A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels

Abstract

The objective of this study was to propose a rough but simple method for estimating the total population need for opioids for treating all various types of moderate and severe pain at the country, regional, and global levels. We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world's population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access. Policies should seek a balance between maximizing access for medical use and minimizing abuse and dependence. Countries should aim to increase the medical consumption to the magnitude needed to address the totality of moderate and severe pain.

Full text

Journal of Pain & Palliative Care Pharmacotherapy. 2011;25:6–18.
Copyright ©2011 Informa Healthcare USA, Inc.
ISSN: 1536-0288 print / 1536-0539 online
DOI: 10.3109/15360288.2010.536307
ARTICLE
A First Comparison Between the Consumption of and the
Need for Opioid Analgesics at Country, Regional, and
Global Levels
Marie-Josephine Seya, Susanne F. A. M. Gelders, Obianuju Uzoma Achara,
Barbara Milani, and Willem Karel Scholten
ABSTRACT
The objective of this study was to propose a rough but simple method for estimating the total population need for
opioids for treating all various types of moderate and severe pain at the country, regional, and global levels. We
determined per capita need of strong opioids for pain related to three important pain causes for 188 countries.
These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived
from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels
for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption
for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people
(83% of the world’s population) live in countries with low to nonexistent access, 250 million (4%) have moderate
access, and only 460 million people (7%) have adequate access. Insufcient data are available for 430 million
(7%). The consumption of opioid analgesics is inadequate to provide sufcient pain relief around the world. Only
the populations of some industrialized countries have good access. Policies should seek a balance between
maximizing access for medical use and minimizing abuse and dependence. Countries should aim to increase
the medical consumption to the magnitude needed to address the totality of moderate and severe pain.
KEYWORDS Access, accidents and injuries, cancer, consumption, demographics, education and training,
health policy, HIV/AIDS treatment, legislation (health), need, opioid, pharmaceuticals products, policy, statis-
tics, substance abuse
Dr. Marie-Josephine Seya and Dr. Obianuju Uzoma Achara are afliated
with School of Pharmacy, Temple University, Philadelphia, Pennsylvania,
USA. Dr. Marie-Josephine Seya is also afliated with the BMS Virology
Policy and Advocacy, Rutgers University Ernest Mario School of Phar-
macy, Plainsboro, New Jersey, USA.
Dr. Susanne F. A. M. Gelders is an independent consultant in Maas-
tricht, The Netherlands.
Dr. Barbara Milani and Dr. Willem Karel Scholten are afliated with
Essential Medicines and Pharmaceutical Policies, World Health Organiza-
tion, Geneva, Switzerland.
This study was done as part of WHO’s Access to Controlled Medications
Programme. It was funded through grants from the US Cancer Pain Re-
lief Committee and the World Health Organization, which for this purpose
was also supported by the Dutch Ministry of Health. The WHO Collab-
orating Centre for Policy and Communication in Cancer Care provided
opioid consumption data. The authors would also like to thank Dr Colin
Mathers for his advice on the selection and collection of statistical data,
Dr Ahmadreza Hosseinpoor for his assistance with statistical calculations,
Dr Richard Laing and Professor Albert I. Wertheimer for commenting on
the manuscript, and Dr Philip Jenkins for editing a previous version of the
manuscript.
Address correspondence to Willem Karel Scholten, PharmD, MPA, Essential
Medicines and Pharmaceutical Policies, World Health Organization, Geneva,
1211 Switzerland (E-mail: wk.scholten@bluewin.ch).
INTRODUCTION
Oral opioids are key components for the treatment of
moderate to severe pain, and several are regarded as
essential medicines (1). Despite the effectiveness of
opioid analgesics, many people live in pain because
they do not receive appropriate treatment. The re-
alization of Millennium Development Goal (MDG)
8e, i.e., “... to provide access to affordable essen-
tial drugs in developing countries,” is likely to be fur-
ther away for opioid analgesics than for any other
class of medicines. Pain can vary from mild to severe,
and different pain levels require different analgesics.
Paracetamol, acetylsalicylic acid, nonsteroidal anti-
inammatory medicines (NSAIMs) and opioids with
a ceiling effect (often called “weak-acting opioids”)
are not effective for moderate to severe pain. NSAIMs
can have serious side effects, leading to concerns over
6

