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1997 Joranson DE, Gilson AM. U.N. Agency: Global Action
Needed to Improve Opioid Availability. APS Bulletin. 7(2): 10-11.
U.N. Agency: Global Action
Needed to Improve Opioid Availability
David E. Joranson, MSSW; Aaron M. Gilson, MS MSSW
Editor's note: For the November/December 1995 issue of APS Bulletin, Robert T. Angarola and I
wrote
"International Efforts Under Way to Provide Adequate Medication for Pain Control" (Angarola
& Joranson,
1995). This article reports the results of the international survey of governments conducted by
the International
Narcotics Control Board in 1995 and presents the board's recommendations for action to correct
inadequate
availability of opioids for medical uses.
The International Narcotics Control Board (INCB) has published a survey of national
governments on the
worldwide availability of opioid analgesics for the relief of pain in cancer, AIDS, and other
conditions (INCB,
1995). INCB is an agency within the United Nations International Drug Control Program,
headquartered in
Vienna. INCB has the responsibility to monitor national implementation of the principal
narcotic control treaties,
the 1961 Single Convention on Narcotic Drugs (United Nations, 1977a) and the
1971
Convention on Psychotropic Substances (United Nations, 1977b).
The Single Convention specifically recognizes the need to ensure medical
availability of opioids, as
well as to prevent their diversion and abuse. INCB invited the International Association for the
Study of Pain
(IASP) to comment on the report. In response, IASP surveyed its national chapters, including
the American Pain
Society (APS). INCB's report summarizes the responses from IASP national chapters. Several
of the board's
recommendations for action are directed not only to national governments, but also to health
professionals and
IASP.
Overview of survey results
Of the 209 governments surveyed, 65 (31%) responded; these governments represent 50%
of the world's
population. Less than half (48%) of this sample of national governments reported that
morphine - in any dosage
form - was stocked in all hospitals with cancer programs. Thirty-six governments (55% of the
sample) indicated
they had examined their healthcare systems and laws and regulations for impediments to opioid
availability. Only
four governments did not identify impediments; the remaining 32 identified an average of five
impediments from
a list of 13. The most frequently identified impediment was concern about addiction. Most of the
identified
impediments were related to concerns about addiction, diversion, restrictive drug laws,
insufficient importation of
opioids, and inadequacies in healthcare systems.
Over half (54%) of the governments indicated that their countries experienced periodic
unavailability of opioids
due to insufficient importation, delays in distribution, unanticipated increases in demand,
administrative delays, or
insufficient manufacture. It was also evident that some governments have difficulty estimating
the amounts of
opioids needed each year; 60% reported having had to request permission from INCB to amend
their annual
authorization to allow for increases in morphine, fentanyl, and pethidine (meperidine).
National governments also identified numerous legal restrictions on opioids. Many
governments indicated that
their laws carried tough penalties for violation of prescribing requirements and had provisions
that (a) required the
reporting to the government of patients who were prescribed opioid analgesics, (b) restricted the
maximum doses
of opioids, and (c) limited the amount of opioids that physicians could prescribe for
patients.
Less than half (48%) of the governments reported that their national narcotics law
recognizes that opioids are
indispensable for the relief of pain and suffering, although this is a fundamental principle of the
Single
Convention. Only 63% had a law recognizing the government's duty to ensure availability
of opioids for
medical purposes.
Over half of the responding governments (65%) indicated they had national policies to
improve the medical use
of opioids. These policies focused principally on cancer and acute pain, with some attention to
chronic pain,
AIDS pain, and pediatric pain.
Conclusions
After reviewing the data, the board concluded that the medical need for opioids is far from
being satisfied.
Although a small but significant number of governments is making efforts to address
impediments and to improve
the availability of opioids for medical uses, many problems remain that should be addressed.
With regard to
regulatory restrictions on opioids, INCB said that such controls should not be so strict that they
eliminate, for all
practical purposes, the availability of opioids for medical uses.
Recommendations
INCB's recommendations are a blueprint for actions by national governments, the World
Health Organization
(WHO), health professionals, and nongovernmental organizations. Recognizing the need for
further action of its
own, INCB said it would continue to examine the situation and would examine the adequacy of
the national
governments' annual estimates of opioids. In the year 2000, INCB will reevaluate progress
toward improving
opioid availability and issue new findings and recommendations.
Significance of the INCB report
Implementation of the WHO's three-step analgesic method for cancer pain relief is often
impeded by drug
regulatory and health system impediments at the national level (WHO, 1990). WHO
recommends a three-part
national strategy of policy, education, and drug availability to correct this situation (WHO,
1996). The new report
from INCB complements recommendations from international health authorities by urging
government narcotics
regulators to collaborate with health professionals to identify and address impediments to opioid
availability and
to ensure that each government's annual estimate adequately covers the country's medical needs
for
opioids.
The INCB report offers a strong rationale for national IASP chapters, national palliative
care associations, and
cancer care institutions to develop working relationships with their national narcotics regulators
to improve opioid
availability for the patient.
APS has responded to this challenge. The APS Board of Directors has asked the Analgesic
Regulatory Affairs
Committee to prepare a plan of action for implementing the INCB recommendations in the
United
States.
Availability of the INCB report
The INCB report, Availability of Opiates for Medical Needs (1995) is
available from the
International Narcotics Control Board, Vienna International Centre, Room E-1313, PO Box 500,
A-1400 Vienna,
Austria, as U.N. Publication No. E.96.XI.6. It is also available on the World Wide Web at http://www.undcp.org:80incb_hp.html.
The WHO Collaborating Center for Policy and Communications has also published a
special issue of Cancer
Pain Relief about the INCB report for world wide distribution, in English, French and Spanish
(Joranson &
Colleau, 1996).
Single copies and subscription information are available from the WHO Collaborating
Center, Pain & Policy
Studies Group, 1900 University Avenue, Madison, WI 53705.
