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No Opiates for the Masses: Untreated Pain, International Narcotics Control, and the Bureaucratic Production of Ignorance

Published online by Cambridge University Press:  11 March 2016

Luke Messac
Luke Messac*
Affiliation:
University of Pennsylvania
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Journal of Policy History , Volume 28 , Issue 2 , April 2016 , pp. 193 - 220
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Copyright © Donald Critchlow and Cambridge University Press 2016 

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Footnotes

I am grateful to the archivists at the United Nations Library in Vienna and Pennsylvania State University for their assistance in locating primary-source materials. Thank you also to Susan Lindee, who taught the graduate seminar in which the first draft of this article was produced. Thank you also to Julie Livingston, Sara Berry, Jeremy Greene, Jane Guyer, Philippe Bourgois, and Sara Rendell, who commented on drafts, as well as to the participants in the African History Seminar at Johns Hopkins University and the 2014 meeting of the Society for the Social Studies of Science in Buenos Aires, where portions of this paper were presented. The University of Pennsylvania’s Department of History and Sociology of Science and Medical Scientist Training Program each provided funding for conference and research travel.

References

NOTES

1. A note on terminology: “Narcotic” is an actor’s category in this narrative, a catch-all term for drugs subject to abuse, including opioids, cannabinoids, and stimulants. “Opiates,” such as codeine, morphine, and heroin, are drugs derived from the opium poppy (Papaver somniferum); it is the term I use most often in this article. “Opioids,” by contrast, are all substances that bind to opioid receptors in the body; the term includes all opium-derived drugs in addition to synthetic drugs like fentanyl and hydrocodone. It is the favored term for painkilling drugs in medicine today, but it was not commonly used before the identification of opioid receptors in the early 1970s.

2. This patient’s story is also recounted in Luke Messac, “The Borders of Policy: What If Global Health Solutions Depend on ‘Them’ being Less—Rather than More—Like ‘Us?’” New Physician 62 (November–December 2013): 6.

3. See Donald McNeil Jr., “Fear of Morphine Dooms Third World Poor to Die Painfully,” New York Times, 9 September 2007. With the exception of cancer, the conditions listed here are acute episodes (often treated in hospitals) for which opioid therapy is often medically indicated in the United States. For common chronic pain conditions other than cancer, such as chronic back pain, expert guidelines from American specialty physician groups in 2015 generally advise doctors to use non-opioid therapies before beginning to consider prescribing opioids. Outpatient opioid use is subject to diversion to nonmedical uses, and any opioid use can potentially foster or feed an addiction. Still, the benefit of pain relief from opioid use is generally held to be greater than the risks of addiction or diversion for patients with certain acute conditions and for many patients with cancer. By contrast, most guidelines consider the risks of opioid use to be greater than the benefits for most chronic noncancer pain. This weighing of risks and benefits has become especially urgent in the United States in the early decades of the twenty-first century, as the role of Purdue Pharmaceuticals (manufacturer of Oxycontin) in promoting opioid use for chronic noncancer pain has drawn heavy criticism, and as deaths from opioid overdose have increased precipitously. For more on the history of disputes over medical indications for opioid therapy in the United States, see Kolodny, Andrew et al., “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction,” Annual Review of Public Health 36 (2015): 1–16Google Scholar.

4. International Narcotics Control Board, Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs: Ensuring Adequate Access for Medical and Scientific Purposes (New York, 2010), 86–87Google Scholar.

