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WORKING PAPER 6 Isabel Pereira Arana Holds a bachelor’s degree in political science from the University of Los Andes (2008) and a master’s degree in development studies with an emphasis on conflict and peacebuilding from the Graduate Institute of International and Development Studies in Switzerland (2015). Her research focuses on the impact of drug policies on rural development, public health, and armed conflicts. She is currently the research coordinator for drug policy at Dejusticia, where she places special emphasis on access to controlled medicines for palliative care and psychoactive substance use disorders, as well as the implications of Colombia’s peace process for the country’s drug policies. She is a member of the Collective of Drug Studies and Law and a representative of the Members’ Advisory Council of the International Drug Policy Consortium. Her publications include Palliative Care: A Human Rights Approach to Health Care (2016); A Balancing Act: Drug Policy in Colombia after UNGASS 2016 (co-author, 2017); and Voices from the Coca Fields: Women Building Rural Communities (co- author, 2018). Lucía Ramírez Bolívar Holds a law degree with a specialty in constitutional law from the National University of Colombia (2008) and a master’s degree in social work with an emphasis on international social work, poverty, and inequality from the University of Chicago (2015). She has worked as a human rights researcher, professor, litigator, and activist—particularly on the issues of drug policy, forced migration, and women’s rights—at international development agencies and nongovernmental organizations in Colombia and the United States. At Dejusticia, she initially served as a drug policy researcher and is now the research coordinator for migration.Her publications include Voices from the Coca Fields: Women Building Rural Communities (co-author, 2018); Género y derecho: Módulo de formación auto dirigida para jueces y juezas de la Rama Judicial (2016); Outcome Evaluation of an International Diversity Curriculum (2016); Comunidades de política pública en justicia en equidad (2005); and Institucionalización de las formas de justicia comunitaria: ¿Creación o solución de conflictos? (2004). Fraught with Pain Access to Palliative Care and Treatment for Heroin Use Disorder in Colombia Isabel Pereira Arana Lucía Ramírez Bolívar Working Paper 6 FRAUGHT WITH PAIN Access to Palliative Care and Treatment for Heroin Use Disorder in Colombia Pereira Arana, Isabel. Fraught with Pain : access to palliative care and treatment for heroin use disorder in Colombia / Isabel Pereira Arana, Lucía Ramírez Bolívar ; traductor Morgan Stoffregen. -- Bogotá : Dejusticia, 2019. 180 páginas : mapas y tablas ; 15 x 25 cm. -- (Working papers) Título original : Los caminos del dolor. Acceso a cuidados paliativos y tratamiento por consumo de heroína en Colombia. ISBN 978-958-5441-95-8 versión impresa 1. Abuso de drogas 2. Drogadicción 3. Heroína 4. Drogas alucinógenas. I. Ramírez Bolívar, Lucía, autora. II. Stoffregen, Morgan, traductor. III. Tít. IV. Serie. 362.299 cd 22 ed. A1639937 CEP-Banco de la República-Biblioteca Luis Ángel Arango ISBN 978-958-5441-95-8 printed version ISBN 978-958-5441-96-5 digital version Dejusticia Calle 35 No. 24-31, Bogotá D.C. Telephone: (+57 1) 608 3605 [email protected] https://www.dejusticia.org This document is available at https://www.dejusticia.org Creative Commons Attribution-Non Commercial Share-Alike License 2.5 Translation: Morgan Stoffregen Cover photo: Sebastián Restrepo Calle Layout: Diego Alberto Valencia Cover design: Alejandro Ospina Bogotá, August 2019 Contents ACKNOWLEDGMENTS .....................................................................9 INTRODUCTION ..............................................................................13 The Importance of Understanding How Drug Control Policies and Access Barriers Affect People Who Use Drugs and Those Who Suffer from Pain ..........................................................16 Methodology ��19 The Book’s Structure and Some Conceptual Clarifications ........................................25 CHAPTER 1. THE STATE’S RESPONSE TO PAIN: CHALLENGES TO ENSURING THE AVAILABILITY OF OPIOID MEDICINES .................................................................29 Opioid Medicines: Straddling the Divide between Essential and Controlled ....................................33 Opioids in Palliative Care ....................................................40 Heroin Dependence and Treatment with Opioids ............45 The Right to Health in Colombia and Its Relationship with the Regulation of Opioid Medicines ...52 CHAPTER 2. LIVES ON THE MARGINS: HEROIN USE AND THE SEARCH FOR TREATMENT IN COLOMBIA ..................59 The “Big H” in Armenia, Pereira, Cali, Santander de Quilichao, and Cúcuta ....................................................61 Legal and Policy Response toward People Who Use Drugs ..........................................72 Access to Methadone Maintenance Therapy ...................82 Barriers to Accessing Health Services and Their Impact on the Human Rights of PWUD ..................95 CHAPTER 3. PAIN’S REVOLVING DOORS: THE DISTANT PROSPECT OF PALLIATIVE CARE ...................... 