Availability of Opioid Analgesics

Home , Opiate, Trimeperidine

Chapter II. Narcotic DRUGS 11 and opiate raw materials will also continue to rise. consumption of opioids may decline, owing to expected Figure 4 presents the global level of consumption of growth in the consumption of synthetic opioids. opiates and synthetic opioids, including buprenorphine and pentazocine, which are opioids controlled under the 62. Overall, the available data indicate that the amount 1971 Convention, during the 20-year period from 1994 of opiate raw materials available for the manufacture of to 2013. To allow the aggregation of consumption data narcotic drugs for pain relief is more than sufficient to for substances having different potencies, the levels of satisfy the current level of demand as estimated by consumption are expressed in billions of S-DDD. Governments. In addition, both production and stocks continue to increase.

Figure 4. Global consumption of opioids, 1994-2013 B. Availability of opioid analgesics

14 63. Opioid analgesics are essential medicines for palli- 34 12 ation therapy. They are prescribed mainly in relation to cancer, but palliation therapy is also needed for other 10 health situations that require the management of pain D D (such as surgery and childbirth) and for chronic condi- - D

S 8

o tions such as cardiovascular diseases, chronic respiratory

s n o

i diseases, HIV/AIDS and diabetes.

l 6 l i B

4 64. Each year, around 5.5 million terminal cancer patients, 1 million end-stage HIV/AIDS patients and 2 800,000 patients with lethal injuries caused by accidents or violence, in addition to patients with chronic illnesses, 0 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 patients recovering from surgery, women in labour and paediatric patients, are subjected to untreated or under- Year treated moderate to severe pain. All in all, WHO estimates Opiatesa Synthetic opioidsb Opioidsc that annually tens of millions of people are suffering 35 Source: International Narcotics Control Board. without adequate treatment. a Including buprenorphine, an opiate controlled under the 1971 Convention. 65. It is estimated that, out of the 20 million people in b Including pentazocine, a synthetic opioid controlled under the 1971 Convention. need of palliative care at the end of their lives, about c Including opiates and synthetic opioids. 80 per cent live in low- or middle-income countries.36 According to the Worldwide Palliative Care Alliance, every year at least 100 million people worldwide would benefit from palliative care; however, fewer than 8 per 61. Over the past 20 years, global consumption of opi- cent of people in need of palliative care have access to it. oids has more than tripled. The consumption of opiates as According to the Harvard Global Equity Initiative-Lancet a percentage of total consumption of opioids fluctuated Commission on Global Access to Pain Control and between 62 per cent in 1994 and 52 per cent in 2006, ris- Palliative Care, “the absence of palliative care also under- ing again to 61 per cent in 2013. As a result, the share of mines efforts to improve human well-being, and synthetic opioids, which are used for the same indications as opiates, increased from 38 per cent in 1994 to 48 per cent in 2008, but declined to 39 per cent in 2013. Between 34 World Health Organization, Model List of Essential Medicines, 2010 and 2013, the ratio of consumption of opiates to syn- 19th list (April 2015, amended June 2015). Available from www.who.int/ thetic opioids stabilized at about 60 per cent for opiates medicines/publications/essentialmedicines. and 40 per cent for synthetic opioids. Throughout the 35 World Health Organization, Ensuring Balance in National Policies period, the supply of opiate raw materials from which on Controlled Substances: Guidance for Availability and Accessibility of Controlled Medicines (Geneva, 2011). opiates were obtained was sufficient to cover increasing 36 Report by the secretariat of the World Health Organization on the demand. It is expected that the demand for opiates will strengthening of palliative care as a component of integrated treatment increase again in the future, while their share of the total throughout the life course. 12 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS impoverishes a host of interventions intended to reduce 1. Global patterns of consumption of human suffering and strengthen health systems”.37 opioid analgesics

66. In many countries, especially in less developed regions, the possibility of preventing, treating and curing cancer early is severely limited by a number of factors, (a) Inadequate access including a lack of early detection and prevention policies, and the limits of the health system. In many situations, palliation may be the only option available for handling 70. The data available to INCB indicate an increase in an increasing number of cases. the level of reported consumption in S-DDD in the 2011- 2013 period in comparison with the 2001-2003 period 67. Other internationally controlled drugs, such as (see maps 1 and 2). In particular, there was visible pro- methadone and buprenorphine (an opioid analgesic gress with regard to availability in Latin America and in which is controlled under the 1971 Convention and the Middle East. In Latin America, consumption of opi- whose use in substitution therapy continues to increase), oid analgesics could possibly be even higher than reported can be used in the management of pain but are mostly because methadone (which is not included in the global used in the treatment of drug dependence. However, their S-DDD calculation because of its prevalent use in opiate use is also limited in some countries despite a consider- substitution treatment) is more frequently used for pain able prevalence of heroin abuse. relief in this region than in other regions. Very little is used for drug dependence treatment, since the prevalence 68. In spite of the common prevalence of the above- of heroin abuse is relatively low and therefore opiate sub- mentioned conditions in all regions, pain relief drugs are not stitution treatment services are not common. available in sufficient quantities, are difficult to obtain because of unduly restrictive procedures, and are not prescribed, 71. There have been some small improvements in the owing to a lack of training and capacity of health profession- Russian Federation and in some countries in Central als or because of fear of addiction, which discourages health Asia. However, the situation remains problematic in most professionals from prescribing such medications. of Africa and parts of Asia.

