Global opioid usage: Is it a feast or famine affair?
By Smrithi Sriram
St George's, University of London
Pain relief is a key challenge in disease management and is a universal human right. Opioids are drugs that are essential in alleviating pain, but side effects such as tolerance, increased sensitivity to pain and dependence can arise from incautious usage .
The inequalities in global opioid is reflected in the WHO’s (World Health Organization) 2003 report where 6 developed countries took up 79% of the global morphine consumption and developing countries utilized only 6% . This inequality in opioid availability prevents patients in pain suffering in poverty from being entitled to their basic human right.
On one hand, developing countries are adopting strategies to increase their consumption shortage ergo treat pain better whilst on the other hand developed countries are dealing with their opioid epidemic by preventing misuse and overdose. Whilst the opioid disparity seems like a feast or famine affair between developed and developing countries, I felt the importance to question if the lack of consumption of opium in developing countries arises solely due to overuse by developed countries?
Low- and middle- income countries
Patients in low- and middle- income countries (LMIC) face setbacks within their countries as seen in Latin America, Malaysia, India and Africa.
Developing countries face cultural barriers reflected in their laws governing opioid consumption like in Latin America where the cost of licensing, import, distribution and restriction on storage and sales contribute to the hike in opium’s retail price . This makes opioid unaffordable to patients suffering in poverty. In addition to the financial burden, cancer facilities are not easily accessible by all, as seen in India .
In Malaysia 46% of physicians suggested they did not have sufficient medical training to tackle cancer pain, in addition to this patient had the fear of addiction due to confusion with laws of opioid usage .
Countries like Africa where the HIV/ AIDS pandemic exists in par with cancer pain suffer from drug availability, consuming less than 1mg per capita compared to the global mean consumption of 5.99mg per capita .
Europe, Canada and the United States of America consume a large proportion of opioids globally, with United States being well known for “The American opioid crisis”. The presence of private practices in America means the goal is patient satisfaction, which leads to over prescription of opioids for cancer and non-cancer pain. This leads to the risk of overdose and addiction, killing about 130 Americans every day and causing issue with personal relationships and finances .
However, to combat this, safer alternatives exist but insurance plans set require prior approval and higher prices. In addition to this, insurer have set many hurdles for approving addiction treatments than for opioids itself .
WHO came up with a 3-step ladder model (figure 1) for analgesics which provides cost-effective treatment plans. Though this is just one solution more models should be made to serve the complexity of pain treatment. Other solutions such as change in drug delivery methods also prove to be an effective solution .
Figure 1. WHO, 2020. WHO cancer pain ladder for adults.
Feast or famine
Though, some countries follow solutions like better education in pain management for physicians, awareness of the gift and burden of opioids to public and efforts to change political views WHO suggests the disparity still exists. Whilst it seems right to conclude that developed countries are responsible for the consumption gap, it cannot be a certain answer due to setbacks within each LMIC that has to be addressed.
 Trang et al, 2015. Pain and Poppies: The Good, the Bad, and the Ugly of Opioid Analgesics
 Manjiani et al, 2014. Availability and Utilization of Opioids for Pain Management: Global Issues
 CDC, 2020. Opioid basics (Understanding the Epidemic)
 Thomas and Ornstein, 2017. Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers