Developing Countries Lag in Opioid Use for Pain Relief

By C. Vidya Shankar MD

February 26, 2016

NEW YORK (Reuters Health) - Low and medium income countries face many hurdles in providing opioids for pain relief and palliative care, a new analysis found.

"Absence of training and lack of awareness among health professionals" were the main hurdles to use of analgesic opioids in resource poor settings, Dr. Stefano Berterame from the International Narcotics Control Board, Vienna, Austria, told Reuters Health by email.

"Even if these countries may be able to procure the needed opioids they often face the problem of lacking the health infrastructures and palliative care services," he added.

In a paper online February 3 in The Lancet, Dr. Berterame and colleagues note that a United Nations convention has declared that despite their risks, opioids are "indispensable for the relief of pain and suffering."

Yet 90% of global opioid use is restricted to developed countries, while more than five billion people in developing countries have only limited access, the paper points out.

The research team obtained country-specific data for 2001-2013 from the International Narcotics Control Board and sent questionnaires about opioid use to 214 national authorities; responses were received from 106 countries.

Opioid use was calculated for each country in terms of the "defined daily doses for statistical purposes (S-DDD) per million inhabitants per day."

While opioid use had increased more than two-fold during the study period, the gains were restricted to North America, western and central Europe.

Specifically, the S-DDD index (opioid doses per million population) worldwide increased from 1,417 in 2001-2003 to 3,027 in 2011-2013. In North America, it went from 16,046 to 31,453, and in western and central Europe from 3,079 to 9,320 doses.

Africa, Asia, Central America, the Caribbean, South America, East and Southeast Europe reported only minimal gains.

Lack of awareness and training on opioid use was the most common barrier, reported in 34% of the countries. Fear of opioid dependency (32%), financial constraints (30%), supply constraints (29%), cultural barriers (28%), fear of diversion to illicit use (28%), international trade controls (21%) and regulatory issues (18%) were the other reasons reported.

Countries with greater number of barriers had the lowest opioid use, although the differences were not statistically significant when adjusted for gross domestic product and human development index.

"Improvement remains unlikely in the absence of specific strategies," the researchers conclude.

In a related commentary, Dr. James F. Cleary and colleagues at the University of Wisconsin School of Medicine and Public Health in Madison call for a "multi-pronged approach," including better education, affordable opioids, regulatory reforms and implementation of WHO Palliative Care resolutions.

"In our analysis, gross domestic product and human development index have a significant role in determining the use and the presence of obstacles at a country level," Dr. Berterame pointed out.

He concluded, "Without an overall effort on social and economic progress it would be difficult to effectively improve access in low and middle income countries."

This study was funded by the United Nations International Narcotics Control Board.


Lancet 2016.