foreign powers selling opium. American industrialists were particularly keen to curry favor with China after reports of discrimination against Chinese immigrants in the United States prompted merchants in China to plan an embargo on American goods. The United States proposed an international meeting in Shanghai to aid the Chinese in their anti-opium campaign.^{Footnote 16} The 1909 International Opium Commission and subsequent meetings before World War I (1912) and during the interwar years (1925, 1931, 1936) each produced limited control measures with weak or absent enforcement mechanisms. These meetings have been amply documented in the historical literature,^{Footnote 17} and I will explain relevant parts of the architecture of control in the next section. But one trend in the early meetings and treaties is worthy of note: colonial powers advocated for the legitimacy of “quasi-medical” use of opiates, that is, opiate use in “traditional” medical systems not conforming to “Western” biomedical standards.^{Footnote 18} Even as the desire to avoid embarrassment impelled European powers to send delegates to international meetings, the revenues garnered from opium were too important to allow for significant controls in colonial holdings.

Narcotics Control as Existential Struggle: Anslinger and the Postwar World

The United States continued to wield significant influence in the international treaty negotiations during the interwar period. The United States never joined the League of Nations, which convened many of the interwar negotiations. Nor did it become a party to some of the early drug-control treaties, including the 1925 International Opium Convention and the 1936 Geneva Convention for the Suppression of the Illicit Traffic in Dangerous Drugs; U.S. officials argued that these treaties were not rigorous enough.^{Footnote 19} But the United States was central to the international treaty negotiations process throughout. The meetings in 1925, for instance, were convened by the League of Nations at the insistence of the United States,^{Footnote 20} and at the 1931 conference the United States had more delegates than any other country.^{Footnote 21}

Yet it was not until after World War II that the United States’ prohibitionist position found powerful allies in Europe. By the late 1940s, as their Asian colonies began to secure independence and China “fell” to Communists, European nations were no longer concerned with maintaining revenues from the sale of raw opium. In the postwar decades, European and American officials both sought strict controls on organic opiates (while opposing control of the synthetic drugs produced by their own manufacturers).^{Footnote 22}

No individual was more zealous in the pursuit of opium control than Harry Anslinger of the United States. After serving in various federal agencies as an investigator of smuggled contraband during the 1920s, Anslinger was named the first commissioner of the Federal Bureau of Narcotics by President Herbert Hoover in 1930. In addition to his role with the Federal Bureau of Narcotics, Anslinger was the U.S. representative to the UN’s Commission on Narcotic Drugs. Anslinger was long-lived in both positions; he retained his domestic post at the Federal Bureau of Narcotics until 1962 and his diplomatic post at the Commission on Narcotic Drugs until 1969.

In his memoirs, Anslinger traced his devotion to the fight against illicit narcotics to the toll exacted by opium in his otherwise idyllic small-town boyhood home.^{Footnote 23} While he reveled most in the pursuit of traffickers, Anslinger understood his domestic duties to include ensuring adequate supplies of opiates for medical and scientific purposes. In 1939, shortly after the outbreak of war in Europe, Anslinger worked to build U.S. government stores of six hundred thousand pounds of opium (the equivalent of four years’ domestic consumption) in order to ensure uninterrupted supplies for military and civilian medical use.^{Footnote 24} Speaking before American audiences, of medical students or women’s groups or pharmacists, Harry Anslinger admitted the need to balance the necessary medical uses of opium-derived painkilling drugs with the dangers of addiction. “Opium,” he declared, “is like the finger of God: it smites and it heals. It is both the Angel of Mercy and the curse of mankind.” ^{Footnote 25} Still, health professionals complained that they risked prosecution for unwittingly prescribing opiate analgesics to addicts (similar concerns among physicians in the United States during the 1980s will figure prominently later in this history).^{Footnote 26}

While in domestic affairs Anslinger maintained some sense of balance between licit and illicit use, in diplomatic dealings his focus was almost entirely on the perils of illicit opium. During Anslinger’s tenure in international narcotics-control negotiations, he constantly stressed the dangers of opiates, not just to the user but also to entire societies. During World War II, Anslinger accused Japan of a “far-reaching conspiracy” to “enslave the Orient” and “soften up” its enemies with a “new chemical warfare—opium.”^{Footnote 27} After the war, Anslinger presented a report to a meeting of the Commission on Narcotic Drugs alleging that the Japanese government had run a manufacturing facility for narcotic drugs in Manchuria intended to “enslave, ruin, or kill 200 million people.” At that meeting, the commission passed a resolution recommending to the ad hoc Committee on Genocide that “the use of narcotics as an instrument of genocide” should be included in the Convention on Genocide.^{Footnote 28}

