Thursday, October 28, 2010

World Opioid Consumption

Image from www.painpolicy.wisc.edu
The Pain & Policy Studies Group (PPSG) at the University of Wisconsin recently released its figures for 2008 comparing the opioid consumption of all the countries reporting to the INCB (International Narcotics Control Board).  I am always fascinated by these reports.  One because I always find it shocking, and it helps my palliative care advocacy flame burn brighter.  Two, because the information makes a great graphic for talks on why palliative care is necessary world-wide.  Some day, I hope to not find them so interesting, but unfortunately I think that day is still distant.  


Let's face it, almost everyone wants to avoid the experience of severe pain personally and for their loved ones.  The reality, as illustrated by the interactive DCAM (Drug Control and Access to Medicines) Consortium Opioid Consumption Map, is that most of humanity does not have that luxury.

Guess which color is > 10 mg morphine/capita
Image from www.dcamconsortium.net




We know that a very small number of countries consume the great majority of opioids.  Christian has previously written about the International Pain Crisis, and his post links to four others on this topic.  One might deduce from looking at the multicolored map that the U.S. has too much compared to the rest of the world.  In fact, one just has to walk into most any hospitals in the U.S. to see that pain in our own country is not well controlled despite having almost 648 mg morphine equivalents/capita.  What does this mean for the others, like Japan, which has 19.3 mg morphine equivalents/capita, or for Nigeria which has 0.018 mg morphine equivalents/capita?  The answer... lots of untreated pain.

The scope of the problem is dizzying.  All these countries have people who have painful acute and chronic illnesses, sustain traumatic injuries, and require surgery.  The least fortunate of these people have access to very small quantities of opioids if any, many times the weaker ones like codeine or tramadol.  They often use NSAIDs and acetaminophen (paracetamol) with all the inherent morbidity and mortality of these supposedly safer drugs. 


So what is the problem?  Opiophobia, lack of affordable, reliably-produced opioids for manufacturing and political reasons, restrictive drug laws, lack of education for doctors, pharmacists, nurses, and in some places, the lack of a coordinated health care system itself.  The list goes on and on.  When countries do get opioids, sometimes they get the expensive ones, like fentanyl patches, without getting an adequate, reliable supply of the much cheaper morphine first.  I'm not against fentanyl patches or the many benefits of a diverse selection of opioids.  I think that is all just fine and dandy.  However, with limited funds spent on the more expensive opioids when cheaper ones would do, it stands to reason that less people get treated especially in the very low resource countries.  I won't even start to discuss issues involved in opioids and managment of dyspnea, other than to say "Uff-dah!" (that's for you, Drew).

Just for the sake of curiosity, I tagged all the places I've been on the morphine equivalents chart. (Ukraine didn't report for 2008.  Taiwan isn't yet recognized by the WHO or UN (a topic for a different blog), and so is not included.)


Image from www.dcamconsortium.net


Huh!  Where I'm especially grateful I didn't get injured.... noted.  Good thing I buy travel AND ambulance jet insurance.  Please know I am not commenting on the quality of the healthcare in these countries.  But, with more pain medication access, I would argue that whatever quality, high or low, of the rest of their health care system, the quality of palliative care, and therefore care in general, would improve.  

Thankfully, the folks at PPSG are working to improve access to opioids for people across the globe. The Opioid Consumption Overview is just one of the many things they do.  They collect and evaluate state policies that govern pain management, and have added their voice to the REMS debate here in the U.S. They have also been busy trying to change those international opioid consumption data sets through a myriad of activities, including the International Pain Policy Fellowship program, which started in 2006. The goal of this program is to assist low and middle income countries to have improved access to the pain medications on the WHO essential medications list through drug policy advocacy.  (Click here for an article describing some of the work of one of the fellows.) It is supported by the Open Society Foundations (formerly Open Society Institute) and LIVESTRONG.  A big thanks to both of those organizations for their support of the fellows!

Finally, I would be remiss if I did not mention how impressed I have been with the creativity and knowledge of some of my international palliative medicine peers who have limited access to opioids.  Those who have a strong grasp on pharmacology can craft a sophisticated adjuvant medication plan with the anticonvulsants, steroids, antidepressants, NSAIDS, acetaminophen, etc. they do have. However, they would all say that they could provide much better palliation with more opioids in their toolkits.


By the way, has anyone else noticed our own supply issues? I keep getting emails from my pharmacists telling me that one medication or another is on backorder.  I'm sure many of you are changing your patients' medications to deal with the problem.  I know I have had to at times.  Manufacturing aside, there is the need for more prescriber education, and a separate concern about REMS... so we are not done here at home.  


It truly will take a village, or maybe one big interdisciplinary team, to improve access to opioids and palliative care at home and around the world.  Other wonderful resources for information on international palliative medicine efforts and resources are IAHPC (International Association for Hospice and Palliative Care) and IPCRC.net (International Palliative Care Resource Center).  Final thought, I want to close by thanking AAHPM for offering a free International Corresponding membership and adding scholarships to the Annual Assembly for physicians from HINARI countries this year.  Bravo!   


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