Page 336 Guide to Pain Management in Low-Resource Settings

324 David E. Joranson

lead to overreactions and more restrictions on essen- What are the reasons for
tial medicines that can undermine confi dence in their inadequate availability and access?
therapeutic use. When diversion occurs, the response
should be quick and balanced, i.e., the person or per- Th e lack of opioid analgesics in a country is not a “sup-
sons responsible should be held accountable, without ply side” problem. According to the INCB, the United
interrupting patient access to pain relief. National lead- Nations’ principal regulatory body for narcotic drugs,
ers in pain management and palliative care should dis- there is no insuffi ciency of raw materials for manufac-
cuss balanced approaches to diversion with the govern- turing opioid medicines. Instead, the problem is the re-
ment before it happens. sult of system barriers within countries that result in a
low or sometimes nonexistent demand for opioids.
How can I fi nd out about the opioids Th e INCB periodically surveys national govern-
that are used in my country? ments, in consultation with the WHO, to explore the
status of opioid availability and the reasons why they
Th e PPSG has posted on its website extensive infor- are not adequately available. Governments have report-
mation about the consumption trends of selected opi- ed that the following barriers contribute to the lack of
oids in each country. Governments are required to re- availability of opioids in their countries:
port consumption statistics to the U.N. International • Concerns about addiction;
Narcotics Control Board (INCB). Th e INCB in turn • Insuffi cient training of health care professionals;
provides the data to the PPSG/WHOCC. “Consump- • Regulatory restrictions on opioid manufacture,
tion” means the amount of opioids that are distributed distribution, prescribing, or dispensing;
by manufacturers or distributors to the retail level in • Health care professionals’ reluctance to stock opi-
the country, such as to physicians, pharmacies, hos- oids because of concerns about legal sanctions.
pitals, hospices, pain clinics, and palliative care pro- Th ese factors and interaction among them can act as
grams. Opioid consumption statistics are an indicator a vicious circle—low national availability can lead to low
of the capacity of a country to relieve moderate to se- medical use, resulting in weak demand, which in turn fos-
vere pain. ters continued low availability. Insuffi cient medical edu-
Th e opioid consumption trend graphs include infor- cation about pain, combined with regulatory restrictions
mation for fentanyl, hydromorphone, methadone (also and exaggerated concerns about opioid analgesics and ad-
considered essential for the treatment of opioid depen- diction, may conspire to maintain the status quo. Howev-
dence), morphine, oxycodone, and pethidine (meperi- er, it is possible to break out of this cycle if there is leader-
dine). Th ese data do not tell us which dosage forms of ship both from health professionals and government.
the opioid are being consumed in a particular country.
If the graphs for a country show no consumption What can the “National Competent

of a particular opioid, this is an indicator that the drug Authority” do to improve
may not available, or it could be a problem in report- availability and access?
ing. Th e consumption statistics are updated annually by
the PPSG as new data are received. Th ese statistics can Key to breaking the cycle and improving availability and
be used to study the consumption trends for the strong access is the National Competent Authority (NCA).
opioids in the world, a region, your country, or any Th is is an agency in every country, often located in the
country. Opioid consumption statistics can be used in Ministry of Health. It is intended to be responsible for
the evaluation of long-term outcomes of eff orts to im- implementing the government’s international narcot-
prove availability. ics treaty obligations to ensure adequate availability of
Consumption statistics can be found in the Coun- narcotic drugs for medical and scientifi c purposes. Th e
try Profi les on the PPSG website. Users can download Country Profi les on the PPSG website provide contact
the graphs and tables of data and use them for presenta- information for the NCA for each country.
tions without special permission, with appropriate cita- Th e NCAs have been asked by the INCB to work
tion. Examples of slide presentations relevant to inter- with health professionals to determine and anticipate
national and national pain policy are available at http:// adequately future medical needs for opioid analgesics
www.painpolicy.wisc.edu/internat/conferences.htm. so that the necessary amounts can be imported and