Following Mao Zedong’s Communist victory in 1949, Red China became the bête noire in Anslinger’s global appraisals. “Red China,” Anslinger wrote in his memoirs, “has become the dope-vending dragon of the East.” China, he alleged, was engaged in “long-range dope-and-dialectic assault,” combining profitable opium trafficking and subversive political propaganda in an effort “to make narcotics a new ‘sixth’ column to weaken and destroy selected targets in the drive for world domination.”^{Footnote 29} A map of global opium production in the inaugural issue of the United Nations’ Bulletin on Narcotics in 1949 painted the People’s Republic of China (as well as Tunisia and Mexico) in black so as to draw attention to its production outside the bounds the international treaty regime.

In many respects the People’s Republic of China was an odd target for such an accusation. Mao’s regime was not recognized by the United Nations as China’s legitimate government during this period, so it could not have joined the treaty regime even if it wanted to.^{Footnote 30} A more important reason to question Anslinger’s characterization of the People’s Republic of China is the fact that this regime considered China the main historical victim of the international opium trade. Responding to a century of opium-driven foreign incursions, China’s Communist regime conducted a vigorous, often brutal nationwide anti-opium campaign that targeted both production and consumption between 1949 and 1952.^{Footnote 31} Though traffickers were able to continue some smuggling, China’s Central Financial Committee had outlawed the export of opium as early as November 1950. Yet Anslinger persisted in his accusations. With U.S. troops battling Chinese forces on the Korean Peninsula, Anslinger’s allegations were another means to discredit Mao’s regime.

Throughout his long tenure, Anslinger consistently spoke of an America engaged in an existential struggle against nefarious states trafficking in opium (most often Communist states like the USSR, Mao’s China, and Castro’s Cuba).^{Footnote 32} One component of his effort to stem illicit production was the development of technology able to identify the source of seized opium shipments. Toward that end, Charles Fulton, an employee in Anslinger’s Bureau of Narcotics, submitted a paper to the UN Commission on Narcotic Drugs in 1948 outlining a method of identifying the origin of opium through microscopy.^{Footnote 33} Using his method, it was possible to group opium into regions of microscopic resemblance (e.g., Turkey–Yugoslavia, or Iran–Afghanistan–Mongolia, or India–China–Manchuria), but greater specificity was not yet possible. Anslinger remained devoted to developing such technologies of identification for the rest of his career, yet the poppy proved stubborn in its unwillingness to conform to political borders.^{Footnote 34}

Even in the absence of useful forensic techniques, Anslinger’s primary diplomatic goal was an international agreement establishing a centralized body to rigorously monitor and control the cultivation, trade, and distribution of the world’s opiates.^{Footnote 35} In 1953, Anslinger helped design a treaty that he believed achieved this aim. Two decades earlier, nations that were party to a 1931 convention had begun providing annual estimates of opiate needs for medical and scientific purposes. A Drug Supervisory Body had been responsible for approving the estimates, while a Permanent Central Opium Board was tasked with conducting inspections and imposing embargoes on nations that exceeded the approved figures.^{Footnote 36} But the 1953 Opium Protocol went further, requiring those countries it allowed to produce the world’s licit opium supply to submit annual statistics on the amounts of opium planted, harvested, exported, and stockpiled. The Drug Supervisory Body would make sure that planned global supply matched approved global demand for medically necessary opium.^{Footnote 37} The Commission on Narcotic Drugs, where Anslinger sat, would define the bounds of legitimate opiate use. Together these agencies aimed to ensure that no opium, anywhere in the world, was diverted from approved uses.