5. Ibid., “Table 2: levels of consumption of narcotic drugs,” 60, 67.

6. See International Narcotics Control Board, Report of the International Narcotics Control Board on the availability of internationally controlled drugs, E/INCB/2010/1/supp.1, 44. See also Ghodse, Hamid, International Drug Control into the Twenty-First Century (Burlington, Vt., 2008), 110.Google Scholar

7. Donald McNeil Jr., “Fear of Morphine Dooms Third World Poor to Die Painfully,” New York Times, 9 September 2007. Morphine, first isolated in 1804, is off patent and inexpensive to produce. Generic 10mg immediate-release morphine sulfate tablets cost roughly US$0.01 to produce. For a patient in chronic cancer pain, this translates to $1.80 to $5.40 for a month’s supply of morphine. Yet the complex of regulations surrounding its use (which I will discuss in this article) and the resulting impediments to market competition have helped to vastly increase its price in low- and middle-income countries, where one month’s supply can cost between $60 and $180. See Brennan, Frank, Carr, Daniel, and Cousins, Michael, “Pain Management: A Fundamental Human Right,” Anesthesia & Analgesia 105 (2007): 205–21.CrossRefGoogle Scholar

8. Ghodse, International Drug Control into the Twenty-First Century, 110–13.

9. “Agnotology,” a term coined by Robert Proctor, is used by historians of science to refer to the cultural production of ignorance. It has proved a useful theoretical underpinning for recent transnational histories of medicine, particularly for uses of medicine that are apparent in some places but are rendered invisible in others. See Agnotology: The Making and Unmaking of Ignorance, ed. Robert Proctor and Londa Schiebinger (Redwood City, 2008). See also Londa Schiebinger’s work on the constructed borders of knowledge of abortifacients in Plants and Empire: Colonial Bioprospecting in the Atlantic World (Cambridge, Mass., 2007).

10. While this article focuses on the relatively understudied relationship between international narcotics control and licit, medicinal opiate consumption in poor countries, studies examining the effects of this control regime on illicit opiate use—particularly in the United States, Europe, and China—are numerous. See, for instance, Courtwright, David, Dark Paradise: Opiate Addiction in America before 1940 (Cambridge, Mass., 1982), and Narcotics Culture: A History of Drugs in China, ed. Dikotter, Laamann, and Zhou (Hong Kong, 2004).Google Scholar

11. For more on this period, see Lovell, Julia, The Opium War: Drugs, Dreams, and the Making of China (New York, 2011)Google Scholar. Karl Marx, a journalist during the first Opium War, denounced the “flagrant self-contradiction of the Christianity-canting and civilization-mongering British government” while pursuing its “free trade in poison.” See Brook, Timothy and Wakabayashi, Bob Tadashi, “Introduction: Opium’s History in China,” in Opium Regimes: China, Britain, and Japan, 1839–1952, ed. Brook, Timothy and Wakabayashi, Bob Tadashi (Berkeley, 2000), 2Google Scholar.

12. Paoli, Letizia, Greenfield, Victoria, and Reuter, Peter, “Change Is Possible: The History of the International Drug Control Regime and Implications for Future Policymaking,” Substance Use & Misuse 47 (2012): 923–35.CrossRefGoogle Scholar

13. Ibid.

14. McCoy, Alfred W, The Politics of Heroin: CIA Complicity in the Global Drug Trade (Brooklyn, 1991), 90–93, 100–101Google Scholar. For additional statistics on colonial tax revenues from opium monopolies, see United Nations Office on Drugs and Crime, “A Century of International Drug Control” (Vienna, 2012), 21.

15. Musto, David, “The History of Legislative Control over Opium, Cocaine, and Their Derivatives,” in Dealing with Drugs: Consequences of Government Control, ed. Hamowy, Ronald (Lexington, Mass., 1987).Google Scholar

16. Ibid.

17. The most detailed history of this century of treaty negotiations is William McAllister, Drug Diplomacy in the Twentieth Century: An International History (New York, 2000).

18. Jay Sinha, “The History and Development of the Leading International Drug Control Conventions,” prepared for the Senate Special Committee on Illegal Drugs, Parliament of Canada, 21 February 2001, http://www.parl.gc.ca/content/sen/committee/371/ille/library/history-e.htm.

19. Buxton, Julia, “The Historical Foundations of the Narcotic Drug Control Regime,” Policy Research Working Paper 4553 (Washington, D.C., 2008), 18Google Scholar.

