Interactive data map: Global availability and utilization of opioids for pain management

1 Dec 2015  |  Print

Interactive data map: Global availability and utilization of opioids for pain management

Pain relief as a fundamental human right

The United Nations 1961 Single Convention on Narcotic Drugs acknowledged the medical use of narcotic drugs to be indispensable for pain relief and mandated adequate provision of narcotic drugs for medical use.[1] Almost four decades later, the continuing inadequacy of pain management in large parts of the world compelled the International Association for the Study of Pain (IASP) to formulate the Declaration of Montréal in 2010.[2] They asserted that withholding pain treatment was profoundly wrong and led directly to unnecessary, harmful suffering. Therefore, the IASP defined three human rights regarding pain management (Table 1), and called for their recognition worldwide.

Table 1. Rights asserted by the IASP Declaration of Montréal, 2010[2]

Article 1 The right of all people to have access to pain management without discrimination
Article 2 The right of people in pain to acknowledgment of their pain and to be informed about how it can be assessed and managed
Article 3 The right of all people with pain to have access to appropriate assessment and treatment of the pain by adequately trained healthcare professionals


High pain prevalence + inadequate control = a global public health priority

The shocking prevalence of pain is the foremost reason to regard it as a public health priority.[3,4] An estimated 1 in 5 adults in developed countries suffer from moderate to severe chronic non-cancer pain.[5,6] One systematic review published in 2003 found a mean prevalence of chronic non-cancer pain of 35.5% (range, 11.5 to 55.2%) based on studies from developed countries.[7]

Pain is a well-recognized and often devastating[8] symptom of cancer. More than half of cancer patients (53%, all disease stages) experience pain, with pain being moderate to severe in over one third of patients.[9] Alarmingly, the number of new cancer cases is expected to rise by about 70% over the next two decades,[10] greatly expanding the numbers of patients needing access to pain management.

Adding inadequate management of pain to its high prevalence underscores the healthcare crisis at hand.[3-5] It has been estimated that more than 60% of patients with chronic non-cancer pain[6]or cancer-related pain[8] treated with prescription analgesics experience inadequate pain relief.

Opioid analgesics relieve chronic cancer pain and non-cancer pain

The skilled use of opioid analgesics is considered crucial to the successful relief of cancer pain.[11] Guidelines for cancer pain relief recommended opioid analgesics for use in step II (weak opioids or, alternatively, low-dose strong opioids) and step III (strong opioids) of the analgesic ladder.[11,12]

Increasingly, opioid therapies are also being used to manage chronic non-cancer pain; expert consensus suggests that chronic opioid therapy can be effective for carefully selected and monitored patients with chronic non-cancer pain.[13]

Huge global disparity in opioid analgesic consumption

Opioid analgesics are the only known medicines effective for the treatment of moderate and severe pain.[14] The World Health Organization (WHO) and other international and national entities have been campaigning for many years to improve access to these essential medicines. However, studies show that consumption of opioid analgesics in most of the world remains far below that required to address the needs of patients with moderate to severe pain.[14,15]

Duthey and Scholten, from the WHO’s Department of Essential Medicine and Health Products, analyzed the adequacy of opioid consumption globally for 2010.[14] They compared the actual consumption of strong opioid analgesics with their calculated per capita need. Expressed as a percentage, this generates the Adequacy of Consumption Measure (ACM).

Table 2 shows the descriptive levels of adequacy and the proportion of the global population at each level.[14] The ‘virtually no consumption’ group represents 4.65 billion people who have next to no access to opioids for relief of moderate to severe pain. Largely, these people live in countries in the WHO Africa, South-East Asia and Western Pacific regions. Only 529 million people live in countries with an adequate consumption level. These countries are all located in the WHO American and European Regions (with the exception of Australia), and all are highly developed.[14]

Table 2. Level of adequacy of opioid consumption in the global population[14]

Adequacy of consumption ACM range Global population
Adequate ≥100% 8%
Moderate ≤30% to <100% 4%
Low ≤10% to <30% 3%
Very low ≤3% to <10% 10%
Virtually no consumption <3% 66%


Click on the interactive data map below to explore these findings in more detail.

map_Explore

Barriers to opioid access and use are complex and multilevel

Many barriers preventing ready access to opioid analgesics exist due to their abuse potential.[14] However, measures taken to avert opioid abuse hinder access for legitimate medical purposes.[14] These barriers arise at multiple levels, including the physician, patient and governmental or regulatory level. Table 3 outlines some of the main barriers to adequate opioid prescribing for pain relief.

