Use of and barriers to access to opioid analgesics worldwide

Use of common opioid painkillers such as codeine, morphine and oxycodone has more than quadrupled in Australia over the past decade and doubled worldwide over the same period a report published today in The Lancet by the International Narcotics Control Board (INCB) reveals. Yet at the same time the authors warn that the majority of countries, particularly those in developing and poorer regions have little or no access to basic pain medication and there has been little change over the decade.

A research team from the INCB including Professor Richard Mattick of the National Drug and Alcohol Research Centre at UNSW Australia calculated the daily use of opioid analgesics for countries and regions globally over the period 2001 to 2013, compared the data against the prevalence of health conditions requiring pain relief and surveyed 214 countries about any impediments to availability of the medications.

The authors found that the bulk of the increase occurred in high income western countries and regions including North America, Western and Central Europe and Australia and New Zealand, which together accounted for more than 95 per cent of global opioid use. In Australia use of the medications increased more than four-fold from 3,287 doses per day per million (22 million doses annually) to 13,440 doses per day per million (106 million doses). The needs of the ageing population for cancer pain and increased pain management for chronic non-cancer pain in Western countries are thought to be the main drivers of the increase. As there is no recognised level of appropriate prescribing, it is not known if this use is excessive or appropriate.

By contrast, the majority of poorer and less developed nations including Central America and the Caribbean, Africa, South Asia, East Asia, South East Asia and Eastern Europe had little or no access to opioid pain relief and there had been no significant increase in use in these regions over the period. Over five and a half billion people are estimated to have little or no access to essential pain relief.

"Much of the increased usage that has occurred in high income countries is probably partly due to long term prescribing for non-cancer pain but the absence of real growth in most of the world indicates an ongoing lack of provision of these essential medications," write the authors.

They also caution that increased access will not necessarily lead to misuse but that a balance must be maintained.

"Ensuring access does not necessarily mean increased abuse and diversion, but it is necessary to maintain a balance between control on the one hand, and overly liberal availability on the other," the authors write. "Countries can review legislation and regulatory systems to remove unduly restrictive provisions, while still preventing diversion."

The authors warn that the lack of access in developing nations is highly inequitable and is in contravention of international agreements such as the Universal Declaration of Human Rights which includes the right to medical care including palliative care and the United Nations Convention.

The paper found that the low levels of prescribing in poorer developing countries did not reflect the need for the medications. For example data from the International Agency for Research on Cancer shows that more than half of all cancer cases and cancer deaths occurred in less developed regions. "In these regions the disease is mostly discovered when it is at an advanced stage... By then palliation is often required and access to opioid analgesics is essential," the authors write. Levels of prescribing of opioid painkillers are also well below what is needed to manage AIDS related pain in developing regions, in particular Sub-Saharan Africa and Asia, the report finds.

The authors found that barriers to use in poorer and developing countries included affordability, lack of awareness and training among medical professionals, fear of dependence, limited financial resources, problems in sourcing, fear of misuse and onerous regulations.

Professor Mattick, senior author on the paper said that the correct level of opioid use was unclear. "The ageing populations and greater care for chronic non-cancer pain are likely drivers of increased use in high-income countries," he said. However in lower income developing countries it was clear the low levels of prescribing did not reflect the need for the medications. "The lack of availability of these medications in low-income countries for the management of cancer pain is a terrible situation causing massive suffering," said Professor Mattick.

The report will be available for the Commission on Narcotic Drugs of all countries in March in Vienna and the UNGASS (UN General Assembly Special Session on the World Drug Problem) in New York in April.

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