Improving access to opioids in Asia: a call to action

30 Jul 2015  |  Print

Improving access to opioids in Asia: a call to action

One versus 41.

Any idea what this equation represents?

It is actually the opioid consumption in mg/capita for the Philippines versus South Korea.[1] The figures demonstrate the wide disparity in access to opioid pain medications across Asia. And the Philippines are not alone – many other countries in the region have similarly low levels of opioid use.

To put this into a global context, figures for the USA (750 mg/capita), Australia (427 mg/capita), Germany (396 mg/capita) and the UK (253 mg/capita) are even higher than South Korea.[1] Furthermore, the consumption of opioids in most Asian countries continues to increase at a slower rate than global averages.[2]

A recent study by the Global Opioid Policy Initiative (GOPI) assessed opioid availability and accessibility for cancer patients in Asia.[2] Their findings may help to explain why opioid use remains stubbornly low.

Formulary availability and regulatory barriers in Asia

The GOPI report notes that there are many barriers to opioid use in this region. All of the following were found in multiple countries across Asia:[2]

  • A requirement for patients to pay the full cost of opioid medications
  • Frequent unavailability of some or all opioid formulations
  • A requirement for permission/registration of patients before they become eligible to receive an opioid prescription
  • A requirement for physicians to receive a special authority/license to prescribe opioids
  • Restrictions on prescription forms (eg, a requirement for duplicate prescriptions, special prescription forms, restrictive access to these forms, or a requirement for payment)
  • Limits on the maximum number of days of opioids that can be supplied on a single prescription (as low as 5-7 days in some countries)
  • The use of stigmatizing terminology for opioid analgesics in regulations.

Overall, over-regulation of opioid prescribing for the management of pain is widespread across the region. Indeed, only five countries (Bhutan, Japan, Indonesia, Nepal and South Korea) were found to have fewer than four significant regulations that restrict access to opioids.[2]

Improving the outlook

There are several areas that need to be addressed to improve opioid access in Asia.[2] The first is availability, given that many countries do not have access to a broad range of opioids. The second area is education. Much still needs to be done to improve understanding of the role of opioids in pain treatment among physicians and patients.[2] The third major challenge is government policy and regulations. In much of Asia, there is an urgent need for regulatory review and the repeal of burdensome barriers to opioid accessibility.[2] Finding a balance between maximizing access for rational medical use and minimizing substance abuse is essential; the WHO has developed guidance on how this can be achieved.[3]

A number of ongoing initiatives are focused on bringing about change. A good example is the International Pain Policy Fellowship, which supports programs in individual countries that aim both to evaluate national policy and to improve access to pain medications.[4]

This initiative has had positive outcomes in several countries, for example Vietnam. Here, the group worked with local partners, including the Ministry of Health, to review all policies concerning opioid accessibility and then developed a plan to safely reduce key barriers.[5] By 2010, morphine consumption had increased nine-fold relative to 2003.

The Manila Declaration

Despite successes in some countries, improving access to opioids remains a great challenge in Asia.

At the recent congress of the Association of South-East Asian Pain Societies in Manila, Philippines (March 2015), a number of delegates signed an urgent call to improve access to and availability of essential pain medicines – the so-called ‘Manila Declaration’ (Table 1).[6]

Even with the advent of this declaration, much work remains to be done to turn the hopes of the Declaration into realities on the ground.

Table 1. Manila Declaration 2015[6]

Recognizing that access to pain relieving medication is a critical problem in Southeast Asia, We, the delegates of the 2015 ASEAPS Congress, having given careful consideration to the issues surrounding access to essential pain medicines in this region, commit to uphold the following:
To enhance the awareness of healthcare professionals, policy makers and national regulatory authorities about unmet needs for opioid analgesics through training and the dissemination of current and relevant educational materials.
2. To ensure a balanced and rational approach to national policies and regulatory restrictions on the sale and use of essential substances by actively participating in policy discussions and consistently engaging with key government stakeholders and patient groups in advocating for the review and updating of existing policies and regulations.
3. To assist in developing a data collection system and contribute to its regular updating in order to support government estimations and research initiatives related to national opioid requirements and access to analgesic treatments.
4. To establish meaningful collaboration among various stakeholders (healthcare professionals, government agencies, payers, patients and families, pharmaceutical companies, and drugstores/pharmacies) for (i) the development of safer, more effective and abuse deterrent opioid analgesics; (ii) the exchange of information regarding availability of these medicines; and (iii) better coordination of efforts towards improving access to essential pain medications.
5. To properly educate patients and families on all available options to manage pain, including the appropriate role of opioid analgesics.


  1. 1.International Narcotics Control Board. Opioid Consumption Motion Chart. Available at: Accessed June 2015.
  2. 2.Cleary J, Radbruch L, Torode J, Cherny NI. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Asia: a report from the Global Opioid Policy Initiative (GOPI). Ann Oncol 2013;24 Suppl 11:xi24-xi32.
  3. 3.World Health Organization. Ensuring balance in national policies on controlled substances. Guidance for availability and accessibility of controlled medicines. Available at: Accessed June 2015.
  4. 4.University of Wisconsin-Madison. Pain & Policy Studies Group. International Pain Policy Fellowship. Available at: Accessed June 2015.
  5. 5.Krakauer EL, Phuong Cham NT, Husain SA, et al. Toward safe accessibility of opioid pain medicines in Vietnam and other developing countries: a balanced policy method. J Pain Symptom Manage 2015;49:916-922.
  6. 6.Sixth Association of South-East Asian Pain Societies Congress. Manila Declaration. Available at: Accessed June 2015.