# Pain relief and palliative care are unavailable to most

Source: https://onco.cc/bottlenecks/b-palliative/  
OnCo record `b-palliative` (Bottleneck). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Most people who die of cancer worldwide do so without adequate pain relief.

## Summary

Palliative care improves quality of life, reduces depression and, in at least one landmark randomised trial, lengthened survival when introduced at diagnosis of metastatic lung cancer, yet WHO estimates that only about 14% of people who need palliative care worldwide receive it. Access to opioids, the essential and inexpensive treatment for cancer pain, is restricted in most low- and middle-income countries by regulation, fear of diversion, and lack of trained prescribers, so that the poorest half of the world uses a tiny fraction of the morphine-equivalent opioids consumed by the richest countries. Even in high-income systems, palliative care is introduced late, often in the last weeks of life, and is still confused with hospice. The Lancet Commission's essential package of palliative care costs a few dollars per capita; the bottleneck is policy, training and the position of palliative care within oncology, not science.

## Fields

- Kind: Bottleneck
- Last checked: 2026-09-08
- Stage: access-delivery
- Severity: major
- Metrics: People who need palliative care worldwide who receive it (WHO estimate): ~14% (WHO fact sheet, Palliative care); People who die each year with serious health-related suffering, most in low- and middle-income countries: More than 25 million (2015) (Knaul et al., Lancet Commission on Global Access to Palliative Care and Pain Relief 2018); Median overall survival with early palliative care vs standard care in metastatic NSCLC: 11.6 vs 8.9 months (Temel et al., NEJM 2010)
- Causes: Opioid regulations designed to prevent diversion block legitimate medical use in most low- and middle-income countries.; Palliative care is not integrated into oncology training or cancer plans in many countries.; Clinicians and patients equate palliative care with giving up, so referral happens late.; Palliative services are funded poorly relative to disease-directed treatment.; Workforce shortages leave no one to prescribe, dispense or deliver home-based care.

## Sources

- WHO fact sheet, Palliative care: https://www.who.int/news-room/fact-sheets/detail/palliative-care
- Knaul et al., Alleviating the access abyss in palliative care and pain relief (Lancet Commission 2018): https://doi.org/10.1016/S0140-6736(17)32513-8
- Temel et al., Early palliative care for patients with metastatic NSCLC (NEJM 2010): https://doi.org/10.1056/NEJMoa1000678
- Ferrell et al., ASCO guideline on integration of palliative care into standard oncology care (JCO 2017): https://doi.org/10.1200/JCO.2016.70.1474