Table 3. Barriers to opioid prescribing for pain relief[3,8,14,16,17]

Barrier source Nature of barrier
Physicians
  • Lack of adequate training in opioid use[16]
  • Lack of adequate training in pain assessment[17]
  • Lack of focus on pain as a priority in patient care[8]
  • Lack of standardized guidelines or protocols for opioid use[3]
  • Fear of opioid addiction or opioid misuse[16,17]
  • Burden of mandatory record keeping
  • Fear of regulatory scrutiny or legal prosecution[8,17]
Patients
  • Fear of opioid addiction[16,8]
  • Fear of opioid-related side effects[8]
  • Under-reporting of pain/belief in inevitability of pain[8]
  • Cost of drugs or lack of reimbursement[8]
  • Social stigma associated with opioid use[17]
Legislation/ government
  • Excessive controls to prevent diversion, abuse and dependence[14]
  • Lack of focus on pain relief as an key medical goal[8]
  • Dispensing restrictions
    • Limiting opioid availability to authorized locations/ centers[17]
    • Limits on indications, dose or duration for prescriptions[17]
  • Poor healthcare infrastructure/lack of funds
  • Inadequate access to specialized pain care


Future directions: Addressing inadequate and inequitable opioid accessibility

Duthey and Scholten’s study identifies the countries and regions worldwide where opioid consumption falls greatly short of need.[14] Many of these countries are located in South-East Asia, and the Association of South-East Asian Pain Societies (ASEAPS) names access to pain-relieving medication as a critical problem for the region.[18] Their Manila Declaration, an offshoot of the IASP’s Declaration of Montréal,[2] represents an urgent call to improve access to and availability of essential medicines.[18] Through education, advocacy, and collaboration, members of ASEAPS are committed to eliminating the barriers that restrict the distribution of pain medications for legitimate medical use.

Clearly, an enormous amount of work remains to be done before universal pain management becomes a reality. This will entail a combination of approaches targeted at all the levels at which resistance or barriers exist, including physicians, patients, policy makers, medical societies, legislators and governments.[3] ASEAPS is building on the example of the IASP, and it is hoped that other stakeholders around the world will also champion the cause in their regions to take the message and the initiatives further.

While such a vast proportional of the global population continues to suffer pain needlessly, improving access to opioid analgesics and other essential medicines remains an ethical imperative worldwide.

References:

  1. 1. United Nations Office on Drugs and Crime. Single Convention on Narcotic Drugs, 1961. As Amended by the 1971 Protocol Amending the Single Convention on Narcotic Drugs, 1961. New York, NY: United Nations; 1972. Available at: www.unodc.org/pdf/convention_1961_en.pdf. Accessed April 2015.
  2. 2. International Association for the Study of Pain. Declaration of Montréal. Declaration that Access to Pain Management is a Fundamental Human Right; 2010. Available at: www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=1821. Accessed April 2015.
  3. 3. Brennan F, Cousins MJ. Pain Relief as a Human Right. Pain: Clinical Updates 2004;15:1-4.
  4. 4. Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health 2011; 11:770.
  5. 5. International Association for the Study of Pain, European Federation of IASP Chapters. Fact Sheet. Unrelieved pain is a major global healthcare problem. Available at: www.iasp-pain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/20042005RighttoPainRelief/factsheet.pdf. Accessed April 2015.
  6. 6. Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287-333.
  7. 7. Harstall C, Ospina M. How prevalent is chronic pain? Pain: Clinical Updates 2003;11:1-4.
  8. 8. Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol 2009;20:1420-1433.
  9. 9. van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG, et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 2007;18:1437-1449.
  10. 10. World Health Organization. Cancer. Factsheet No297. February 2015. Available at: www.who.int/mediacentre/factsheets/fs297/en/. Accessed April 2015.
  11. 11. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 2012;13:e58-e68.
  12. 12. World Health Organization. Cancer pain relief with a guide to opioid availability. 2nd ed. Geneva: The Organization; 1996.
  13. 13. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-130.
  14. 14. Duthey B, Scholten W. Adequacy of opioid analgesic consumption at country, global and regional level in 2010, its relation to development level and changes compared to 2006. J Pain Symptom Manage 2014;47:283-297.
  15. 15. Seya MJ, Gelders SF, Achara OU, et al. A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels. J Pain Palliat Care Pharmacother 2011;25:6-18.
  16. 16. Jamison RN, Sheehan KA, Scanlan E, et al. Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Manag 2014;10:375-382.
  17. 17. Taylor AL, Gostin LO, Pagonis KA. Ensuring effective pain treatment: a national and global perspective. JAMA 2008;299:89-91.
  18. 18. Association of South-East Asian Pain Societies. Manila Declaration; 2015. Available at: aseaps2015.org/wp-content/uploads/2014/04/Manila-Declaration-ASEAPS-2015.pdf. Accessed April 2015.

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