In the midst of efforts to curtail and prosecute the illicit trade, comparatively little effort was made to ensure that the overwhelming focus on preventing diversion did not leave patients needing opiates in pain. This was true in spite of treaty language adopted in 1961 that recognized the importance of pain relief. That year’s Single Convention on Narcotic Drugs, which sought to unify the agreement of 1953 with previous treaties, included in its preamble an acknowledgment of the role of narcotics in medicine:

One would assume, reading this passage, that the treaty regime would be administered with medicinal opiates in mind.^{Footnote 39} Yet this was rarely the case. The World Health Organization (WHO) did participate in the treaty regime in an advisory role, but its task was simply to determine the addictive potential of drugs and their proper places on the international schedule of controls.^{Footnote 40} Thus health experts were consulted not to advance access to pain relief but to determine the relative dangers of different drugs. As the next section will explain, even the treaty mechanisms most suited to ensuring adequate availability of narcotics—the annual national estimates of the coming year’s needs and reports on past consumption—were used to police overconsumption rather than to highlight underconsumption.^{Footnote 41}

Anslinger had helped foster a single-minded focus in the international narcotics-control regime, prioritizing international trafficking while virtually ignoring legitimate medical needs outside the United States. Ignorance about the scarcity of opiates in the Global South would become even more total in the years after Anslinger left the Commission on Narcotic Drugs in 1969. The fear of opioids he had instantiated and the focus on overproduction and overconsumption in all countries save the United States helped render vast inequalities invisible in the narcotics-control statistical regime.

The War on Drugs and the Invisibility of Pain in the Global South

Palliative-care physician and ethicist Eric Krakauer attributes the lack of opioid analgesics in poor countries to “opiophobia”—an irrational fear of opioids that “congealed into national opioid policies and regulations around the world that are highly restrictive and imbalanced.”^{Footnote 42} The previous section detailed the growth of this fear of opioids; this section focuses on how these fears “congealed” into restrictive policies in Asia, Latin America, and Africa. Here the focus is on the work of the International Narcotics Control Board, an “independent and quasi-judicial control organ” that combined the functions of the Drug Supervisory Body and the Permanent Central Narcotics Board (formerly known as the Permanent Central Opium Board) when it was formed in 1969. The INCB’s presentation of national-level statistics selectively highlighted excessive production and consumption but obscured the reality of entire continents with low per-capita consumption. In addition, the overarching concern with opiate abuse (in publications of INCB statistics, in the counsel of cosmopolitan technical advisers, and in the projects given financial assistance by international drug-control agencies), contributed to the spread of policies and practices that curtailed access to opiates in health facilities.

The rendering of a global statistical portrait of licit narcotic use was, by the 1960s, an established feature of the UN control regime. Since 1931, the Drug Supervisory Body had collected estimates of future opiate needs and past consumption for medical and scientific purposes from countries around the world. In the late 1960s, this task was handed over to the newly formed International Narcotics Control board (INCB). Annual reports from the INCB demonstrate the board’s focus on overconsumption. One table from a 1970 report details per-capita therapeutic doses of opiates consumed annually, but it includes only the top fifty countries with the highest consumption rates. Most of the nations are wealthy; the only African countries in the top fifty are South Africa and Egypt. The report includes no commensurate table of those nations with the lowest per-capita consumption.^{Footnote 43}

INCB reports also chastised the national agencies charged with making estimates of future opiate needs (often ministries of health or drug agencies housed therein) for submitting figures that it considered too high. The INCB complained, in a 1969 report, of “a persistent tendency towards quantitative overestimation of narcotic drugs requirements.”^{Footnote 44} The INCB asked countries to report “the number of doctors, dentists and veterinarians practicing in a country … since it shows the extent of health services.”^{Footnote 45} This request stemmed from a 1962 UN “commentary” on the 1961 Single Convention prepared by Adolf Lande, a Jewish lawyer who had fled Austria after Hitler’s invasion and settled in the United States before serving as secretary of both the Permanent Central Narcotics Board and the Drug Supervisory Body. Though the 1961 Single Convention’s text did not state which cadres of health workers could legally prescribe opiates, Lande’s commentary listed “doctors,” “dentists,” and “veterinarians” as the only “qualified persons duly authorized” to exercise “therapeutic functions.”^{Footnote 46} Neither Lande’s commentary nor the INCB report made note of the fact that many poorer countries in the Global South relied on nurses and practitioners other than doctors to staff health centers and hospitals. Yet such providers were, according these documents, unfit to prescribe opiates. In nations where doctors were scarce, calculations of opiate “needs” based on the numbers of doctors inevitably produced estimates far below calculations based on morbidity.

