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1992 Joranson DE. Progress and issues in opioid
availability. IASP Newsletter
1992;(July/August):9-10.
Progress and Issues in
Opioid Availability
David E. Joranson, MSSW
David E. Joranson is Associate Director
for Policy Studies, Pain Research Group,
University of Wisconsin Medical School,
Madison, Wisconsin
Oral opioids such as morphine are the cornerstone of global efforts to relieve pain in cancer
(WHO 1990). The
World Health Organization considers a country's morphine consumption to be an important
indicator of progress
in pain relief. While global morphine consumption has been low and stable for many years,
an increase began in
1984, coincident with the inception of the WHO cancer pain relief program.
In 1990, approximately 80% of all morphine was consumed in only 10 developed countries
that have consistently
ranked highest in per capita consumption: Australia, Canada, Denmark, Iceland, Ireland,
New Zealand, Norway,
Sweden, the United Kingdom, and the United States (UN 1991). The remainder was
consumed in 133 other
countries representing most of the world's population. But the largest percentage increases
have occurred in some
countries with historically low per capita consumption. For example, from 1984 to 1990
the reported use of
morphine increased significantly in: Germany (former FRG) (900%), France (733%), Israel
(700%), Finland (667%),
Norway (627%), Spain (513%), Austria (367%), Japan (307%). Furthermore, morphine
has recently become
available for the first time in Mexico, Vietnam, and India (Anon 1988, 1989a, 1989b;
Bhatia 1990). Nevertheless,
over 60 countries reported no morphine consumption in 1990.
The Single Convention on Narcotic Drugs, a drug control treaty that has been ratified by
more than 130 governments, recognizes that: (1) opioids are indispensable for the relief of pain, and (2) their
availability for the treatment
of pain must be ensured (UN 1961; Angarola 1990). However, there are a number of
factors that may limit a
country's use of opioid analgesics, including lack of awareness about the cancer pain
problem, lack of health care
resources and training, absence of national commitment to cancer pain relief, insufficient
manufacture of opioid
analgesic medications, and anti-drug laws or their implementation (WHO 1990; UN
1989).
In 1989 the International Narcotics Control Board (INCB) expressed concern that the
medical need for opioid
analgesics throughout the world is not being met, and called on member governments to
reevaluate their needs for
opioids in the treatment of pain, especially cancer pain (UN 1989). The INCB asked
governments to: (1) examine
the extent to which their health care systems and drug laws and regulations impede
availability of opioid analgesics,
and (2) develop action plans to correct the situation. The INCB has written to national drug
control authorities to
assess their response to these recommendations.
Excessive legal constraints on the medical use of opioid analgesics for the treatment of pain is a
topic of increasing
discussion in the pain management community. Efforts have begun to identify regulatory
impediments (Joranson
1990a; Caraceni 1987; Zenz and Sorge 1991; Jage 1991; Rogers 1986; Angarola and Wray
1989). Such efforts should
distinguish between perceived and real regulatory impediments. The identification and removal
of real regulatory
impediments should be undertaken in cooperation with drug regulatory authorities; they have a
dual responsibility to
guard against diversion and abuse and also to ensure opioid availability for medical use.
Regulators need to have up-to-date information about the medi cal need for opioids in their
countries so that the national estimate of need that is
submitted annually to the INCB is adequate. In several countries, professional groups are
working with regulators
to change drug regulations that impede pain management (Anon 1990a; 1990b: Joranson et al. in
press; Joranson
1990b; Dahl et al. 1989). It is critically important for cancer pain workers to establish and
maintain a dialogue with
their national drug regulator (UN 1990). Guidelines for improving opioid availability consistent
with international
treaties have been prepared for health workers and regulators by a WHO Expert Committee and
will soon be available
(WHO in press). National and international studies of drug regulation, opioid availability and
regulatory impediments
are needed; the author is interested in collaborative efforts.
References
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benefits and risks, J. Pain
Sympt. Manage., 5 (1990) S6-S11.
Angarola, R.T. and Wray, S.D., Legal impediments to cancer pain treatment. in: Hill C., W.S.
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