20. Sinha, “The History and Development of the Leading International Drug Control Conventions.”

21. The United States sent four delegates. League of Nations, Records of the conference for the limitation of the manufacture of narcotic drugs, 27 May–13 July 1931, Geneva. Volume 1: Text of the debates. United Nations Library, Vienna.

22. McAllister, William, “Conflicts of Interest in the International Drug Control System,” Journal of Policy History 3, no. 4 (1991): 494–517.CrossRefGoogle Scholar These drugs, fabricated from nonorganic raw materials and also subject to abuse, included barbiturates, amphetamines, and hallucinogens.

23. Anslinger, Harry J. and Oursler, Will, The Murderers: The Story of the Narcotics Gangs (New York, 1962), 8.Google Scholar

24. McAllister, Drug Diplomacy in the Twentieth Century, 132.

25. Harry J. Anslinger, “Narcotics” (year unknown), Harry J. Anslinger Papers, Pattee Library, Pennsylvania State University.

26. While encouraging American physicians and pharmacists to seek out federal narcotics authorities if they expected their patients were malingering addicts, Anslinger assured them that “no harm is done is done to a practitioner who may be actually operating entirely within the law and in accordance with the tenets of his profession.” Harry J. Anslinger, “Address by Hon HJ Anslinger, US Commissioner of Narcotics, at the Convention of the International Association of Chiefs of Police, Milwaukee, Wisconsin, September 12, 1940,” Harry J. Anslinger Papers, Pattee Library, Pennsylvania State University.

27. Harry J. Anslinger, “American Policy: Constitution Follows Our Flag. Japanese Policy: Opium Precedes Their Flag” (year unknown), Harry J. Anslinger Papers, Pattee Library, Pennsylvania State University.

28. “Tightening World’s Narcotics Control,” United Nations Bulletin 4, no. 12 (1948): 495.

29. Anslinger, The Murderers.

30. The United States continued to accept the Republic of China’s claim that it was the sole legitimate government of China until 1971.

31. Paoli et al. recounts the effort: “The opium suppression campaign reached its peak in the second half of 1952, when over 80,000 drug traffickers were arrested, over 30,000 were sent to prison, many for life, and at least 880 were sentenced to death. Users were forcibly rehabilitiated either at home or in treatment facilities run by the government, with the exception of the elderly and the sick, who could be granted an exemption.” Paoli, Greenfield, and Reuter, “Change Is Possible,” 929.

32. See McAllister, Drug Diplomacy in the Twentieth Century.

33. “Tightening World’s Narcotics Control,” United Nations Bulletin 4, no. 12 (1948): 496.

34. Anslinger kept personal copies of reports on new research methods for determining the origin of opium. At a meeting of the Commission on Narcotic Drugs in October 1950, the Government of Canada presented a report evaluating a method comparing the concentration of porphyroxine-meconidine in opium poppies cultivated in different countries. Yet despite the initial enthusiasm for this method, it also proved far from definitive. Indian poppies generally had the highest concentrations of the chemical, but the range of values in almost every other country overlapped significantly. See United Nations Economic and Social Council, “Methods of Determining the Origin of Opium by Chemical and Physical Means, further data on ‘porphyroxine-meconidine,” E/CN.7/207, 19 October 1950. Harry J. Anslinger Papers, Pattee Library, Pennsylvania State University.

35. Anslinger, The Murderers, 295.

36. McAllister, Drug Diplomacy in the Twentieth Century, 181.

37. Ibid., 181. The full title of the 1953 treaty is: “Protocol for Limiting and Regulating the Cultivation of the Poppy Plant, the Production of, International, and Wholesale Trade in, the Use of Opium.” Much to Anslinger’s chagrin, the 1961 Single Convention would loosen the restrictions on opium production.

38. “Preamble,” 1961 Single Convention on Narcotic Drugs. https://www.unodc.org/pdf/convention_1961_en.pdf (accessed 22 December 2015).