United Nations documents also instructed national officials to base estimates of future opiate needs on past consumption figures.^{Footnote 47} Many nations did just this. On a form completed in hasty scrawl and submitted to the PCOB in 1967, the Principal Pharmacist of Malawi’s government-run Medical Stores explained his methodology for establishing the nation’s 1968 opiate needs in a single sentence: “Calculations are based on past consumption and estimated future consumption.”^{Footnote 48} The pharmacist cited no formula for “estimated future consumption.” Malawi, like other poor nations, did not have the manpower or financial resources to undertake epidemiological surveillance studies needed to establish the morbidity burden of medical conditions for which opioid therapy was medically indicated. Prior to the 1990s, international drug-control agencies did not provide assistance for such studies, so Malawi’s cursory explanation was both common and expected. While international narcotics-control officials felt their instructions for calculating opiate needs helped prevent diversion, they also served to entrench low consumption.

The problem of underconsumption was virtually never mentioned in INCB reports between the 1960s and the late 1980s. A reader could easily surmise that access to opiates was a problem nowhere in the world. INCB statistical tables listed national requests for absolute amounts of different opiates but did not regularly include population statistics or per-capita figures.^{Footnote 49} In INCB annual reports sub-Saharan Africa merited scarcely any mention at all, and when it did, it received words of warning about the specter of drug abuse. The annual reports organized their statistics and analysis by region. Africa was always the last, often afforded less than a page of discussion. The continent’s health needs were not explored, save for the risk that new hospitals would make Africa a prime target for diversion. “The African governments should . . . take steps to prevent this problem from arriving on a large scale in the future,” counseled a 1974 report. “With the increase in medical services, the rapid urbanization and the likelihood of further use of Africa by traffickers, the Governments should strengthen their internal control services.”^{Footnote 50}

With the issue of accessibility so thoroughly ignored, the potential problems of abuse and illicit traffic remained at the forefront of international narcotics drug-control policy, particularly in the Global South. This focus was even more myopic after the late 1960s, when the U.S. government became concerned once more with an inundation of illicit opiates. Soldiers returning from Southeast Asia brought home addictions developed in the “Golden Triangle,” the name given to Burma, Laos, and Thailand, then the global epicenter of opium production.^{Footnote 51} Fears of domestic and international instability, long repeated by the (recently retired) Anslinger, returned with a vengeance. At a June 1971 press conference, President Richard Nixon declared drug abuse “Public Enemy Number One.” As in Anslinger’s day, American politicians and officials discussed opiates in terms of existential crisis and overseas invasion.

Among other measures, the United States responded to this threat by funding a new effort within the United Nations to aid other nations in combating illicit drug cultivation, trafficking, and use. The Nixon administration, which was particularly interested in halting the cultivation and distribution of opium poppy, coca leaves, and marijuana, proposed a new fund to be placed under the auspices of the United Nations. Officials in the Nixon Administration believed communist and nonaligned nations would be more likely to accept funding from the United Nations than directly from the U.S. Treasury.^{Footnote 52} In November 1970, after U.S. officials secured the support of the UN Secretariat, the Economic and Social Council (ECOSOC) passed a resolution calling for the establishment of a United Nations Fund for Drug Abuse Control (UNFDAC). In 1971 the U.S. government provided an initial $2 million contribution for the fund, which would provide technical assistance “in the establishment and improvement of national drug-control administrations and enforcement machinery and the training of needed personnel.” The ECOSOC resolution did not mention pain relief or any licit uses of drugs; instead, the UNFDAC was to devote its attentions to “the problem of the abuse of narcotic drugs and psychotropic substances.”^{Footnote 53}

The UNFDAC funded salaries of antinarcotic law enforcement personnel and equipment purchases,^{Footnote 54} as well as “training seminars” for national drug-control authorities to “permit fuller compliance with the drug control treaties.”^{Footnote 55} UNFDAC-funded training sessions for national drug-control administrators were held around the world; in 1975 alone, a total of seven courses with 281 participants were held in Islamabad, Ankara, Geneva, and La Paz.^{Footnote 56} When training materials did mention the use of opiates in medical settings, they used lurid stories of criminality from the United States and Europe to stress the need for vigilant monitoring of physicians and pharmacists. A document distributed at a UN training for law enforcement officers in East Africa in 1970 (just before the establishment of the UNFDAC) warned, “There are careless, indifferent or unscrupulous men engaged in this trade [medicine] as in any other. One needs only to think of the doctor in Europe who gave an addict a prescription for 1000 tablets of narcotics in one lot . . . or of the chemist . . . who first produced heroin there (and later when under arrest gave the formula to his mistress who sold copies of it).”^{Footnote 57}

