Using a Morphine Equivalence Metric to Quantify Opioid Consumption: Examining the Capacity to Provide Effective Treatment of Debilitating Pain at the Global, Regional and Country Levels
Pain management is a critical component of palliative care, but inadequately-treated pain remains a global public health problem and is especially prevalent in low- and middle-income countries. There are many different factors that can contribute to inadequate pain relief, including practitioners’ understanding of pain and knowledge of effective treatment options, as well as peoples’ willingness or ability to seek medical care. However, pain management in developing countries often is additionally hampered by the lack of available medications for treating pain that is moderate or severe (i.e., potent opioid analgesics such as hydromorphone, morphine, or oxycodone).
Global medical use of opioid analgesics was influenced significantly in 1986 by the promulgation of the World Health Organization’s (WHO’s) report entitled Cancer Pain Relief, and again with its republication in 1996. In these documents, the WHO conceptualized a threestep analgesic ladder as a guide for recommending various pharmacologic agents depending on the severity of the pain being treated. The WHO suggests potent opioids as first-line treatment when a patient’s pain has been assessed as moderate to severe (1-2). Unfortunately, some construe the WHO analgesic ladder’s “step-like” approach to mean that treatment should be based on a sequential path up the steps (i.e., initial treatment should comprise the weakest medications, regardless of pain severity). It is more widely understood, however, that the analgesic ladder has come to represent that weaker medications, such as NSAIDS or codeine, not be used initially when a patient presents with severe pain because these will likely be ineffective, and create the potential to prolong patients’ pain, suffering, and diminished functioning.(3)
Despite a general increase in opioid consumption throughout the world beginning around 1986, there remains a notable disparity in level of medical use between developed and developing countries. To address this inequality, the WHO has recommended that developing countries devote appropriate resources to pain and palliative care because most people who present with cancer or AIDS are diagnosed at the late stage, when pain often is prevalent and severe.(4;5) Recently, the Commission on Narcotic Drugs,(6;7) the United Nations Economic and Social Council,(8) the World Health Assembly,(9) and the WHO(10) have called on national governments to improve treatment of pain, especially in developing countries, to ensure the medical availability of opioid analgesics for this purpose, and to recognize that providing palliative care is an urgent and humanitarian responsibility. Likewise, the International Narcotics Control Board (INCB), the independent and quasi-judicial body of the United Nations, has consistently recognized the importance of opioid medications for medical purposes.(11-14) The INCB is charged with implementing the international drug control treaties, including the Single Convention on Narcotic Drugs of 1961 (the Single Convention),(15) which obligates governments to address abuse and diversion of controlled medication while maintaining their availability for legitimate medical and scientific purposes.(14)