39. The 1961 Single Convention had the most to say about medicine when it sought to set the bounds of legitimate practice. Anslinger, like his predecessors in American delegations, had long sought the immediate prohibition of all use of opiates outside the bounds of “Western” medicine. In the 1961 Single Convention, he reluctantly settled for a provision calling for abolition of such uses of opiates after a “transitional” period. Following the coming into force of the convention, parties reserved the right to allow “quasi-medical use of opium” for fifteen years, and to allow coca-leaf chewing and nonmedical use of cannabis for twenty-five years. See Article 49, “Transitional Reservations,” 1961 Single Convention on Narcotic Drugs. https://www.unodc.org/pdf/convention_1961_en.pdf (accessed 30 March 2015).

40. The World Health Organization Expert Committee on Drug Dependence fulfilled this role.

41. University of Wisconsin Pain and Policy Studies Group. “Do International Model Drug Control Laws Provide for Drug Availability?” Journal of Pain and Palliative Care Chemotherapy 23, no. 2 (2009): 145–52.Google Scholar

42. Krakauer, Eric et al., “Opoid Inaccessibility and Its Human Consequences: Reports from the Field,” Journal of Pain and Palliative Care Chemotherapy 24 (2010): 239–43.Google Scholar

43. International Narcotics Control Board, Statistics on Narcotic Drugs for 1970: Furnished by Governments in Accordance with the International Treaties and Maximum Levels of Opium Stocks (Geneva, 1970)Google Scholar.

44. International Narcotics Control Board, Estimated World Requirements of Narcotic Drugs and Estimates of World Production of Opium in 1969 (Geneva, 1969), v.Google Scholar

45. Ibid., ix.

46. The 1961 Convention never mentions “doctors,” “dentists,” or “veterinarians” at all. The restriction appears in the UN commentary (ostensibly “prepared by the Secretary-General,” though the foreword thanks “Mr. Adolf Lande … for his valuable assistance in preparing the Commentary”) when interpreting Article 19, paragraph 1, subparagraph a. In the Single Convention this passage reads: “1) The parties shall furnish to the Board each year for each of their territories, in the manner and form prescribed by the Board, estimates on forms supplied by it in respect of the following matters: a) Quantities of drugs to be consumed for medical and scientific purposes …” The United Nations’ Commentary on the Single Convention, however, states in regard to this passage: “The Board consequently calls to the attention of Governments that the phrase: ‘quantity to be consumed’ means the quantity to be supplied for retail distribution, use in medical treatment or scientific research, to any person, enterprise or institute (retail pharmacists, other authorized retail distributors, institutions or qualified persons duly authorized to exercise therapeutic or scientific functions: doctors, dentists, veterinarians, hospitals, dispensaries and similar health institutions, both public and private; scientific institutes).” United Nations, Commentary on the Single Convention on Narcotic Drugs, 1961 (prepared by the Secretary-General, 1962), 224.

47. UN’s Commentary on the Single Convention on Narcotic Drugs, 1961 (prepared by the Secretary-General), Article 19, paragraph 1, subparagraph a, part 3.

48. “Form B/S: Annual estimates of requirements of narcotic drugs,” in “Dangerous Drugs Legislation and Administration,” Location 2/28/1F, Box 12569, Malawi National Archives,” Malawi National Archives, Zomba.

49. Vast disparities in per-capita consumption become visible once these population statistics are included. Using the 1969 INCB report and population figures for the same year (from the CIA World Factbook), wide disparities in per-capita statistics become visible. In one of innumerable such examples from the 1969 report alone, the per-capita estimated need for codeine (a major opioid analgesic) in the United States was more than 106 times the per-capita figure requested by Malawi, an impoverished southern African nation. International Narcotics Control Board, Comparative Statement of Estimates and Statistics on Narcotic Drugs for 1969, Furnished by Governments in Accordance with the International Treaties (Geneva, 1970).

50. International Narcotics Control Board, Statistics on Narcotic Drugs for 1974: Furnished by governments in accordance with the international treaties and maximum levels of opium stocks (Geneva, 1974), 36.Google Scholar

51. “The First Two Years of the UNFDAC,” Bulletin on Narcotics 4 (1973): 2.