Another purpose of UNFDAC technical assistance was to promote the enactment of strict narcotics-control legislation in every nation.^{Footnote 58} National legislation was to be based on “model laws” written by INCB members. One model law, published in the 1969 Bulletin on Narcotics and written by Charles Vaille, a former chairman of both the Commission on Narcotic Drugs and the Drug Supervisory Body, proposed controls on opium prescription and distribution that would prove onerous in many nations of the Global South. Echoing Lande’s interpretation of the 1961 Single Convention, the model law stated that opiates for use in human medicine could be supplied only “by doctors or pharmacists legally authorized”—no allowance was made for nurses or other health professionals.^{Footnote 59} In addition, physicians and pharmacists who prescribed inappropriately or failed to keep full records were to be subject to “the same prison sentences and fine as are inflicted under the Penal Code for housebreaking.”^{Footnote 60}

Narcotics-control laws adopted in Latin America, Africa, and Asia during the 1970s and 1980s reflected this globalization of fear of illicit trade and use. In Panama, oral morphine and transdermal fentanyl could be obtained at only one site in the country, the National Institute of Oncology. Nurses were not allowed to prescribe oral morphine; general practitioners were allowed to prescribe it for no more than forty-eight hours at a time.^{Footnote 61} In Paraguay, pharmacists and physicians who failed to keep long-term records or to send quadruplicate records of opiate prescriptions to the central government within ten days could suffer heavy fines or license revocation. Those found to have written a prescription lacking “a therapeutic reason justifying or warranting their use” faced a minimum of two years and a maximum of eight years in prison.^{Footnote 62} In India, following passage of the Narcotic Drugs and Psychotropic Substances Act in 1985, hospitals seeking to purchase morphine from another state within India had to procure five licenses in each state. If any of the licenses should expire before the shipment, the delivery would be illegal. In the ensuing years, Indian hospitals and pharmacies stopped stocking morphine for fear of penalties arising from the raft of new regulations. Consumption of licit morphine in India fell by 97 percent between 1985 and 1997.^{Footnote 63}

Some nations legislated particularly extreme penalties for doctors found guilty of unlawful prescription practices. Especially in states with authoritarian regimes, statutes justified draconian punishments using language that reflected both the dangers posited by international narcotics-control officials and (historically grounded) fears of foreign profiteers. In newly-independent Guinea-Bissau (an former Portuguese colony), a 1976 law decreed that “doctors who prescribe opiates without therapeutic justification or in doses exceeding therapeutic doses and likely to foster narcotic abuse will be punished with three to six years of hard labor.” The statute justified the punishment with the following declaration:

Later INCB documents would to insist that laws like Guinea-Bissau’s went far beyond the dictates of UN treaties. This is, strictly speaking, true. None of the treaty language mandated such long sentences, though a 1988 treaty called for “sanctions which take into account the grave nature of these offences, such as imprisonment and other forms of deprivation of liberty, pecuniary sanctions and confiscation.”^{Footnote 65} Still, penalties like Guinea-Bissau’s were predictable reactions to the tone of existential struggle that the Commission on Narcotic Drugs fostered when it called for the inclusion of narcotics trafficking the 1948 Genocide Convention, or when Anslinger decried Red China’s “dope-and-dialectic assault.” The specter of opium-fueled national demise, conjured early in the Cold War and amplified in the 1970s, made legislation that severely limited access to legitimate forms of pain relief appear necessary. Thus the inordinate fear of opiates, which Ghodse and other commentators within the UN attributed to ignorant physicians or officials in the Global South, is at least partly attributable to the UN and—more fundamentally—to rhetoric and policies designed to respond to abuse within wealthier countries.