Journal of Pain & Palliative Care Pharmacotherapy 7
the long-term safety of chronic use. Despite a century
of medical chemistry, suitable alternatives to strong
opioids for treatment of moderate to severe pain have
not been found.
Indeed, several barriers contribute to the insuf-
cient utilization of opioid analgesics. These barriers
are multifaceted and may be related to legal aspects,
policy, knowledge, or attitudes. In many countries
several of these aspects are present. Most of these
barriers trace back to fears of abuse and dependence
of opioids, particularly the fear of prescribed opi-
oids being diverted to illicit circuits (2, 3). Therefore,
many laws and government policies primarily focus
on rendering opioids unavailable, without acknowl-
edging that their rational medical use is benecial to
patients in pain (2, 4, 5). Still today, in many coun-
tries, patient access to opioids for cancer pain is pro-
foundly restricted through legislation (6). However,
for terminal patients dependence is irrelevant. More-
over, during treatment of chronic noncancer pain,
dependence rarely results (7). Diversion of prescrip-
tion medicines from domestic distribution channels
has been reported (8). However, this is not a rea-
son not to prescribe opioids to patients. Reports from
India and Malaysia show that diversion by patients
is rare or nonexistent (9, 10). When patients can-
not access pain relief, this may result in excruciating
suffering, suicide, or the use of street-bought heroin
(11).
In recent years the problem of inadequate pain re-
lief has attracted more and more the attention of the
international community. United Nations (UN) bod-
ies, including the World Health Assembly, the Eco-
nomic, Social and Cultural Council, the Commission
on Narcotic Drugs, and the International Narcotics
Control Board (INCB), declared that access should
improve (9, 12–15). Since 2006, the INCB has re-
quested annually that all governments promote ratio-
nal medical treatment with narcotic drugs and psy-
chotropic substances (8, 16–19). There is recogni-
tion now that pain relief is part of the human right to
the highest attainable standard of mental and physical
health, or is even a human right on its own (20–22).
Some countries (e.g., Uganda, Romania, Colombia)
have made serious efforts to improve opioid accessi-
bility (23–26).
A comparison of consumption of and need for
opioids is an important tool to recognize inadequa-
cies of access to opioids as medicine. Various simple
methods have been suggested to establish the mor-
phine needs of a country (27–29). However, these
methods fail to take into account the specic mor-
bidity patterns in the countries themselves and do
not relate to the adequacy of the actual use of opioid
analgesics.
METHODS
At country level, we collected mortality data for
cancer, human immunodeciency virus (HIV), and
injuries, and calculated the per capita amounts of
opioids that would be sufcient to treat the pain re-
lated to these diseases (“Need of morphine equiva-
lents (selected diseases) in mg per capita”). Cancer
and HIV/AIDS (acquired immunodeciency syn-
drome) are the two major causes of chronic severe
malignant pain, and injuries are an important cause
of acute moderate to severe pain. Pain can also have
many other causes. We also calculated the actual per
capita consumption of relevant strong opioids (mor-
phine, fentanyl, oxycodone, hydromorphone, and
pethidine) from the per capita consumption of each
of them (“Consumption of morphine equivalents in
mg per capita”). These statistics are relatively reliable,
because governments cannot import strong opioids
without submitting these gures to the INCB.
No objective standard exists for an adequate level
of opioid consumption, and we therefore had to de-
velop such a standard ourselves. The selection of
reference countries should be independent from the
opioid consumption. Therefore, we took the top
20 countries from the Human Development Index
(HDI) for 2004 as reference countries (30). We ar-
bitrarily took their average ratio between calculated
per capita consumption and per capita need as a stan-
dard for an adequate consumption level. We nor-
malized the ratio by designating this average to be
an “adequacy of consumption measure” (ACM) of
1.00. Furthermore, we calculated for each country
the amount of opioids that could be adequate for pain
treatment (“Adequate consumption (all pain condi-
tions) in kg”), and from this we calculated the global
requirements.
Data Collection
We collected data from 188 countries. For the ac-
tual consumption gures, we used 2006 data from the
INCB for all relevant strong opioids and calculated
their joint consumption in “morphine equivalents,”
i.e. the dosage of a substance that equals the analgesic
potency of 1 mg oral morphine (using multiplication
factors inversely proportional to their Dened Daily
Dosages). We excluded methadone, because this is
usually used for treatment of opioid dependence.
For each country, we retrieved population data
(2006), the age-standardized mortality rate for can-
cer (2002), and the age-standardized mortality rate
for lethal injuries (2002) from the World Health
Organization (WHO) Statistical Information System
(WHOSIS) Database. For deaths due to HIV/AIDS
C
2011 Informa Healthcare USA, Inc.

