Recent studies have reported that most cancer patients globally: Asia, Africa, Latin America, Eastern Europe, and the Middle East, do not receive adequate relief from pain because of excessive regularity restrictions on the availability and accessibility of opioids.1–7 This study provides updated figures related to the consumption of leading opioids globally and in Middle Eastern countries.
GLOBAL CONSUMPTION OF OPIOIDS: AN UPDATE
Consumption of Opiates
The overall consumption of opiates in the world has increased during the past 2 decades. During this period it increased 2.5 times. An increase of 19.8% was reported for 2004 to 2008 (Fig. 1).
Consumption of Synthetic Analgesics
The overall consumption of synthetic analgesics increased during the past 2 decades. During this time period it increased 5 times. An increase of 31.1% was reported for 2004 to 2008 (Fig. 2).
Consumption of Opioids
The overall consumption of opioids increased 3.5 times during the past 2 decades (Fig. 3). As a result, the share of consumption of opiates in the total consumption of opioids globally declined from 71% in 1989 to 57% in 2008.
Consumption of Morphine
During 2004 to 2008, the increase in the global consumption of morphine was very close to that of opiates at large, including morphine, hyromorphone, oxymorphone, codeine and oxycodone (morphine, 16.6%; opiates, 19.8%) (Figs. 1, 4).
The 10 leading consumers of morphine globally and in all ‘Organisation for Economic Co-operation and Development’ countries, are listed in Figure 5. The latter, which consist of 5.5% of all reporting countries to the International Narcotics Control Board (INCB), consumed 91.6% of all the global consumption of morphine, whereas all other countries consisting of 94.5% of all reporting countries consumed only 8.4%.
Further analysis of the global distribution of morphine consumption in 2008 shows that North America (USA and Canada) consumed 61%, Europe 26.4%, Australia and New Zealand 3.7%, and Japan 0.9%. All other countries together consumed only 8% of the global consumption of morphine in 2008 (Fig. 6).
Consumption of Fentanyl
During 1989 to 2008, the increase in the global consumption of fentanyl was 45.2% (Fig. 7).
By and large, the increase in the global consumption of fentanyl is substantially higher than that of all the synthetic analgesics grouped together: 45.2% versus 31.1% for 2004 to 2008. The 10 leading consumers of fentanyl globally, all ‘Organisation for Economic Co-operation and Development’ countries, are listed in Figure 8. The latter, which consist of 5.5% of all reporting countries to the INCB, consumed 78.9%, whereas all other countries consumed only 21.1%.
Further analysis of the global distribution of fentanyl consumption in 2008 shows that the 10 leading countries consumed 78.9%, whereas all other countries together consumed 21.1% of the global consumption of fentanyl in 2008 (Fig. 9).
The consumption of fentanyl, a synthetic opioid, is steadily rising, reaching new record levels in 2008 (1.5 tons, globally). Fentanyl is the synthetic opioid with the highest consumption rates in terms of doses consumed; the physiochemical and pharmacologic properties of fentanyl are different from those of morphine because of the striking differences in their lipophilic profile. This results in a rapid blood-brain penetration and greater access to the brain and to the central opioid receptors (μ-opioid receptors). As a result, fentanyl is reported to be 75 to 100 times more potent than morphine.
When comparing the global trends in the consumption of morphine with that of fentanyl, it became clear that the consumption of fentanyl exceeded that of morphine during 2004 to 2008 (morphine, 16.6%; fentanyl, 45.2%). Figure 10 shows the yearly increase in doses consumed globally (morphine vs. fentanyl).
WHAT IS OCCURRING IN MIDDLE EASTERN COUNTRIES?
Consumption of Morphine
Figure 11 shows the changes in morphine consumption in 7 Middle Eastern countries compared with those in the United States for 2004 to 2008. A marked increase was reported for the United States whereas 4 of the 7 Middle Eastern countries reported a more moderate increase in their morphine consumpion (Israel, Jordan, Saudi Arabia, and Egypt); no changes were reported for Cyprus, whereas a decrease in consumption was reported for Turkey.
Consumption of Pethidine (Meperidine)
Figure 12 shows that whereas in the United States pethidine consumption decreased during 2004 to 2008, 5 of 7 Middle Eastern countries reported an increase in the consumption of this opioid (Cyprus, Lebanon, Turkey, Saudi Arabia, and Egypt); no changes were reported for Israel, whereas a decrease in pethidine consumption was reported for Jordan.
Consumption of Fentanyl
Figure 13 shows that there is an increase in fentanyl consumption in the United States and in 5 Middle Eastern countries (Israel, Cyprus, Turkey, Egypt, and Jordan) during 2004 to 2008. In 2 Middle Eastern countries (Lebanon and Saudi Arabia) no changes were reported for this time period.
