Pain, Palliative Care

“Always look on the bright side!” Lessons from Malaysia’s opioid consumption.


Being with colleagues at the Asian Pacific Hospice Palliative Care Network meeting last week was inspiring, re-energizing and stimulating. I am still feeling that way after the 36 hour trip back to Madison.  Congratulations to the organizers especially Drs Noreen Chan and Ednin Hamzah, the Scientific Program c0-chairs and  Drs Devaraj and Rajagopal, the conference co-chairs.

On the opening day of the conference, I shared with Noreen (from Singapore) and Ednin (Malaysia) how impressed I was that Malaysia had made a significant jump in its opioid consumption as measured by Morphine equivalents (1) on the  PPSG opioid consumption map.

Noreen was a little taken a back.  She still thought that Singapore was about the same as Malaysia at about 1.2 mg of Morphine/person in 2008. In fact when I checked later, Malaysia was at 1.1 mg/person in 2008, just below Singapore’s. This is despite an almost four fold greater GDP for Singapore ($14,000 vs $45000).

However Malaysia’s opioid consumption in 2008 measured in morphine equivalents was 27 mg/person compared with Singapore’s at 5.9 mg/person. And Malaysia’s consumption had jumped from 3.85 mg/person in 2004 when it was behind Singapore at 5 mg/person.  How does one explain that?

Well we were interrupted in our discussion and I will confess to thinking little else about it until Dr Mary Cardosa (Malaysia) presented during a plenary on “Pain Management.” She commented that she was surprised that Malaysia had moved up a “color” on the PPSG maps and that she had gone looking for an explanation.  So she showed the slide for Malaysia’s opioid consumption as expressed in morphine equivalents, with the consumption of all six drugs included  (shown below).  Malaysia had in fact had little improvement in morphine consumption.  All of the increase was in methadone which is primarily used for harm reduction and the treatment of opioid dependence (the conversion factor is 4). Singapore has not policy for using methadone for harm reduction.

I was a little deflated with this result but Ednin lifted my spirits. While there has been little change in morphine consumption in Malaysia, he was encouraged that the graph showed that it is quite possible to improve access to an opioid in Malaysia, moving from none in 2001 to almost 8.7 mg/person in 2008.  Ednin and Mary have asked me to meet with Malaysian Health Ministry officials in November, when attending the Asian Pacific Cancer Congress in Kuala Lumpur, to address the need for improved access to opioids for pain relief.

And we will also be working to improve our work at PPSG in the near future with the inclusion of maps that show “morphine equivalents minus methadone.”

jfclearywisc

(1) Morphine equivalents are calculated from conversion ratios drawn from another WHO Collaborating Center and provide a separate measure of combined opioid use for morphine, oxycodone, hydromorphone, fentanyl, pethidine and methadone.

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide

Discussion

One thought on ““Always look on the bright side!” Lessons from Malaysia’s opioid consumption.

  1. It is an achievement that Malaysia increased its methadone consumption so much by establishing treatment programmes for heroin dependence. Malaysia prevents large numbers of new HIV infections (caused e.g. by the needle sharing heroin users often do) by putting in place good methadone treatment programmes.

    By preventing HIV, countries prevent many cases of moderate and severe pain among HIV patients during progressed stages of their disease. Therefore, it is something that pain advocates should not forget to include in their advocacy. In the end it is better to prevent pain than to treat. WHO estimates that if all countries would have good treatment programmes for heroin dependence, around 130,000 new HIV infections would be prevented every year.

    There is hardly any country that uses methadone for pain treatment. I am investigating this at the moment. I first inventory by a former intern showed that it is mainly the US and Malawi, but we may find a few more, once we progress with this project.

    Conclusion for PPSG should be not to delete, but to split off the methadone from the graphs. Similar graphs for methadone separately will be highly useful, including for pain policy advocates!

    Willem Scholten
    Team Leader, Access to Controlled Medicines
    World Health Organization
    Geneva, Switzerland.

    Posted by Willem Scholten | July 25, 2011, 7:30 AM

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