TABLE 1a. Adequacy of Consumption Measure (ACM) of Countries in the WHO African Region
Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006) Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006)
Algeria 5.95 0.44 4530 0.0033 Lesotho 50.82 No data 2316 No data
Angola 16.14 0.02 6104 0.0000 Liberia∗11.45 No data 936 No data
Benin 12.23 0.14 2447 0.0005 Madagascar 8.54 0.05 3737 0.0003
Botswana 41.16 4.15 1747 0.0044 Malawi 28.58 0.01 8858 0.0000
Burkina Faso 11.90 0.02 3904 0.0001 Mali 11.78 0.02 3220 0.0001
Burundi 13.86 0.12 2587 0.0004 Mauritania 10.30 0.29 716 0.0013
Cameroon 17.68 No data 7341 No data Mauritius 4.63 6.13 132 0.0580
Cape Verde∗∗ 6.88 0.67 82 0.0042 Mozambique 30.59 0.31 14,654 0.0004
Central African
Republic
28.45 No data 2771 No data Namibia 36.19 1.57 1692 0.0019
Chad 12.31 No data 2944 No data Niger 11.04 0.04 3464 0.0002
Comoros 8.65 No data 162 No data Nigeria 14.19 No data 46,899 No data
Congo 16.60 0.09 1399 0.0002 Rwanda 16.00 0.04 3459 0.0001
Cote d’Ivoire 20.82 0.06 8996 0.0001 Sao Tome and
Principe∗∗
7.23 0.07 26 0.0004
Dem. Rep. of
the Congo
14.11 0.02 19,547 0.0000 Senegal 9.47 No data 2612 No data
Equatorial
Guinea
15.20 No data 172 No data Seychelles∗∗ 7.11 6.03 14 0.0371
Eritrea 11.52 0.17 1235 0.0007 Sierra Leone 12.72 No data 1668 No data
Ethiopia∗10.79 0.02 19,962 0.0001 South Africa 31.16 5.39 34,367 0.0076
Gabon 20.06 No data 601 No data Swaziland 8.79 No data 228 No data
Gambia 10.74 No data 408 No data Togo 13.00 0.18 1903 0.0006
Ghana 11.93 3.88 6268 0.0142 Uganda 18.64 0.79 12,726 0.0019
Guinea 11.07 No data 2322 No data United Rep. of
Ta n z a n i a
20.54 No data 18,509 No data
Guinea-Bissau 14.40 No data 541 No data Zambia 34.97 0.82 9342 0.0010
Kenya 21.36 2.34 17,835 0.0048 Zimbabwe 53.36 No data 16,120 No data
WHO AFRO
region
17.06 1.03 301,500 0.0017
∗Calculations based on HIV data for 2007 from the WHO Statistical Information System (WHOSIS) Database.
∗∗Calculations based on cancer and injury mortality only (no data for HIV mortality available).
∗∗∗Mortality data for Serbia were quoted from Jancovic et al. (32) (Table 1d).
∗∗∗∗Calculations based on HIV data from UNAIDS Country factsheet 2008 for India (Table 1e).
∗∗∗∗∗In Austria morphine is also used for opioid agonist therapy (Table 1d).
8