113 The Need for Palliative Care in Colombia ..................... 114 Legal and Policy Response toward People in Need of Palliative Care .................................... 121 Access to Palliative Care ................................................. 130 Barriers to Accessing Palliative Care ............................. 144 CHAPTER 4. TOWARD HEALTH CARE FIT FOR PAIN RELIEF .......................................................151 Some Final Considerations .............................................. 152 Overarching Recommendations ...................................... 156 Recommendations concerning Pain Relief in Palliative Care ........................................... 160 Recommendations concerning Pain Relief for People Who Use Heroin ....................................161 A Future Research Agenda on Colombia’s Response to Pain Relief ................................................... 163 GLOSSARY ................................................................................... 167 REFERENCES .............................................................................. 169 ANNEX. List of Opioid Medicines in Colombia ...............................176 ACKNOWLEDGMENTS Our ability to traverse the cities studied in this book and to witness the realities experienced by the two populations addressed in our research was made possible thanks to the generosity and solidarity of many individuals committed to improving the quality of life of people who are in a state of suffering. The realities documented herein unveil the collective wisdom present in the quest for solutions in the midst of pain. Each visit, each street round, each encounter with a patient was facilitated by the desire of professionals to bring us closer—without sugar- coating and without reticence—to a particular reality. In Bogotá, where our research process began, Inés Elvira Mejía, Julián Quintero, Yanina Sil- va, and Pablo Zuleta put us in touch with community and harm reduction programs in the five cities of study. Meanwhile, Marta Ximena León, from the Colombian Observatory for Palliative Care, and Martha Franco and Mercedes Franco, from the Palliative Care Association of Colombia, con- nected us to palliative care professionals in each city. Andrés López, from the National Narcotics Fund, was a key ally who facilitated communica- tion with departmental-level narcotics funds, thus providing important institutional information for our research. He, together with his colleague Diana Agudelo, also reviewed the final manuscript and provided useful insights. With this map of contacts in hand, we embarked on the path to Cúcuta, Cali, Santander de Quilichao, Armenia, and Pereira. In each city, we met individuals who were weaving their cities’ re- spective histories and who shared challenges, possible solutions, and pathways to see what was being experienced by people who use heroin and patients who are at the end of life. We are enormously grateful to the staff of mayors’ and governors’ offices, to the community workers, to the Working Paper 6 9 health professionals working in palliative care and methadone programs, to the social workers, and to each person who spent time with us during this book’s fieldwork phase. At Dejusticia, several interns made valuable contributions to our research. During the second semester of 2017, Federico Mejía helped com- pile databases of contacts for our field visits to each city. During the first semester of 2018, Ángela María Sánchez helped us prepare and send dozens of derechos de petición that sought to gather information from public and private entities. During the second semester of 2018, Antonio Sánchez listened to several hours’ worth of interviews, noting key aspects of each conversation and systematizing the information for subsequent analysis. Also during the semester, Ana María Malagón helped us send additional inquiries to those entities that had failed to respond to our initial information requests, and she designed an instrument for systematizing the quan- titative and qualitative information contained in entities’ responses. In ad- dition, she provided logistical support for the workshops we conducted in November of that same year. We extend our deepest appreciation

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