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1994 Joranson DE. Global opioid consumption: trends,
barriers,
and diversion.
IASP
Newsletter 1994 September/October:4-5.
Global Opioid Consumption:
Trends, Barriers, and Diversion
David E. Joranson, MSSW
Pain Research Group, University of Wisconsin Medical School, and World Health
Organization Collaborating
Center for Symptom Evaluation in Cancer Care, Madison, Wisconsin, USA
Programs to improve cancer pain relief are growing worldwide. Strong opioid analgesics
such as morphine must
be available to caregivers who manage severe cancer pain (WHO, 1986). In fact, the World
Health Organization
(WHO) uses morphine consumption as one indicator of progress to improve cancer pain relief
(WHO, 1990). Although
the commercial availability of opioid analgesics in the United States is generally sufficient for
medical needs, this is
not true for the majority of the world's population. This article summarizes recent trends in
global opioid consumption
and suggests a method for assessing barriers to opioid availability, with a discussion of the risk
of opioid diversion
(Joranson, 1993).
In nearly half of the countries in the world, there is little or no use of morphine. Almost all
of the morphine that is
produced for medical purposes is consumed in developed countries. Although these countries
also use other opioid
analgesics, consumption of morphine continues to be used as an indicator, because morphine is
widely accepted and
used throughout the world and because reasonably good data are available.
Global morphine use, low and stable for many years, finally began to increase in 1984 with
the inception of the
WHO cancer pain relief program. By 1991 (the most recent year for which statistics are
available), global
consumption of morphine had increased by 272% over 1984 consumption. As of 1991, the 10
countries with the
highest consumption of morphine used 57% of the world supply (in alphabetical order):
Australia, Canada, Denmark,
Iceland, Ireland, New Zealand, Norway, Sweden, the United Kingdom, and the United States.
The top 20 consumer
countries, all of which are developed countries, consumed 86% of the morphine in the world.
The remaining amount
was consumed by countries that have the majority of the world's population.
The United Nations health and narcotic control agencies have recognized that insufficient
use of opioid analgesics
is traceable to several barriers, including restrictive laws and regulations that interfere with
opioid production and
distribution. According to the International Narcotics Control Board (INCB): "Prevention of
availability of opiates
for medical use does not necessarily guarantee prevention of the abuse of illicitly procured
opiates. Overly restrictive
approaches may, in the end, merely result in depriving a majority of the population access to
opiate medications"
(United Nations, 1989a).
Health professionals should understand how the international and national drug regulatory
systems work so they can
effectively identify and address barriers to opioid availability. Many professionals may not
know, for example, that
their country's narcotic control laws are supposed to ensure the availability of opioids for medical
needs. The WHO
Expert Committee on Cancer Pain Relief and Active Supportive Care recently released a Guide
to Opioid Availability
to educate health professionals who want to improve opioid availability in their countries (WHO, 1993). The guide
explains regulatory systems that can make opioids available - or unavailable - and encourages
cooperative efforts with
national drug regulators.
For example, the Expert Committee comments on special multiple copy prescription
programs used by some governments: "The extent to which these programmes restrict or inhibit the prescribing of opioids to
patients who need them
should be questioned.... Health care workers may be reluctant to prescribe, stock, or dispense
opioids if they feel that
there is a possibility of their professional licenses being suspended or revoked by the governing
authority in cases
where large quantities of opioids are provided to an individual even though the medical need for
such drugs can be
proved" (WHO, 1990).
The 20-page guide also explains how the "national estimate" of medical need for opioids is
established and how it
can be changed. General recommendations are made for the regulation - not over-regulation - of
health professionals
who prescribe, dispense, and administer opioids. The guide is now available in Spanish, due to
the efforts of health
professionals in Colombia and the Colombian Ministry of Health.
Professionals who understand both cancer pain problems and the drug regulatory system
are better prepared to take
actions to address barriers to opioid availability. A systematic process should be used, beginning
with the
identification of the barriers in a particular country or province. A brief questionnaire is
available to help health
professionals identify barriers at different points in the drug distribution system and to assess the
relative importance
of each (Joranson, 1993).
After barriers to availability are identified, an action plan should be developed to remove
them. The appropriate
individuals or organizations should contact government agencies, policy makers, pharmaceutical
manufacturers, and
other private industries to begin a dialogue that leads to mutual understanding and change. The
goal is to achieve a
positive regulatory climate that clearly recognizes the rational use of opioid analgesics to manage
cancer pain.
Drug abuse is a reality throughout the world. Regulators and health professionals must
share the responsibility for
preventing diversion of opioids to illegal uses. All professionals who use controlled drugs
should follow reasonable
procedures to prevent diversion. The INCB has determined that controls over opioid distribution
in the world are
working well and the diversion of morphine is small compared to the large volume distributed
(United Nations, 1989b).
In the United States, although morphine use has increased significantly, diversion of controlled
substances (including
opioids) has been decreasing.
The educational and policy work of the Wisconsin Cancer Pain Initiative (WCPI) and the
Pain Research Group at
the University of Wisconsin have focused unprecedented attention on the rational use of opioid
analgesics throughout
the state. From 1986 to 1990, morphine consumption in Wisconsin increased by 160% (from
421 to 1093 kg),
exceeding the national average by 21% in 1990. The number of cases in which prescription
morphine was seized by
police was less than 10 per year during this five-year period. Compared with the several hundred
cases of serious
amphetamine diversion per year in the 1970s, the frequency with which morphine and other
opioid analgesics has
appeared in recent police reports is very low (Joranson, 1993).
The use of opioid analgesics can increase significantly without increases in opioid
diversion and abuse, if reasonable
controls are exercised during drug distribution. If diversion occurs, the answer is to stop those
responsible for
diversion, not to limit the necessary medical supply or distribution of opioids to
patients.
References
Joranson, DE. Availability of opioids for cancer pain: recent trends, assessment of system
barriers, new World
Health Organization guidelines, and the risk of diversion, Journal of Pain and Symptom
Management, 8 353-360. (1993)
United Nations. Report of the International Narcotics Control Board for 1989: Demand for and
Supply of Opiates
for Medical and Scientific Needs. United Nations, Vienna, 1989a.
United Nations. Report of the International Narcotics Control Board for 1989. United
Nations, Vienna,
1989b.
World Health Organization. Cancer Pain Relief. World Health Organization, Geneva,
1986.
World Health Organization. Cancer Pain Relief and Palliative Care, Report of a WHO
Expert Committee, World
Health Organization. Geneva, 1986.
World Health Organization Cancer and Palliative Care Unit. Cancer Pain Relief- A Guide
to Opioid Availability.
World Health Organization, Geneva, 1986.