TABLE 1b. Adequacy of Consumption Measure (ACM) of Countries in the WHO American Region
Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006) Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006)
Antigua and
Barbuda∗∗
7.80 No data 15 No data Guyana 10.10 5.21 170 0.0226
Argentina 8.07 2.26 7212 0.0122 Haiti 12.41 0.15 2678 0.0005
Bahamas 12.84 28.77 96 0.0981 Honduras 9.26 No data 1475 No data
Barbados 14.06 No data 94 No data Jamaica 9.81 6.28 605 0.0280
Belize 14.73 No data 95 No data Mexico 4.99 0.76 11,999 0.0067
Bolivia 14.21 No data 3035 No data Nicaragua 6.86 1.13 867 0.0072
Brazil 7.98 10.83 34,522 0.0594 Panama 7.55 3.18 567 0.0185
Canada 7.81 456.59 5810 2.5601 Paraguay 7.98 0.35 1097 0.0019
Chile 7.76 6.51 2920 0.0367 Peru 10.16 No data 6405 No data
Colombia 7.00 3.09 7289 0.0193 Saint Kitts and
Nevis∗∗
5.86 No data 7 No data
Costa Rica 7.12 4.34 715 0.0267 Saint Lucia∗∗ 7.00 8.01 26 0.0501
Cuba 7.33 3.56 1887 0.0212 Saint Vincent
and the
Grenadines∗∗
8.40 1.36 23 0.0071
Dominica∗∗ 7.80 5.43 12 0.0305 Suriname 13.98 1.18 145 0.0037
Dominican
Republic
9.64 0.92 2117 0.0042 Trinidad and
To b a g o
11.49 No data 348 No data
Ecuador 7.42 1.24 2238 0.0073 United States of
America
7.43 420.70 51,401 2.4787
El Salvador 6.78 2.87 1047 0.0185 Uruguay 10.90 No data 829 No data
Grenada∗∗ 10.77 5.72 26 0.0233 Venezuela 6.60 1.07 4102 0.0071
Guatemala 5.79 0.94 1722 0.0071 WHO AMRO
region
7.51 171.40 153.60 0.9437
See Table 1a for denitions of footnotes.
9

TABLE 1c. Adequacy of Consumption Measure (ACM) of Countries in the WHO Eastern Mediterranean Region
Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006) Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006)
Afghanistan 8.67 No data 5169 No data Oman∗∗ 5.69 4.10 331 0.0315
Bahrain∗∗ 6.88 9.11 116 0.0580 Pakistan 5.90 0.07 21,692 0.0005
Djibouti 11.41 No data 213 No data Qatar∗∗ 4.07 6.61 76 0.0710
Egypt 4.89 0.85 8289 0.0076 Saudi Arabia∗∗ 5.93 5.65 3272 0.0418
Iran (Islamic
Republic of)
6.24 2.09 10,022 0.0146 Somalia 9.54 No data 1840 No data
Iraq∗∗ 6.13 No data 3989 No data Sudan 9.31 0.27 8020 0.0013
Jordan∗∗ 7.83 10.39 1025 0.0581 Syrian Arab
Republic∗∗
3.27 2.84 1448 0.0381
Kuwait∗∗ 4.23 4.94 269 0.0512 Tunisia 4.59 3.63 1071 0.0346
Lebanon 5.25 5.71 486 0.0476 United Arab
Emirates∗∗
5.44 2.29 528 0.0184
Libyan Arab
Jamahiriya∗∗
4.30 4.76 593 0.0485 Yemen∗∗ 5.89 0.17 2923 0.0012
Morocco 3.78 0.47 2664 0.0054 WHO EMRO
region
6.00 1.33 74.04 0.0086
See Table 1a for denitions of footnotes.
10