The increased popularity in the consumption of fentanyl globally and in the Middle Eastern countries becomes more obvious when comparing the relative percentage of opioid consumption (morphine, pethidine, and fentanyl) among all the opioids consumed during 2006 to 2008. The change in fentanyl consumption is striking (Fig. 14).
The consumption of fentanyl has shown such an impressive rise, despite the fact that it is more expensive and that the equianalgesic doses are higher, might be associated with the fact that this drug, in contrast to morphine, might not be as directly related to “opioids” as morphine.
A more convincing way to express the share of fentanyl in the overall consumption of opioids is through morphine equivalence values (Figs. 15 to 19). Using the Spearman correlation analysis between the increase in total opioid consumption and that of morphine and fentanyl, it became apparent that the increases in the total consumption of opioids and that of fentanyl were significantly correlated at the 0.01 level (2-tailed), but were not so for morphine consumption. In comparison with all other Middle Eastern countries, Israel is consuming relatively high doses of methadone.
Morphine is still scarce for many. The geography of pain relief is skewed in that the 10 richest countries consume more than 90% of the world's supply of morphine, according to the latest report (2008) of the INCB. One reason that between 40% and 70% of these people have little or no access to morphine, is opiophobia. Although long-term opiate users will become dependent, the effect is reversible. Furthermore, it has been strongly acknowledged that morphine is medicine's oldest and most powerful pain medication, particularly for terminal patients with severe and chronic pain.8 Many patients and their families view morphine medication as anticipation of death and taking this opioid is a last resort. There are many people in the world who believe that opioids hasten death, as they feel that an offer of opioids signifies imminent death. That is the reason why patients reject morphine despite the pain experienced as a consequence.
The role of the medical professional in this context is crucial as patients value the professionals' confidence in the use of opioids. If patients detect professional ambivalence toward morphine, their fears are heightened. It is, therefore, important that professionals, patients, and their relatives be better educated, as there are still oncologists who tend to reserve the use of opioids at the final stages of the disease. The World Health Organization guidelines for the management of cancer pain state that analgesic treatment choices should be based on the severity of the pain and not on the prognosis of the disease. Hence, patients at all stages of cancer could have morphine if their pain is sufficient. Unrelieved pain leads to social isolation, loss of role, and depressed mood. Therefore, morphine, if used properly, can actually promote quality of life by allowing patients with pain to function better.
The problem nowadays is that physicians are often afraid to dispense high doses of opioids, hence those who need high doses are still being put through hell.9 In the United States, minorities, children, and women are more likely to be undertreated for pain or do not receive any pain care at all.
Decisions about a patient's pain treatment are now made much more collaboratively, but even in modern times, the process is fraught with moral judgment stemming largely from the nature of available pain treatments and an incomplete understanding of how to use them. It is imperative that oncologists, family physicians, anesthesiologists, pain experts, and others should adopt the notion that palliative care, in general, and pain management, in specific, should not be solely linked to the end of life, but rather seen as a positive option in the less advanced stage of the disease as well.10 Unfortunately, there are many who still think that pain and shortness of breath are an inherited part of death and for the dying patient, strong opiates can take away both the pain and the feeling of drowning. In most Middle Eastern countries, patient access to the medication needed to relieve cancer pain is profoundly restricted. The understanding of pain and the suffering that ensues is a major public issue that needs urgent consideration. The number of people who will need pain relief will rise sharply in the coming years. Cancer, once regarded as a disease of industrialized nations, is now occurring in epidemic proportions in developing countries, where smoking and exposure to carcinogens are on the rise. The World Health Organization predicts that by 2020 there could be 15 million new cancer cases every year—a 50% increase, and most of them will be in the developing countries. Moreover, most sufferers in the developing countries will die from their disease because of a lack of early detection and access to treatment by the time these patients see a physician for the first time. In the Middle East approximately 70% will be terminal.
In conclusion, it is clear that a better understanding of the biology of pain is needed as well as finding more effective treatment modalities for pain. Better public education is highly essential so that consumers understand the danger of letting pain go untreated.
1. Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitude Ann Oncol.. 2009;20:1420–1433
3. International Association for the Study of Pain. Education and training for pain management in developing countries. A report by the IASP developing countries taskforce. http://www.iasp-pain.org/AM/Template
. cfm&Section=Home&Template=/CM/ContentDisplay.cfm&contentID=4982. Accessed January 25, 2010.
5. Silbermann M. Endeavors to improve palliative dare services for patients with cancer in Middle Eastern countries Am Soc Clin Oncol Educ Book.. 2010:217–221
6. Cherny NI, Baselga J, de Conno F, et al. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative Ann Oncol.. 2010;21:615–626
7. Silbermann M. Opioids in Middle Eastern Populations Asian Pac J Cancer Prev.. 2010;11:1–5
Keywords:Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.
opioid consumption; global consumption; opioid availability