The (Re)discovery of Pain: Public Health to the Fore

The overwhelming focus on law enforcement began to wane in the late 1980s, when international-control bodies finally began to discuss untreated pain. This shift was not led by drug-control officials but by public health experts. In 1988 the UN Economic and Social Council passed a resolution calling on the INCB to determine which countries held “excess stocks” of opium.^{Footnote 66} In order to decide on the definition of “excess,” the INCB asked the WHO to help gather information on the licit medical needs for opiates in various regions of the world. The WHO sought information from drug regulators, medical specialists, pharmacists, and national health officials to determine how countries were estimating their needs.^{Footnote 67}

The ensuing report, jointly prepared by the INCB and WHO and published in 1989, revealed that national estimates of opiate needs submitted to the INCB were often based on nothing more than previous years’ imports. Inertia and the expectation of INCB criticism if estimates were increased led national drug-control agencies to leave estimates of need fixed from year to year. The report instructed states to use more sophisticated methods of needs analysis, including “morbidity and mortality patterns, social, cultural and demographic factors, defined daily doses per unit of population, the level of consumption of alternative non-opiate drugs, the pattern of drug selection by medical practitioners in their treatment programmes and data on unmet needs.”^{Footnote 68} The implication in this critique was that neither UNFDAC trainings nor existing practices in many national drug-control agencies had included these methodologies. Yet overt critique of UN agencies was absent from the report; the “non-availability” of opiate analgesics in countries outside the United States and Europe was attributed to those nations’ “level of development” or to their domestic legislators and officials, who “lose sight of or encounter difficulties in ensuring the need for balance between availability of opiates and prevention of their abuse.”^{Footnote 69}

Despite the report’s unwillingness to criticize the organs of the international drug-control regime, it did highlight vast global disparities in opiate consumption. The report included a pie chart that showed both the percentage of global opiate consumption and the percentage of global population in each region, rendering visible the vast disparities in per-capita use. The United States and Europe accounted for 29 percent of the world’s population but 75 percent of opiate consumption. “The WHO,” the report stated, “estimates that at least 3.5 million cancer patients currently suffer needlessly from pain.”^{Footnote 70}

What allowed for the discovery of untreated pain in the international narcotics-control regime in the late 1980s? The WHO had placed morphine on its first Essential Medicines List in 1977,^{Footnote 71} yet WHO publications had not addressed the problem of underconsumption before the 1989 report. The end of the Cold War may have lessened the perceived legitimacy (and omniscience) of the “planned economy” approach to international opiate control in place since the 1931 Geneva Convention. Furthermore, changes in the domestic politics of medicinal opiate regulation in the United States may have loosened the thrall of opiophobia. Just as domestic worries about addiction had impelled the myopic focus of international control for decades, renewed concerns about undertreatment of pain in the United States helped transform the INCB’s discourse.^{Footnote 72} A 1986 consensus statement of an expert panel convened by the National Institutes of Health mentioned surveys demonstrating that many hospitalized Americans suffered unnecessary pain for want of adequate opioids.^{Footnote 73} Prominent physicians, led by Dr. Stratton Hill of Houston’s MD Anderson Cancer Center, rebelled against the fear of prosecution that prevented them from using opioids as medically indicated. By 1989, the Texas State Legislature had passed the Intractable Pain Treatment Act (IPTA), which stipulated that “no physician may be subject to disciplinary action by the board for prescribing or administering dangerous drugs or controlled substances in the course of treatment of a person for intractable pain.”^{Footnote 74} Dr. James Sammons, executive vice president of the American Medical Association, explained his group’s support for the Texas reforms, declaring: “The war on drugs should not be a war on patients.”^{Footnote 75}

The movement in the United States to address undertreated pain helped spur the WHO to acknowledge the global dimensions of the crisis in opioid availability. In a 1985 article in The New England Journal of Medicine, Dr. Kathleen Foley, a neurologist who had established a pain service at New York’s Memorial Sloan-Kettering Cancer Center, called upon governments around the globe “to help make therapeutic approaches [to pain] available, specifically oral narcotic drug therapy.”^{Footnote 76} In 1986 the WHO released its first edition of Cancer Pain and Opioid Availability, proposing a method for relief of cancer pain in resource-poor settings using a few inexpensive drugs (including morphine).^{Footnote 77} The WHO also sought advice from the Pain and Policy Studies Group, a group founded in the late 1980s at the University of Wisconsin Medical School to advocate for “balance” in national and international policies to “ensure availability of essential opioid analgesics for the relief of pain and suffering, while addressing diversion and abuse.”^{Footnote 78} This change in focus among health professionals in wealthy countries helped expand the focus of the 1989 INCB-WHO report beyond the problem of “excess” opioid stocks to inadequate opioid availability in poorer countries.

