©Ruth Fremson/The New York Times
Doing Without: A hospital in Sierra Leone, where painkillers often are not available.

A survey of specialists in Africa, Asia and Latin America has produced a disturbing portrait of the difficulties in offering pain relief to the dying in poor countries. Many suffer routine shortages of painkillers, and the majority of specialists got no training in pain relief or opioid use during their medical education.

In Africa, the report said, 20 percent of all palliative care specialists had no access to morphine or other strong opioids, and 25 percent never had weak opioids like codeine.

About 40 percent in Africa, 35 percent in Latin America and 25 percent in Asia had irregular shortages of morphine or its equivalents.

The report was prepared by Help the Hospices, a British charity that trains hospice workers and supports hospices in poor countries, for World Hospice and Palliative Care Day, last Saturday.

Three hundred questionnaires were sent to all the hospices and end-of-life specialists in poor countries that the researchers could find. Only 69 were returned, so the results cannot be regarded as scientific, but they do show what obstacles exist.

The chief reasons respondents gave for the shortages were restrictive national drug laws, fear of addiction, broken-down health care systems and lack of knowledge by doctors, patients and policy makers.

Respondents described individual problems in their countries. In Honduras and Malawi, patients could get no more than a three-day supply. In the Philippines, a doctor needed two licenses to prescribe morphine.

In individual comments, respondents detailed their complaints.

"Drug companies are not willing to import oral morphine solution as they will not make enough profit due to spending months on legal papers," a doctor in Ecuador wrote.

"It is simply irrational that oral morphine is not available in the country whereas expensive fentanyl patches can be made available for the rich patients," wrote a doctor in Bangladesh.

Dr. Willem Scholten, the World Health Organization official in charge of advocating greater access to painkillers around the world, said his impression was that "the situation is even worse than that found by the survey."

"Only 10 or 15 countries have a reasonable per capita consumption," he said. The gap between them and the rest of the world - about 175 countries - is "very wide."

Fear of addiction, he argued, creates shortages that hurt more people than strict laws protect.

"Globally," he said, "several hundreds of millions of people will require analgesia at least once in their lifetimes, while only a small fraction of this number misuses opioids."