Global disparities persist in opioid painkiller access

Global opioid sales increased by an estimated 4% annually from 2015 to 2019, but massive disparities in access to essential pain relief medications persist between countries, finds a study led by UCL researchers.

Opioid use in some countries in Africa and South America was less than one tenth of 1% of the rates in wealthier countries in North America, Europe and Australia, according to the findings published in The Lancet Public Health.

Some countries are starting to catch up, as the overall picture is one of gradual geographic convergence in opioid consumption.

North America has seen a decline in opioid use, likely the result of efforts to reduce inappropriate prescribing to curb deadly opioid misuse, so multiple European countries, led by Switzerland, Germany, and Spain, have surpassed the United States in opioid sales.

Lead author Dr Wallis Lau (UCL School of Pharmacy) said: “We found that while there is some improvement in a lot of countries, there are still concerningly low rates of opioid use in large parts of the world, even in numerous middle-income countries.

“Opioids have been listed by the World Health Organization as an essential class of medicine for acute pain, cancer-related pain, and palliative care since 1977, so it is troubling that in many parts of the world, people are unable to access this medicine. There is an urgent need to tackle the global gap in opioid access.

“Some countries have low opioid analgesic consumption despite a high cancer prevalence, which could suggest inadequate access to opioid analgesics as much-needed pain control.”

The researchers analysed the global pharmaceutical sales data of 66 countries or regions from the IQVIA-Multinational Integrated Data Analysis System database on opioid analgesics (painkillers) between 2015 and 2019. This included medications such as morphine and codeine, and included both prescription and over-the-counter medications.

They found that across the surveyed countries, opioid analgesic sales increased from 27.52 milligram morphine equivalent per 1,000 inhabitants per day in 2015, to 29.51 in 2019.

The highest rate was found in Canada, at 988 MME per 1,000/day, which had gone down from 1,581 in 2015.

For comparison, the UK rate was at 639 MME per 1,000/day, a slight decline from 2015.

At the other end of the scale, a group of 12 West African countries reported only 0.01 MME per 1,000/day, while a few other countries, including three in South America, also reported rates below 1 MME per 1,000/day.

The researchers say the disparities go beyond factors such as wealth, overall healthcare network quality, or cancer rates, as there are differences in attitudes of doctors and patients towards the use of opioid pain killers. Some relatively wealthy countries such as the United Arab Emirates and Saudi Arabia reported very low rates, at 0.79 and 1.24, respectively, while some countries like Kazakhstan reported low rates of opioid consumption (5.4) despite high cancer prevalence or cancer death rates.

Opioid consumption rates did increase across the study period in most areas that reported low use, including Eastern Europe, Asia, and South America, but not in Africa.

Joint senior author Professor Ian Wong (UCL School of Pharmacy and University of Hong Kong) said: “These findings reinforce the need to recognise palliative care and pain relief as a global public health priority. In countries that already have good access to opioid analgesics, it is important to avoid opioid misuse and overprescribing, without leaving patients undertreated.”

First author, PhD student Chengsheng Ju (UCL School of Pharmacy) said: “Our data calls for global policies to improve the integration of palliative care and pain relief provision into healthcare systems, as well as the promotion of end-of-life care education and staff training.”