TABLE 1d. Adequacy of Consumption Measure (ACM) of Countries in the WHO European Region
Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006) Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006)
Albania∗∗ 8.35 2.54 605 0.0133 Latvia 10.19 21.31 533 0.0916
Andorra∗∗ 6.82 42.97 12 0.2758 Lithuania 9.11 24.62 709 0.1184
Armenia 9.59 0.98 660 0.0045 Luxembourg 8.95 105.36 94 0.5153
Austria∗∗∗∗∗ 7.22 328.23 1373 1.9913 Macedonia (the
former
Yu g o s l a v
Republic of)
8.21 1.27 382 0.0068
Azerbaijan 6.46 0.23 1239 0.0015 Malta 8.40 11.73 78 0.0612
Belarus∗8.16 1.09 1815 0.0059 Moldova 7.43 1.67 651 0.0098
Belgium 8.35 219.79 1990 1.1518 Monaco∗∗ 6.50 No data 5 No data
Bosnia and
Herzegovina∗∗
6.56 No data 588 No data Netherlands 8.72 101.32 3262 0.5087
Bulgaria∗6.82 12.20 1198 0.0784 Norway 7.76 155.92 827 0.8802
Croatia∗∗ 9.05 32.73 941 0.1584 Poland 10.09 42.80 8787 0.1858
Cyprus∗∗ 5.09 13.89 98 0.1194 Portugal 7.92 65.84 1913 0.3642
Czech Republic 9.92 55.74 2309 0.2459 Romania∗7.80 0.08 3837 0.0005
Denmark 9.38 290.79 1163 1.3576 Russian
Federation∗
9.15 1.34 29,947 0.0064
Estonia∗9.44 24.63 289 0.1142 San Marino∗∗ 7.57 No data 5 No data
Finland 6.58 174.07 791 1.1580 Serbia/Montenegro∗∗∗ 7.27 12.81 1635 0.0772
France 7.76 145.15 10,874 0.8187 Slovakia∗∗ 9.21 120.98 1133 0.5752
Georgia 6.62 2.35 670 0.0155 Slovenia 9.01 104.09 412 0.5058
Germany 7.97 381.66 15,039 2.0972 Spain 7.26 131.53 7277 0.7932
Greece 7.49 92.49 1902 0.5410 Sweden 6.62 161.47 1372 1.0682
Hungary∗10.93 69.14 2510 0.2771 Switzerland 6.62 216.76 1127 1.4337
Iceland 9.05 126.88 62 0.6138 Tajikistan 5.23 No data 794 No data
Ireland 8.51 100.21 821 0.5155 Turkey∗∗ 5.15 6.76 8701 0.0574
Israel∗7.30 64.31 1135 0.3858 Turkmenistan∗∗ 5.39 0.12 603 0.0009
Italy 7.42 33.94 9963 0.2002 Ukraine 9.17 3.03 9749 0.0145
Kazakhstan 9.45 No data 3304 No data United
Kingdom
8.07 99.14 11,159 0.5376
Kyrgyzstan 6.11 0.28 734 0.0020 Uzbekistan 4.36 0.14 2688 0.0014
WHO EURO
region
7.89 87.19 159,763 0.4699
See Table 1a for denitions of footnotes.
11

TABLE 1e. Adequacy of Consumption Measure (ACM) of Countries in the WHO Southeast Asian Region
Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006) Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006)
Bangladesh 6.39 0.99 22,760 0.0068 Myanmar 8.73 0.05 9650 0.0003
Bhutan 6.45 No data 96 No data Nepal 7.07 0.28 4466 0.0017
Democratic
People’s
Republic of
Korea∗∗
5.54 0.78 3002 0.0062 Sri Lanka 6.76 1.67 2964 0.0109
India∗∗∗∗ 7.34 0.13 193,184 0.0008 Thailand 8.12 2.46 11,768 0.0133
Indonesia 7.24 0.29 37,869 0.0018 Timor-Leste∗∗ 6.44 No data 164 No data
Maldives∗7.81 No data 53 No data WHO SEARO
region
7.28 0.34 285,975 0.0020
See Table 1a for denitions of footnotes.
12

TABLE 1f. Adequacy of Consumption Measure (ACM) of Countries in the WHO Western Pacic Region
Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006) Country
Need of morphine
equivalents
(selected diseases)
in mg per capita
Consumption of
morphine
equivalents in mg
per capita (2006)
Adequate
consumption (all
pain conditions)
in kg
ACM
(2006)
Australia 7.22 142.68 3383 0.8658 New Zealand∗7.61 72.18 719 0.4154
Brunei
Darussalam
7.86 3.96 69 0.0221 Palau∗∗ 4.99 3.45 2 0.0302
Cambodia 11.88 No data 3852 No data Papua New
Guinea
8.32 No data 1179 No data
China 8.10 2.04 245,892 0.0110 Philippines 5.28 0.43 10,411 0.0035
Fiji 6.35 No data 121 No data Republic of
Korea
9.50 15.63 10,427 0.0720
Japan 6.48 20.22 18,942 0.1366 Samoa∗∗ 5.15 1.98 22 0.0168
Kiribati∗∗ 2.82 No data 6 No data Singapore 7.26 8.72 727 0.0526
Lao People’s
Democratic
Republic
8.52 0.29 1120 0.0015 Solomon
Islands∗∗
4.88 No data 54 No data
Malaysia 8.07 5.54 4816 0.0300 Tonga∗∗ 4.61 2.84 11 0.0270
Marshall
Islands∗∗
6.78 1.86 9 0.0120 Vanuatu∗∗ 4.99 0.67 25 0.0059
Micronesia
(Federated
States of)∗∗
5.04 3.08 13 0.0267 Viet Nam 7.19 0.81 14,154 0.0049
Mongolia 16.92 1.01 1006 0.0026 WHO WPRO
region
7.87 5.50 316,961 0.0302
See Table 1a for denitions of footnotes.
13

