Balance, Pain

2009 INCB Opioid Consumption data now available on PPSG website


The Pain & Policy Studies Group (PPSG) is pleased to announce its annual release of new and updated global, regional, and national consumption data for Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone, and Pethidine. Additionally, the morphine equivalence data on the global, regional and all country profile pages has been updated with the 2009 data as well as the opioid consumption maps and inter active charts.

For more than 10 years, the PPSG has received opioid consumption data from the International Narcotics Control Board (INCB) and we are tremendously grateful to INCB for their willingness to again share with PPSG these raw data for 2009.

In many respects, these data are unique in that they are reported by governments to the INCB. These data represent the annual amount of opioids distributed within a country to the retail level (i.e., hospitals, hospice programs, community pharmacies, etc.). So, they do not necessarily represent the amount of opioids being prescribed, dispensed or used by patients, but still are an important indicator of availability of opioids within a country.

What do the 2009 data tell us?

As has been the case for many years, the 2009 INCB data illustrate the continuing disparities in morphine consumption between high and low- and middle-income countries (as shown by the graphic above):

  • high-income countries (as defined by the World Bank income-level classification) accounted for nearly 93% of medical morphine consumed in the world, but comprised only 17% of the total population. In contrast, low- and middle-income countries, representing the remaining 83% of the world’s population, consumed a mere 7% of the total morphine consumption.
  • In 2009, there was a large and striking difference between the lowest amount of morphine consumed in a country (Niger: 0.0004 mg/person) and the highest amount (Canada*76.75 mg/person)
  • [*Austria reported 177.13 mg/person of morphine in 2009, but uses morphine for opioid substitution treatment, so the second highest, Canada, is listed]
  • 56% of the countries reporting to INCB in 2009 consumed less than one milligram of morphine per person

 

But, there is hope…

Despite such grim statistics, there are some positive messages to be gleaned from these data. There continues to be some notable increases in opioid consumption in a few countries where International Pain Policy Fellows have been making progress to improve the availability of opioids, such as morphine.

  • In Serbia, the milligram per capita consumption of morphine doubled from 2008 to 2009.
  • Similarly, in Vietnam, morphine consumption has been continuously increasing since 2003. In 2009, the amount of morphine (mg/capita) consumed in Vietnam represents an eight-fold increase since 2003.

What do the data look like for your country?

We encourage you to explore your own countrys profile.

  • Do these data reported by your government to INCB seem consistent with what you know about opioid use in your country?
  • What might explain large increases or decreases in a particular year?
  • Is methadone primarily used for opioid substitution treatment in your country rather than for pain management?

While PPSG works towards developing more precise country level indicators of increased access to opioids and improved pain management, we continue to track national opioid consumption data as one important measure. We welcome your thoughts and feedback about these data.

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide

Discussion

3 thoughts on “2009 INCB Opioid Consumption data now available on PPSG website

  1. The contrast between consumption of opioids in the developing world and consumption in the U.S., Canada and Australia is indeed striking.

    Can you please tell me… is it the hope of the PPSG that the developing world will one day consume as much opioids per capita as nations with the highest consumption?

    According to the CDC, the exponential increase (~700%) in consumption of opioids in the U.S. over the past 15 years has led to an epidemic of opioid analgesic overdose deaths and addiction. Canada and Australia have experienced very similar trends. This is an epidemic largely caused by aggressive treatment of chronic non-cancer pain with opioids… a practice that is promoted by drug companies and by the pain groups they fund.

    Clearly, many individuals consuming prescription opioids in nations with the highest consumption are being harmed by opioids rather than helped. A truly balanced view is one that also finds trends on over-consumption of opioids to be a “grim statistic”. Both under-consumption and over-consumption can cause suffering.

    Posted by Andrew Kolodny | October 18, 2011, 5:50 PM
  2. Andrew,
    The mission of PPSG is “Improving Global Pain Relief by Achieving Balanced Access to Opioids Worldwide.”