52. Paoli et al., “Change Is Possible.”

53. “Resolution adopted by the Economic and Social Council on 11 November 1970 requesting the Secretary-General to establish the United Nations Fund for Drug Abuse Control and setting out the long-term action to be taken.” Concerted United Nations Action Against Drug Abuse and Establishment of a United Nations Fund for Drug-Abuse Control,” 11 November 1970. See also McAllister, Drug Diplomacy in the Twentieth Century, 237.

54. In 1981, for instance, the UNFDAC requested international donations to help Malawi purchase four-wheel-drive vehicles and radios to help its “Drug Squad” to hunt growers and traffickers of marijuana. UN Fund for Drug Abuse Control, Country Programme Briefs, 1982, 49–51. United Nations Library, Vienna.

55. These training seminars, which could last as long as four weeks, were held at various locations in Africa, Asia, and Latin America, as well as in a “Central Training Unit” in Geneva. The UNFDAC covered travel, room, and board for officials from around the world. See International Narcotics Control Board, Statistics on Narcotic Drugs for 1974 (Geneva, 1974). See also “The First Two Years of the UNFDAC,” Bulletin on Narcotics 4 (1973): 2.

56. “Individual progress reports on operations financed by the United Nations Fund for Drug Abuse Control,” Division of Narcotic Drugs, 30 December 1975. United Nations Library, Vienna, MNAR/9/1975.

57. M. C. Manby, “The application of intelligence principles by law enforcement agencies to combat the illicit narcotics traffic,” UN Regional Training Mission on Narcotics Control for Law Enforcement Officers in East Africa, February–March 1970, 8. United Nations Library, Vienna MNAR/14/69 (7).

58. International Narcotics Control Board, Report of the International Narcotics Control Board for 1980 (New York, 1980), 32–33.Google Scholar

59. Charles Vaille, “A Model Law for the Application of the Single Convention on Narcotic Drugs, 1961,” Bulletin on Narcotics 21, no. 2 (April–June 1969): 6.

60. Ibid., 10.

61. Krakauer, “Opioid Inaccessibility and Its Human Consequences,” 241.

62. United Nations Library, Vienna, Law No. 1340, Paraguay, E/NL 1987/63, chap. 2.

63. Rajagobpal, M. R., Joranson, David, and Gilson, Aaron, “Medical Use, Misuse, and Diversion of Opioids in India, Lancet 358 (2001): 139–43.Google Scholar

64. Law 1/76, Article 7, from Laws and regulations, E/NL 1987/12, United Nations Library, Vienna (translated from French by author). Guinea-Bissau was not a treaty to the 1961 Single Convention when this law was enacted (Guinea-Bissau did not ratify the Single Convention until 2005), but it did request assistance from the UNFDAC in 1977, one year after the law’s enactment. See “Opening statement by the UNFDAC Executive director,” Interagency advisory Committee on Drug-Abuse Control, Fifth Session, Geneva, 12–14 September 1977. IAAC/13/Add.2, United Nations Library, Vienna. A 1986 report, “Drug Abuse in Africa,” in the INCB’s Bulletin on Narcotics noted that in Nigeria, “death by firing squad is the punishment for illegal possession, use, trafficking or cultivation of such drugs. In formulating policies, no distinction is made between the drug pusher and user.” T. Asuni and O. Pela, “Drug Abuse in Africa,” Bulletin on Narcotics 1 (1986): 6.

65. Article 3, Section 4(a), United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, 1988.

66. Annex II: Economic and Social Council Resolution 1988/10: Demand and supply of opiates for medical and scientific purposes, International Narcotics Control Board. Report of the International Narcotics Control Board for 1989. Demand for and supply of opiates for medical and scientific needs, special report prepared pursuant to economic and social council resolution 1989/15. E.89.XI.5 (New York, 1989), 20.