14 M.-J. Seya et al.
we used data for 2007 from the UNAIDS Report
on the Global AIDS Epidemic 2008, except where
the WHOSIS Database contained these data on
HIV/AIDS. For India we used data from the UN-
AIDS Country Factsheet 2008 (gures for 2007) (see
footnotes, Tables 1a–1f). Mortality data for Serbia
were quoted from Jancovic et al. (2006) (31). Where
AIDS mortality data are presented as “less than,” we
used this limit for our calculations (e.g., if mortality
was “≤10,” we used 10 for our calculations).
Calculation Methods
We calculated the need for morphine required for
pain relief in terminal cancer patients, HIV patients,
and lethal injuries patients in mg per capita, based
on the assumptions that 80% of terminally ill can-
cer patients and 50% of AIDS patients will require
75 mg of morphine per person daily for an average
of 90 days during the last year of their lives and that
15% of patients with lethal injuries will require 75 mg
of morphine daily for an average of 5 days at the end
of their lives (32).
This method of calculating morphine need does
not account for pain from many other causes, includ-
ing nonlethal cancers, nonlethal injuries, non–end-
stage HIV, surgery, sickle cell episodes, childbirth,
chronic nonmalignant pain, and many more. The ac-
tual extent of pain from these other diseases is difcult
to quantify because of a lack of comprehensive epi-
demiological data at the national level and of data on
how much morphine per patient is required on aver-
age for these conditions. Therefore, we had to correct
for these other pain causes. Our correction is based on
the assumption that total morbidity in each country
is proportional to the morbidity for the three causes
mentioned above. The correction factor is the aver-
age of the ratios of (actual consumption:calculated
need) for the highest 20 countries in the HDI. The
average ratio was 22.84. A consumption level equal
to or higher than this average is assumed to be an ad-
equate consumption level and we “normalized” the
aforementioned ratio by introducing an ACM pro-
portional to the ratio, designating the average ratio of
22.84 to be an ACM of 1.00. Consequently, an ACM
of 1.00 or more represents a consumption level re-
lated to adequate access to opioid analgesics. Further-
more, we dened an ACM ≥0.30 and <1.00 as mod-
erate consumption, ≥0.10 and <0.30 as low, ≥0.03
and <0.10 as very low, and <0.03 as virtually nonex-
istent. We calculated the ACM for all countries and
the relation between the HDI and the logarithm of
the ACM (log(ACM)).
We also calculated the required absolute consump-
tion in order to achieve an ACM of 1.00 at the coun-
try level, for each WHO region and for the world,
based on the actual consumption and each region’s
ACM. For countries with an ACM higher than 1.00,
we took the actual consumption as adequate.
RESULTS
For each country, in Tables 1a to 1f we present the
per capita need of morphine equivalents and the ac-
tual per capita opioid consumption, together with ad-
equate consumption in kg and the ACM. Our calcu-
lation method is based on a number of assumptions
(for instance, that the top 20 HDI countries have an
opioid analgesics consumption that is more or less ad-
equate to their need) and it does not take into ac-
count that variations in morbidity patterns between
countries may lead to different needs for opioid anal-
gesics. Therefore, the results should be considered
an indication of the magnitude of adequacy and not
an exact indication of the country needs. Thus, they
should not be used to calculate the health care sys-
tem’s requirements for opioids, as our method does
not take into account the capacity of the health care
system. However, we recommend that the ACM and
the calculated adequate consumption will be used for
policy purposes and in setting mid- and long-term
targets.
We were able to calculate the ACM for 145 coun-
tries. The countries for which the ACM could not
be calculated did not report their consumption data
to the INCB. We fear that many of these countries
also have very minimal consumption, if any. The dif-
ferences between countries are so large that the re-
sults best can be expressed on a logarithmic scale: the
country with the highest ACM in our study (Canada)
has a per capita consumption 50,000 times higher
than the lowest country (Malawi).
Figure 1 shows the relation between the log (ACM)
and the HDI for 139 countries. There is a close rela-
tionship between the development of a country and
the log (ACM). Most people who live in countries
where they have adequate access live in the more in-
dustrialized regions and, conversely, worst access is
found in developing countries. However, some indus-
trialized countries also have inadequate consumption.
Table 2 presents the number of people living in the
WHO regions based on their ACM. From this table
we conclude that:
5.5 billion people (83% of the world’s population) live
in countries with low to nonexistent access;
250 million (4%) have moderate access;
460 million (7%) have adequate access;
for 430 million (7%) insufcient data are available.
Journal of Pain & Palliative Care Pharmacotherapy

