Jim Cleary, Director of the Pain & Policy Studies Group, University of Wisconsin, USA, introduces a research study that has been selected as this month’s ‘Editor’s choice’ in Palliative Medicine.
For almost two decades, the Pain & Policy Studies Group (PPSG) has examined national opioid consumption data as an indicator of the opioids available in a country for cancer pain relief and palliative care. We have consistently found that a small number of mostly high-income countries consume about 90% of the world’s morphine each year, while the remaining countries, comprising over 80% of the world’s population, consume the rest (less than 10%).
In recent years, numerous United Nations authorities, including the Economic and Social Council, the World Health Assembly, the World Health Organization and the International Narcotics Control Board (INCB), have called attention to this striking disparity and urged governments to improve pain relief by ensuring opioid availability for medical purposes. So, what factors account for this enduring discrepancy in morphine consumption among countries?
The international pain and palliative care community has developed a solid understanding of the barriers to adequate opioid availability, and has even found common barriers in both high and low- and middle-income countries (LMICs). However, there has never been a statistical analysis of these influences on opioid availability in a large sample of countries.
We’re delighted that our study has been selected as ‘Editor’s choice’ in the February edition of Palliative Medicine.1 It reflects PPSG’s effort to examine country-level characteristics to determine what accounts for the significant disparity in opioid consumption levels among countries.
After extensive exploration of valid, complete, and available data sources, we included five factors in our analysis:
- Level of Palliative Care Development
- Human Development Index (HDI)
- Number of physicians per 10,000
- Governments’ consistency of submitting reports to the INCB
- Proportion of government funds spent on healthcare.
All of these factors, except for number of physicians in a country, were significantly associated with higher opioid consumption.
A country’s HDI was the most highly predictive factor – those with high HDI demonstrated very high opioid consumption. Increasing HDI, however, is not a necessary component of improving availability of needed medications. Experience confirms that LMICs, with lower HDIs, have been successful at enhancing opioid availability and pain relief.
Positive changes have occurred when countries adopted policies that foster a healthcare infrastructure for pain and palliative care that facilitates appropriate distribution of medications and lessens onerous legal or regulatory restrictions. Such improvements were possible only with full cooperation between healthcare experts and government officials. For example, working with palliative care experts, the Vietnamese government recently amended regulations to repeal a daily maximum dose limit and expand the type of patients permitted to receive an opioid prescription. This is only one of many countries that have achieved similar change.
Working towards change is vital
While our statistical findings provide an important baseline for future research, multiple LMICs have demonstrated through their impressive efforts that an essential predictor for improving opioid availability and pain control is a willingness to work towards positive change. For people suffering from debilitating pain, such successes offer the prospect of enhanced quality of life.
1. Gilson AM, Maurer MA, LeBaron VT, Ryan KM, and Cleary JF,
Multivariate analysis of countries’ government and health-care system influences on opioid availability for cancer pain relief and palliative care: More than a function of human development, Palliative Medicine, February 2013, 27: 105-114, first published on October 26, 2012, doi: 10.1177/0269216312461973. (To download a copy of this paper, please see below).
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