67. Ibid., 3–4.

68. Ibid., 10.

69. Ibid., 13–14.

70. Ibid., 15.

71. “Comparative table of core and complementary medicines on the WHO Essential Medicines List from 1977–2011,” developed by Aziz Jafarov, Tulip Schneider, and Brenda Waning et al., World Health Organization. http://www.who.int/medicines/publications/essentialmedicines/EMLsChanges1977_2011.xls.

72. The mid-1980s also saw increased attention to a history of race-based disparities in pain relief in American medicine, particularly with the 1985 publication of Martin Pernick’s A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America (New York, 1985).

73. “The integrated approach to the management of pain,” National Institutes of Health Consensus Development Conference Statement, 19–21 May 1986.

74. Keith Wailoo, Pain: A Political History (Baltimore, 2014), 138.

75. Ibid.

76. Foley, Kathleen M., “The Treatment of Cancer Pain,” New England Journal of Medicine 313, no. 2 (1985): 84–95.CrossRefGoogle Scholar

77. World Health Organization, Cancer Pain Relief (Geneva, 1986).

78. “Biosketch: David E. Joranson, MSSW.” University of Wisconsin School of Medicine. http://paincenter.stanford.edu/iasp/iasp_conf_day_1/H.%20David%20Joransen,%20Day%201.pdf (accessed 16 December 2013). This group is a “WHO Collaborating Center,” and during the 1990s and 2000s it participated in advisory missions involved in the rewriting of drug-control legislation in India, Malaysia, Italy, and Eastern Europe.

79. World Health Organization Expert Committee on Cancer Pain Relief and Active Supportive Care, Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee (Geneva, 1990), 15.

80. Ngoma, T., “World Health Organization Cancer Priorities in Developing Countries,” Annals of Oncology 17 (July 2006); suppl. 8: viii9–viii14Google Scholar.

81. For more on global public health priorities and inattention to cancer care and treatment during the 1990s and 2000s, see Farmer, Paul, Basilico, Matthew, and Kerry, Vanessa et al., “Global Health Priorities for the Early Twenty-first Century,” in Reimagining Global Health: An Introduction, ed. Farmer, Paul, Kim, Jim Yong, Kleinman, Arthur, and Basilico, Matthew (Berkeley, 2013), 302–39Google Scholar.

82. For a few examples of such maps, see International Narcotics Control Board, Report of the International Narcotics Control Board for 1989. Demand for and supply of opiates for medical and scientific needs, special report prepared pursuant to economic and social council resolution 1989/15. E.89.XI.5 (New York, 1989). See also Human Rights Watch, Global State of Pain Treatment: Access to Palliative Care as a Human Right (New York, 2011).

83. Report of the International Narcotics Control Board for 1994 (New York, 1995), para. 20.

84. “Freedom from Pain and Suffering,” Report of the International Narcotics Control Board for 1999 (New York, 2000), 1–50.

85. International Narcotics Control Board, Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs, 6.

86. Ibid., 16. A defined daily dose (or DDD) is the assumed average maintenance doses per day for a drug used in its main indication for adults. For morphine sulfate, a defined daily dose is 0.1g. See Annex 6.1: Defined daily doses (DDD) of some common medicines, in World Health Organization and Management Sciences for Health, Drug and Therapeutics Committees—A Practical Guide (France, 2003). In 2003, the INCB replaced the DDD with the “defined daily doses for statistical purposes (S-DDD),” to stress that the unit is a technical construct used for the purpose of statistical analysis and is not a recommended prescription dose.

87. This was one of many new recommendations emerging from the Access to Controlled Medicines Programme, established by the WHO in 2005 with the aim of identifying and overcoming regulatory impediments to opioids. International Narcotics Control Board, Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs, 45. Even before this announcement by the WHO, civil society advocacy in Uganda spurred the government to amend earlier, more restrictive legislation. In 2004, an amendment to a 1993 Ugandan statute passed in the legislature allowing clinical officers (a mid-level cadre of health-care workers common in the East African region) and specialized palliative-care nurses to prescribe morphine. Prior to 2004, only doctors, dentists, and veterinary surgeons could prescribe morphine. See Jack Jagwe and Anne Merriman, “Uganda: Delivering Analgesia in Rural Africa: Opioid Availability and Nurse Prescribing,” Journal of Pain and Symptom Management 33, no. 5 (2007): 547–51.