## Connected records

- collections: [GLOBOCAN / Global Cancer Observatory](https://onco.cc/collections/globocan/)
- ideas: [A paediatric palliative care team in every childhood cancer unit](https://onco.cc/ideas/idea-acc-paediatric-palliative-in-every-childhood-unit/), [Algorithm-triggered goals-of-care conversations before crisis](https://onco.cc/ideas/idea-moon-goals-conversation-trigger/), [Automatic palliative care referral triggered by diagnosis, not by decline](https://onco.cc/ideas/idea-acc-automatic-early-palliative-triggers/), [Community health workers trained in cancer triage, navigation and home palliative care](https://onco.cc/ideas/idea-acc-community-health-workers-oncology/), [Earmark a fixed share of every national cancer budget for palliative care](https://onco.cc/ideas/idea-acc-earmarked-palliative-budget-share/), [Home end-of-life care kits and trained family carers where no hospice exists](https://onco.cc/ideas/idea-acc-home-based-end-of-life-kits/), [Locally prepared oral morphine solution, licensed for nurse prescribing](https://onco.cc/ideas/idea-acc-local-oral-morphine-production/), [Make early palliative care and a goals conversation part of every advanced-cancer pathway](https://onco.cc/ideas/idea-cost-early-palliative-default/), [Measure and publish pain control rates in every cancer centre](https://onco.cc/ideas/idea-acc-pain-control-public-audit/), [National opioid quota reform so morphine reaches cancer patients](https://onco.cc/ideas/idea-acc-balanced-opioid-policy-reform/), [Palliative care from diagnosis for every advanced cancer, including opioid access, worldwide](https://onco.cc/ideas/idea-moon-palliative-care-from-diagnosis-everywhere/), [Put the essential palliative care package into every universal health coverage benefit list](https://onco.cc/ideas/idea-acc-essential-palliative-package-in-uhc/), [Single-fraction radiotherapy as the default for painful bone metastases](https://onco.cc/ideas/idea-acc-single-fraction-palliative-radiotherapy-default/), [Train every oncology team in serious-illness conversations and prompt them in the record](https://onco.cc/ideas/idea-acc-serious-illness-conversation-prompts/), [Treat wasting like sepsis: a trigger, a bundle, an audit](https://onco.cc/ideas/idea-bio2-cachexia-pathway-code/), [Trials of low-cost opioid alternatives where morphine supply is unreliable](https://onco.cc/ideas/idea-acc-methadone-and-alternatives-where-morphine-fails/), [Video palliative care as an equivalent default option for patients far from a team](https://onco.cc/ideas/idea-acc-tele-palliative-care-default/), [Volunteer-led neighbourhood palliative networks, the Kerala model, adapted elsewhere](https://onco.cc/ideas/idea-acc-neighbourhood-palliative-networks/)
- cancers: [Cancer of unknown primary, unfavourable (adenocarcinoma and poorly differentiated carcinoma)](https://onco.cc/cancers/cup-unfavourable/), [Cervical cancer](https://onco.cc/cancers/cervical/), [Gastric & gastro-oesophageal junction cancer](https://onco.cc/cancers/gastric/), [Glioma & glioblastoma](https://onco.cc/cancers/glioblastoma/), [Hepatocellular carcinoma](https://onco.cc/cancers/hcc/), [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/), [Oesophageal cancer](https://onco.cc/cancers/esophageal/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/)
- fronts: [Supportive Care & Survivorship](https://onco.cc/fronts/supportive-care/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [International Agency for Research on Cancer (IARC / WHO)](https://onco.cc/institutions/iarc/), [Irish Cancer Society](https://onco.cc/institutions/irish-cancer-society/), [Li Ka Shing Foundation](https://onco.cc/institutions/li-ka-shing-foundation/), [Marie Curie](https://onco.cc/institutions/marie-curie-uk/), [Shaare Zedek Medical Center](https://onco.cc/institutions/shaare-zedek/)
- key papers: [Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report](https://onco.cc/key-papers/paper-knaul-lancet/), [Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update](https://onco.cc/key-papers/paper-ferrell-j-clin-oncol/), [Temel: early palliative care alongside chemotherapy improved quality of life, mood and survival in lung cancer](https://onco.cc/key-papers/paper-temel-early-palliative-care-nejm-2010/)
- people: [Dame Cicely Saunders](https://onco.cc/people/cicely-saunders/), [Elisabeth Kübler-Ross](https://onco.cc/people/elisabeth-kubler-ross/), [Li Ka-shing](https://onco.cc/people/li-ka-shing/), [Randy Pausch](https://onco.cc/people/randy-pausch/)
- technologies: [Cannabis and cannabinoids for pain, appetite and cancer control](https://onco.cc/technologies/cannabinoids-pain-appetite/), [Enteral and parenteral nutrition support](https://onco.cc/technologies/enteral-parenteral-nutrition/), [Massage therapy in cancer care](https://onco.cc/technologies/massage-therapy-cancer/), [Music therapy and music medicine](https://onco.cc/technologies/music-therapy-cancer/)
- roadmaps: [Global access and affordability roadmap: essential medicines and generics → biosimilars and frugal trials → reliance, pooling and homegrown innovation](https://onco.cc/roadmaps/global-access-roadmap/), [Supportive care and survivorship roadmap: making treatment bearable → proving it extends life → caring for tens of millions afterwards](https://onco.cc/roadmaps/survivorship-roadmap/)

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