The change to a focus on public health was not entirely salutary for previously neglected patient populations, for public health experts had their own preoccupations and presumptions. A 1990 report of the WHO Expert Committee on Cancer Pain Relief and Active Supportive Care—a committee chaired by Dr. Foley—argued pain relief was even more important in poor countries because opiates were inexpensive, while cancer treatment with the goal of cure was complicated and costly. The Expert Committee’s report claimed that in developing countries palliative care was “the only realistic option for most cancer patients.”^{Footnote 79} The WHO stuck to this position as late as 2006, when an article summarizing the WHO’s “comprehensive” approach to cancer control stated: “Palliative care … should be given a high priority in every country. This is especially true in poor countries where … the majority of cancer patients will remain uncured in the coming decades.”^{Footnote 80} The approach the WHO advised for poor countries entailed persistent inattention to chemotherapy, radiation, and curative treatment generally.^{Footnote 81}

Still, from the late 1980s the rhetoric from officials in the bureaucratic organs of the international narcotics-control regime had changed. The 1990 WHO Expert Committee report included a map depicting the stark global disparities in licit per-capita opiate consumption.^{Footnote 82} During the 1990s, the INCB studied opioid access more frequently, making note of the dearth of opiate consumption in developing countries in its 1994 annual report^{Footnote 83} and devoting the first chapter of its 1999 annual report to the issue of untreated pain.^{Footnote 84} In November 1999, for the first time, the board initiated a mechanism whereby countries with “missing or particularly low estimates were contacted in order to ensure adequate availability of opioids for the treatment of pain.”^{Footnote 85} It also established an aspirational annual per-capita minimum standard for national opioid consumption, setting this “adequacy” threshold at 200 “defined daily doses” (DDD) per million inhabitants.^{Footnote 86} Recognizing that licit demand for opiates exceeded the capacities of the few physicians in resource-poor settings, in 2010 the WHO recommended Ministries of Health change regulations to allow nurses to prescribe morphine.^{Footnote 87}

Yet despite such recognition of gross disparities in access to pain relief, the absence of morphine and other opioids in clinics of the Global South remains a persistent problem. The 1980s movement to liberalize prescribing practices for pain in the United States did help precipitate a rapid increase in global consumption of morphine. According to Ghodse, consumption “practically doubled during each five-year period” between 1984 and 1998, but almost all of this increase is attributable to increased consumption in wealthy countries.^{Footnote 88} Global consumption continued to increase after 2000, but a 2010 INCB report showed Asia, Africa, and Central America remained significantly below the INCB’s own adequacy threshold.^{Footnote 89}

In recent years a civil society movement calling for access to pain relief in poor countries has grown to include prominent academics, physicians, and human rights groups. On the fiftieth anniversary of the Single Convention on Narcotic Drugs in 2011, Human Rights Watch produced a report highlighting the continued absence of pain relief for AIDS and cancer patients in the Global South.^{Footnote 90} Some of these advocates have garnered critics, particularly for their financial ties to opioid manufacturers. A 2011 exposé by the Milwaukee Journal-Sentinel revealed $2.5 million in drug company donations to the Pain and Policy Studies Group, a potential conflict of interest that had gone undisclosed in articles published by the group’s members.^{Footnote 91} The Journal-Sentinel insinuated that the group’s work was in some part responsible for the “epidemic of narcotic painkiller abuse” in the United States. With this revelation, Anslinger’s warnings about profiteers seeking to make addicts of Americans had been resuscitated. This time, the peddler was not a foreign government but an American pharmaceutical company (Purdue Pharma, manufacturer of Oxycontin), and evidence of wrongdoing was far stronger.

For its part, the INCB maintains a focus on preventing diversion of opioids, even at the expense of addressing the (recognized) inaccessibility of pain relief for medically indicated purposes.^{Footnote 92} There is, according to a 2012 INCB report, a difference between a country’s “needs” for controlled substances (“the quantities that would be necessary to provide medical treatment for the health problems of a country’s population”) and its “requirements” (“the quantities that are necessary to provide medical treatment through the existing health-care infrastructure in a country and under conditions where controlled substances are used rationally and are not diverted”).^{Footnote 93} The INCB indicated that national requests to import opioids sufficient to address existing morbidity might be denied if “existing health-care infrastructure” was not sufficient to prevent inappropriate use or even if such imports increased “the possibility of diversion or abuse.”^{Footnote 94}