Journal of Pain & Palliative Care Pharmacotherapy 15
-5.00
-4.00
-3.00
-2.00
-1.00
0.00
1.00
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
HDI
log (ACM)
FIGURE 1. Relation between the log (ACM) and the Human Development Index (HDI) for
139 countries. (Function formula: log (ACM) =−6.4113 +6.200 ×HDI; N=139; correlation
coefcient: .895; Pvalue: <.0001.)
In 2006, the world used 231 tonnes of morphine
equivalents. If all countries increased their consump-
tion to adequate levels, the required amount would
be 1292 tonnes, or almost 6 times higher.
DISCUSSION
The method we developed and applied for all relevant
strong opioids and to all countries, also taking into
account morbidity levels, allows insight into which
countries need to improve pain treatment and by what
magnitude. So far there has been no overview avail-
able of the total per capita consumption for all com-
bined strong opioids. Furthermore, the lack of access
to opioid analgesics for pain treatment was known to
be considerable, but up till now the scale of the prob-
lem was not known to the extent that we have demon-
strated in this study. We are aware that improvement
of our method is possible, but because no similar
method is available, we wanted to start a discussion
and encourage that others build on our method.
Study Limitations
Our method relies on an extrapolation based on the
assumption that total pain prevalence is proportional
to the morbidity from three diseases that result
in moderate to severe pain. For the three diseases
that we selected, most of the suffering is related
to the end-of-life stage and, therefore, our choice
is reasonable. It should be borne in mind that in
countries where HIV or cancer mortality is extremely
high, the method will exaggerate the opioid need.
TABLE 2. Number of People (in Thousands) Living in Countries, According to Adequacy of Consumption Measure (ACM) and
Region
ACM
AFRO
population
(thousands)
AMRO
population
(thousands)
EMRO
population
(thousands)
EURO
population
(thousands)
SEARO
population
(thousands)
WPRO
population
(thousands)
Global population
in thousands (%)
ACM ≥1 (adequate
consumption)
0 335418 0 128622 0 0 464040(7%)
0.3 ≤ACM <1(moderate
consumption)
0 0 0 227658 0 24670 252328(4%)
0.1 ≤ACM <0.3 (low
consumption)
0 0 0 127390 0 127953 255343(4%)
.0.03 ≤ACM <0.1 (very low
consumption)
1338 206346 76506 94160 0 78566 456916(7%)
ACM <0.03 (virtually no
consumption)
502501 303900 399919 283081 1718985 1510365 4718751(72%)
No data 269953 49280 63858 25944 2063 21810 432908(7%)
Total 773792 894944 540283 886855 1721048 1763364 6580286(100%)
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2011 Informa Healthcare USA, Inc.

