Opioid Policy, Availability and Access in Developing and Nonindustrialized Countries
Joranson DE, Ryan KM, Maurer MA. Opioid policy, availability and access in developing and nonindustrialized countries. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica's Management of Pain. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010;194-208.
More than two decades ago, an expert committee of the World Health Organization (WHO) concluded that most pain due to cancer could be relieved if health professionals would use a relatively simple analgesic method and if patients could have access to opioids such as oral morphine.1 The WHO analgesic method also has been endorsed for relief of pain due to HIV/AIDS.2
United Nations (UN) health and regulatory agencies repeatedly have appealed to health professionals, their organizations, and governments to cooperate in order to implement the WHO analgesic method and remove barriers that block patient access to opioid pain medications.3, 4, 5, 6, 7 Although drug regulations and opioid availability have improved in some countries, the vast majority of cancer and AIDS patients in the developing world, and many in developed countries, still lack access to these essential medications. This chapter focuses on opioids that are indicated for moderate to severe pain associated with cancer and AIDS, such as morphine, oxycodone, and fentanyl.
A further disparity exists in reported medical consumption of opioid analgesics between developed nations with a small proportion of the global population and the large and growing population of developing countries. With the shifting burden of cancer and AIDS to developing countries, the public health problem of inadequate availability of pain medications is deepening.8,9
Health professionals who manage pain must know about the regulation of opioid analgesics. Just as effective clinical management of pain rests on a body of knowledge, treatment methods, and communication between the clinician and patient, so the task of ensuring access to pain medications in any country depends on knowing the role and responsibilities of national governments and on communication between drug regulators and health professionals.
This chapter outlines the body of knowledge about government drug control policy and the methods that are being developed to assist health professionals and governments to improve opioid analgesic availability and access. “Opioid availability” refers to whether a country has stocks of opioid analgesics either at the manufacturer or retail level of the drug distribution system. The term may be used in referring to the presence of opioids within a country, or at any point throughout the drug distribution system, including in the health care facilities that provide medical care for patients. Alternatively, “opioid accessibility” refers to patients' ability to obtain the opioid pain medications they need for pain relief. Clearly, patient access is not possible unless opioids are available in a country. Therefore opioids may be legally available within a country or even a health care facility, but patients may not be able to access them for a variety of reasons. Cooperation of governments with pain and palliative care experts and their national and international organizations is emphasized.