Most medications in the WHO Model List of Essential Medicines for Pain and Palliative Care, 21st Edition 2019,23 especially controlled substances namely, opioids, are required for the delivery of quality palliative care. Access to opioid medications for pain control is an enormous problem worldwide. Over eighty per cent (84.25%) of the world’s population lacks adequate access to opioid medications for pain control. Australia, Canada, New Zealand, the United States, and several European countries accounted for more than 90% of the global
consumption of opioid analgesics while Low-and-Middle-Income Countries (LMICs) consumed only 10% of global opioids.24 25 26
The UN Single Convention on Narcotic Drugs,27 approved by most countries in 1961, called for balance between mitigating diversion of licit opioids and other psychoactive substances while also allowing for adequate provision of these drugs for medical and scientific use. Since that time, the major focus has remained on control of illicit use of these drugs, and even restricting licit medicines, with little emphasis on enhancing access for medical and scientific use. The worldwide palliative care community and related human rights organizations have advocated for balance to be restored by paying equal attention to both medical use and prevention of illicit use. In 2016, the Commission on Narcotic Drugs (CND) included “access to controlled medicines” as an area of focus in the UN General Assembly Special Session and High-Level Meeting on the World Drug Problem.28 A subsequent 2019 Ministerial Declaration29 reinforced the need and commitment to address the pathos of disparity in access and availability of controlled substances for medical and scientific purposes, especially for pain and palliative care.
While the true need for opioids per capita remains under debate, and will vary by country depending on age, disease rates, causes of death and many other factors, Seya et al30 published an estimate of opioid need for 188 countries. They used average usage in the 20 top countries in the Human Development Index (HDI) as a reference point for development of an adequacy of consumption measure (ACM). According to this analysis 83% of the world’s countries have low to non-existent access to opioids, 4% have moderate access, and 7% have adequate access, while for the remaining 6% of countries insufficient data is available. Notably, recently, Scholten et al31 extended this investigation by using the “adequacy of opioid consumption” (AOC) index and compared it across countries with high HDI. Indeed, the average opioid analgesic consumption of the top-20 countries
Chapter 3 What are the main barriers to palliative care development?
of the HDI increased from 84 morphine milligram equivalents per capita (2000) to 256 morphine milligram equivalents per capita (2015). However, the overall consumption for all countries, due to limited access in most countries was only about 33.25 mg per capita and the consumption of morphine, mainly used in palliative care was less than 5 mg per capita (Table 1).
Key indicators of opioid availability are the reports of opioid usage that are published by the International Narcotics Control Board (INCB)24. There is enormous variability in consumption per capita around the world and many barriers to increasing the availability and consumption of opioids for medical and scientific use. These barriers include overly strict regulation, limitations on available forms of medication particularly oral opioids, lack of supply and distribution systems, limitations on who can prescribe, fear of law enforcement intervention into medical use, and so forth. In this regard, in using the INCB data for practical application, Gilson et al32 revealed the relevance of a morphine equivalence (ME) metric in demonstrating the extent that morphine consumption relates to total consumption of other widely used licit opioids. It is that metric that is reflected in the maps below (Figures 28 and 29) and are shown for global and country comparisons. Further opioid consumption data and interactive graphics can be found at the Indiana University Walther Centre in Global Palliative Care &
Supportive Oncology website at http://painpoilcy.iu.edu
Population 7510990456
Global Morphine Consumption (mg/person) 4.9281591
ME in mg/person ALL Opioids Minus Methadone
Morphine 4.9281591
Codeine 0.17824061
Fentanyl 15.0297903
Hydromorphone 2.21417603
Pethidine 0.06187702
Oxycodone 10.83745
Total ME in mg/person minus Methadone 33.2496931
Table 1
2017 Global Opioid Consumption Data (International Narcotics Control Board)
Chapter 3 What are the main barriers to palliative care development?
Implementation
Palliative care programme development has been very uneven internationally (see Chapter 4 for mapping of existing services) and is correlated with Human Development Index levels, Universal Health Coverage, and World Bank Income Group.33 Without policy support for palliative care and funding mechanisms, growth is restricted to whatever is achieved by pioneers making sacrifices to create hospice and palliative care services in their communities. To reach the huge numbers of people with palliative care needs that are not receiving the services they need will require further integration into existing health care
systems, including primary care and long-term care. Home based care is especially important and should be prioritised over creating new facilities. Some inpatient care is needed but the vast majority of palliative care services can be delivered in the places people call home.
Figure 28 Morphine use worldwide (Mg/Capita) 2017
Figure 29
Morphine equivalent total opioid use worldwide (minus methadone) 2017
0.00 0.01 - 0.23 0.24 - 1.06 1.07 - 3.49 3.50 - 217.22 Data not available Not applicable
0.00 0.01 - 0.89 0.90 - 4.04 4.05 - 24.79 24.80 - 510.69 Data not available Not applicable
Total Morphine consumption per capita Consumption in mg/person
Total Opioid consumption (minus Methadone) per capita Consumption in mg/person
Chapter 3 What are the main barriers to palliative care development?
Figure 30
Public health model for palliative care development34