16 M.-J. Seya et al.
However, owing to underreporting, morbidity statis-
tics usually underestimate the actual morbidity, in
particular in developing countries. Thus, for such
countries, the needs we calculated will be too low.
Also, we excluded methadone, because it is mostly
used for treatment of opioid dependence. Therefore,
our method underestimates the adequacy of opioid
analgesic consumption for the few countries that
use methadone mainly for pain management Several
opioids are also used in anesthesia. A validation of
our method could be part of future work.
We related our standard of adequacy to the top
20 countries of the HDI. We realize that taking the
top 10 or the top 30 would have inuenced the out-
come considerably. Not taking the latter is supported
by the nding that the countries for which more im-
pediments are reported rank 25 and higher, and from
the countries ranking 1 to 20, hardly any is reported
as having high access barriers (6). The former (i.e.,
taking the top 10) might be considered, but in that
case we would be setting the targets for improvement
even higher for those countries with lower levels of
adequacy of opioid consumption.
Relation to Other Medicines’ Accessibility
and MDG 8e
Only 460 million people live in countries with ad-
equate consumption levels. This means that the re-
maining 6 billion will not be treated adequately when
in pain. Cameron et al. collected availability data
from 36 countries for a standard list of 15 core generic
medicines and found a public sector availability rang-
ing from 9.7% (Yemen) to 79.2% (Mongolia). Al-
though the level of availability cannot be compared
directly with the consumption level, merely consider-
ing that 72% of the world’s population live in coun-
tries that do not consume strong opioids, it is not
rash to conclude that the situation for strong opioid
analgesics is much worse than it is for these 15 core
medicines in general (33). Therefore, we conclude
that MDG 8e on access to essential medicines is fur-
ther away for opioid analgesics than for other classes
of essential medicines.
Explanation for Inadequacy of Opioid
Analgesic Consumption
Patients have a right to be treated with controlled
medicines listed in the WHO Model List of Essential
Medicines and a right to be protected against drug
abuse and dependence (2, 20). Therefore, drug
control and public health policies should seek the
optimum public health outcome, which is a balance
between maximizing access for legitimate medical
use and minimizing abuse, dependence, and diver-
sion. However, this is not currently the case in most
countries. Exaggerated fear that pain patients will
become dependent and that prescribed opioids will
be diverted from their intended use prevents patients
from receiving any pain treatment at all. There is no
doubt that this balance should be ensured.
National policies, laws, and regulations often have
a number of drawbacks that hamper adequacy of pain
management. Lack of medical knowledge and bias to-
wards pain management with opioids also affect the
adequacy of opioid consumption. There is no eco-
nomic reason why countries should not go through a
transition towards adequate management of pain, as
the prices in developed countries for morphine tablets
and methadone syrup at supplier level are only a few
US cents per unit. However, studies and surveys have
reported that opioid analgesic cost at the patient level
is higher in developing countries than in developed
countries and this makes them unaffordable outside
health system treatment programmes. The cost of
opioid analgesics can be a limiting factor in devel-
oping countries where palliative care programs and
pain relief are not subsidized by national health sys-
tems and where the market size is based on the out-
of-pocket purchasing power of patients (34, 35).
Working on Improvement
We suggest that countries that wish to improve ac-
cess to these medicines take our gures as a work-
ing hypothesis to measure adequacy of access. For all
countries with low access, this will work, because the
difference between their current level and adequate
consumption is so large. At the country level, we rec-
ommend that governments take the outcome of our
method, which represents approximately the magni-
tude needed to address the totality of moderate and
severe pain, as a long-term target for the development
of the estimates that they have to submit to the INCB
annually and strive for an adequate consumption level
of opioid analgesics. This means that they will reach a
level related to an ACM of 1.00 or more. For the esti-
mates themselves, the INCB and WHO are currently
preparing a Joint INCB-WHO Manual for Calculating
Estimates for Drugs Under International Control and we
recommend that countries apply this as soon as it is
ready. Governments should not submit much higher
estimates than the country can absorb for rational use
by the health system, in order to prevent diversion to
illicit circuits. However, estimates should always be
slightly higher than the amount that actually will be
required, in order to ensure that importations will not
be blocked.
Journal of Pain & Palliative Care Pharmacotherapy

Journal of Pain & Palliative Care Pharmacotherapy 17
Consumption will not increase spontaneously, but
only if countries address actively all barriers that
impede access to adequate pain management. Gov-
ernments can do so by implementing the guidelines
on balanced controlled substances policies that the
WHO Access to Controlled Medications Programme
(ACMP) will publish approximately simultaneously
with this article. These guidelines will address all rel-
evant policy aspects of controlled medicines access.
The guidelines will include a practical checklist and
will also be available for interested individuals.
WHO has developed the ACMP in consulta-
tion with the INCB.34 WHO will manage the
ACMP, which will support countries when improv-
ing access to opioid analgesics and other medicines
controlled under the international drug control con-
ventions. Among other activities, the ACMP is devel-
oping treatment and policy guidelines and can assist
when reviewing policies and legislation. INCB rec-
ommends that countries work with the ACMP and
provide it with sufcient resources to reach its objec-
tives (8).
Declaration of interest
The authors report no conicts of interest. The au-
thors alone are responsible for the content and writ-
ing of this paper.
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RECEIVED: 5 October 2010
ACCEPTED: 27 October 2010
Journal of Pain & Palliative Care Pharmacotherapy