88. International Drug Control into the Twenty-first Century, ed. Hamid Ghodse (Burlington, Vt.), 106.

89. International Narcotics Control Board, Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs, 18.

90. Human Rights Watch, Global State of Pain Treatment.

91. John Fauber, “UW a Force in Drug Growth: Research Group Receiving Millions from Pharmaceutical Firms Helped Liberalize Use of Opioids,” Milwaukee-Wisconsin Journal Sentinel, 2 April 2011.

92. See, for instance, Allyn Taylor’s chronicle of a 2006 controversy between the INCB and WHO over the scheduling of ketamine on controlled substances lists. Allyn Taylor, “Addressing the Global Tragedy of Needless Pain: Rethinking the United Nations Single Convention on Narcotic Drugs,” Journal of Law, Medicine and Ethics (Winter 2007): 556–70.

93. International Narcotics Control Board, Guide on Estimating Requirements for Substances under International Control (New York, 2012), 6 (italics added).Google Scholar

94. Ibid., 13. In a personal interview, a UNODC official explained that in order to guard against the danger of diversion to illicit purposes—the primary focus of INCB officials—national authorities are asked not to increase year-over-year estimates for opium consumption by more than 10 percent.

95. Proctor, Robert, “Agnotology: A Missing Term to Describe the Cultural Production of Ignorance (and Its Study),” in Agnotology: The Making and Unmaking of Ignorance, ed. Proctor, Robert and Schiebinger, Londa (Redwood City, 2008), 8.Google Scholar

96. University of Wisconsin Pain & Policy Studies Group, “Opioid Consumption Maps: Morphine Equivalence, mg/capita,” http://ppsg-production.heroku.com/ (accessed 16 December 2013).

97. For an example of this type of active construction of ignorance, see Allan Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America (New York, 2006).

98. Krakauer, “Opioid Inaccessibility and Its Human Consequences,” 242.

99. Brennan, Frank, Carr, Daniel, and Cousins, Michael, “Pain Management: A Fundamental Human Right,” Anesthesia & Analgesia 105 (2007): 205–21.CrossRefGoogle Scholar

100. For wrenching ethnographic descriptions of this pain and its effect on patients and providers in cancer wards in Botswana, see Julie Livingston, “The Next Epidemic: Pain and the Politics of Relief in Botswana’s Cancer Ward, in When People Come First: Critical Studies in Global Health, ed. Joao Biehl and Adriana Petryna (Berkeley, 2013), 182–206.

101. Marc, Bloch, The Historian’s Craft: Reflections on the Nature and Uses of History and the Techniques and Methods of the Men Who Write It, trans. Peter Putnam (New York, 1953), 39.Google Scholar

102. For an account of U.S.-British tensions over the legitimate medical uses of opiates, see Peter Bartrip’s commissioned history of the British Medical Association, Themselves Writ Large: The British Medical Association, 1832–1966 (London, 1996), 304–12Google Scholar.

103. Emergency medicine physician Knox Todd demonstrated the persistence of these disparities by showing that Latinos and African-Americans were less likely than whites to receive opioids for pain relief for long-bone fractures in Los Angeles and Atlanta, respectively. See Todd, K. H., Lee, T., and Hoffman, J. R., “The Effect of Ethnicity on Physician Estimates of Pain Severity in Patients with Isolated Extremity Trauma,” JAMA 271, no. 12 (1994): 925–28.CrossRefGoogle Scholar

104. International Narcotics Control Board, Report of the International Narcotics Control Board on the Availability of Internationally Controlled Drugs, 5.

105. Recently the UNODC removed all model laws from its website. An official at the UNODC explains that this was done to prevent legislators around the world from “copying and pasting” from the document without considering local context. Though this is surely a salutary move, it does further obscure the crucial role of the UN treaty regime in fashioning draconian regulations around licit opiate use around the world.