A recently published report by the World Health Organization (WHO) titled “Left behind in pain: extent and causes of global variations in access to morphine for medical use and actions to improve safe access” discusses significant disparities in the consumption of narcotic analgesics between countries. The report also presents the results of expert surveys, particularly regarding measures that could be crucial for ensuring patient access to narcotic analgesics.
According to estimates, over 95% of all opioids (in morphine-equivalent doses) are distributed in high-income countries, while only 0.03% are found in low-income countries. Furthermore, even if morphine is available in these countries, patients with medical opioid needs typically have access to an average of only 10 mg of morphine-equivalent opioids per year (Knaul F.M. et al., 2018), which is less than half a day’s standard starting dose for adults. Many individuals lack access altogether.
Turkey, Australia, France, and China were the main cultivators of opium poppy (Papaver somniferum) for pharmaceutical production in 2021. From 2015 to 2020, 80% of the global sales of commercially available morphine products in raw form were attributed to 10 pharmaceutical companies (IQVIA, 2022).
In 2021, a total of 33,115 kg of morphine was distributed for medical (and scientific) purposes worldwide. The distribution of morphine for medical consumption was highly uneven, with over 80% allocated to countries in the WHO American and European regions, particularly those classified as high-income by the World Bank. For example, in the American region, the distribution of morphine for consumption was concentrated in the United States (76.7%) and Canada (12.6%).
The consumption of morphine per day and per million population in high-income countries in 2021 amounted to 125.9, 24.9, 6.7, and 2.0 defined daily doses (DDD) for countries with high, above-average, below-average, and low-income levels, respectively. The corresponding figures
for the consumption of other strong opioids, excluding morphine (such as fentanyl, hydrocodone, hydromorphone, oxycodone, and pethidine), were 3,028.6, 152.3, 6.7, and 2.4 DDD respectively.
Interestingly, there is no correlation between the overall level of opioid consumption and the medical need for these medications, as indicated by calculations of the number of days with moderate to severe pain or breathlessness per population (Knaul F.M. et al., 2022). While some low-income countries may have similar needs to high-income countries, they report significantly lower levels of opioid consumption.
Moreover, a systematic review of literature reveals that the frequency of opioid dependence, misuse, or abuse following medical use for pain management is reported at 4.7% (Higgins C. et al., 2018).
To improve safe access, the respondents of the survey identified five priority actions across various regions:
- Creating and implementing a package of essential services and products to promote the rational use of morphine (Americas, Southeast Asia, Eastern Mediterranean regions).
- Establishing affordable pricing for medical morphine (Americas, European regions, Western Pacific region).
- Developing integrated distribution networks (African, European regions).
- Expanding access for individuals with non-cancer and non-HIV-related conditions, as well as children (Americas, European region).
- Enhancing access to long-term care facilities, home care, and hospice institutions (Western Pacific region).
By focusing on these priorities and implementing appropriate measures, global efforts can be directed towards improving the safe and equitable access to narcotic analgesics, ensuring that patients receive the pain management they require regardless of their geographical location or income level.