    So our desire (hope has all sorts of connotations in palliative care) is exactly that. It is not that all countries have a consumption equal to the USA Canada, or Australia but that all people of the world have balanced access to opioids when needed for medically appropriate reasons as laid out by the 1961 Single Convention.

    PPSG is reporting the data and we look for and plan to correct the deficiencies that may exist in preventing access for medical appropriate use. We bundle these together as policy, education and drug availability. Again it is up to others to establish what is medically appropriate use. I think there is often confusion with PPSG and the Alliance of State Pain Initiatives. While both grew out of the Wisconsin Cancer Pain Initiative of the 80s, since its formation PPSG has not been in the business of recommending therapies. Yes, our publications will make reference to other published papers, but there has been enough work to correct the deficiencies in the US that prevent many cancer patients from getting appropriate pain relief. A recent study of Wisconsin Cancer Patients near the end of life showed many still receiving inadequate pain relief.

    Interestingly, the Competent Authority for the USA (the Deputy Assistant Administrator, Office of DIversion Control, Drug Enforcement Authority) requests permission from the INCB for a quantity of opioids and reports on that “consumed” each year. Yes the DEA!! So, it is certainly interesting and appropriate to ask the questions you are asking?

    In fact when we first used the Gapminder feature, I was exchanging emails with colleagues at WHO about the US situation and asking the question “Is it excessive?” Much of the overall rise in total opioid consumption is for Methadone (1 mg methadone = 8 mg morphine). Methadone is the drug most associated with these “opioid related deaths’ in the current epidemic according to the CDC report. So similar to last weeks blog on “Opium, sinner or saint?” it is not necessarily the drug, it is often the way it is used or prescribed. Just like NSAIDs with 16,000 deaths a year. Not necessarily a bad drug but often not used well.

    So let me ask the question of you and other readers.

    What would be an appropriate level in mg/person? For the USA? For Vietnam and Serbia? For the world?

    @jfclearywisc

    Posted by Pain policy & palliative care | October 19, 2011, 11:16 AM
  3. Jim,

    I have a few comments and questions for you but the first thing I need to respond to is your statement that NSAIDs are causing “16,000 deaths a year.”

    According to the CDC, there were only 3,320 deaths in the US in 2007 caused by all types of ulcer and gastritis, let alone those due to NSAIDs. The source for this 16,000 deaths figure is a 1999 NEJM article. It was an extrapolation from a small number of actual deaths identified in a database (ARAMIS) of 4,258 rheumatoid arthritis patients.

    I don’t blame you for thinking that this is true, since this figure is widely repeated… especially at physician education events that are sponsored by drug companies that make opioids. Exaggerating the risks of a competing class of medication is one of the tricks of the trade when it comes to drug marketing. Unfortunately, this is exactly the sort of misinformation that leads to over-prescribing of opioids….reminds me of the way the Porter & Jick letter to NEJM was used to minimize the risk of addiction.

    Another correction that I’d like to point out was your statement that methadone accounted for more drug deaths than other opioids. It’s true that methadone deaths are disproportionately high but there are more deaths from oxycodone.

    My question for you is whether or not you believe that the U.S. has “balanced access” right now? As you know, I strongly believe that we are as unbalanced (in the opposite direction) as developing nations with overly restrictive opioid regs. Do you agree that there can be such a thing as prescription opioids being too easily accessible? Do you believe it’s appropriate for hydrocodone (Vicodin, Norco) prescriptions to be available with five refills?

    With regard to the PPSG, please correct me if I’m wrong but your advocacy with FDA, DEA and state medical boards for liberal access to opioids hasn’t been limited to palliative care. Would you agree that this advocacy has had a greater effect on enhancing access to opioids for treatment of chronic non-cancer pain than it’s had on use of opioids for palliative care?

    -Andrew

    Posted by Andrew Kolodny | October 19, 2011, 6:09 PM

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