69. Consequently, severe pain is often left untreated, 72. The United States, Canada, Australia and some although medical professionals have the capacity to relieve countries in Western Europe have increased their levels most such pain. Untreated pain diminishes the quality of of consumption to above 10,000 S-DDD per million life of patients, their families, their friends and their com- inhabitants per day. In some of these countries, there has munities, and may lead to wider losses for society.38 been a considerable increase in prescription drug abuse, which Governments have taken action to reduce without limiting access for people in need of pain relief 37 F. Knaul and others, “Closing the divide: the Harvard Global Equity Initiative-Lancet Commission on Global Access to Pain Control medicines. and Palliative Care”, The Lancet (8 March 2015). 38 N.I. Cherny and others, “The Global Opioid Policy Initiative 73. Overall, there has been encouraging progress (GOPI) project to evaluate the availability and accessibility of opioids for towards ensuring availability and increasing access to opi- the management of cancer pain in Africa, Asia, Latin America and the Carribean, and the Middle East: introduction and methodology”, Annals oid analgesics, but that goal is still a distant one for a of Oncology, Vol. 24, Suppl. No. 11 (2013), pp. xi7-xi13. considerable number of countries. Chapter II. Narcotic DRUGS 13

Map 1. Availability of opioids for pain management (2001-2003 average)

Consumption in S-DDD per million inhabitants per day < 1 1-100 101-200 201-2,000 The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. The final boundary between SouthSudan and the Sudan has not 2,001-5,000 yet been determined. The dotted line represents approximately the Line of Control in Jammu and Kashmir 5,001-10,000 agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain > 10,000 and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas).

Source: International Narcotics Control Board. Note: Opioids defined as codeine, dextropropoxyphene, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, ketobemidone, morphine, oxycodone, pethidine, tilidine and trimeperidine.

Map 2. Availability of opioids for pain management (2011-2013 average)

Consumption in S-DDD per million inhabitants per day < 1 1-100 101-200 201-2,000 The boundaries and names shown and the designations used on this map do not imply officialendorsement or acceptance by the United Nations. The final boundary between SouthSudan and the Sudan has not 2,001-5,000 yet been determined. The dotted line represents approximately the Line of Control in Jammu and Kashmir 5,001-10,000 agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain > 10,000 and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas).

(b) Evolution of the consumption of 76. In Asia, the situation is mixed. Here, most countries opioid analgesics over time saw an increase in their consumption during the past dec- ade, although with varying trends at the subregional level. 74. In the past two decades, global consumption of opi- A moderate increase was observed in East, South-East oid analgesics expressed in S-DDD has increased consid- and West Asia, while there was a decrease in South Asia, erably. The long-term trend shows an overall increase of which continued to have the lowest level of consumption 618 per cent between the 1991-1993 period and the 2011- in the world. This decrease is probably attributable to a 2013 period (see figure 5). That trend was especially pro- considerable decrease to the consumption of opioid anal- nounced during the initial years: between 1991-1993 and gesics in India as a consequence of legislative restrictions 2001-2003, there was an increase of 240 per cent, com- that had been introduced in the past. Those restrictions pared with an increase of 84 per cent between 2001-2003 have recently been lifted, but it will take some time before and 2007-2009. The growth rate declined further to the gap in consumption is closed. 14 per cent during the period between 2007-2009 and 2011-2013. The increase in consumption is mainly the 77. In Africa, the situation is problematic and result of an increase in the consumption of fentanyl and, consumption continues to be very low despite progress to a limited extent, the consumption of morphine. Global in a few countries. Patterns of consumption fluctuated consumption of codeine and pethidine for the treatment considerably both in countries with higher levels of of pain has decreased. consumption and in countries with lower levels of consumption. This is probably due to a lack of capacity of competent national authorities to estimate correctly Figure 5. Global trend in the consumption of their national needs. opioid analgesics, 1991-1993, 2001-2003, 2007-2009 and 2011-2013 averages 78. In Central America and the Caribbean, the overall

3 500 trend shows increased consumption, but there were considerable variations among countries. Consumption in y

a 3 000 d Central American and Caribbean countries was still r e p

s below an adequate level. In South America, most countries t 2 500 n a t i had increased their consumption in 2011-2013, even b a

h 2 000 n

i though some of them had experienced drops in

n o i l

l consumption in earlier periods. The data for these two i 1 500 m

e subregions, but particularly for South America, have p

D 1 000

D some limitations because, while methadone is used in S- D 500 some of the countries of the region as a pain relief medication and not in substitution treatment—heroin 0 1991-1993 2001-2003 2007-2009 2011-2013 abuse in the region is not common—it is excluded from the S-DDD calculation at the global level. Source: International Narcotics Control Board. 79. In Europe, the overall trend showed an increase, 75. The growth in consumption of opioid analgesics with some stabilization for some countries. observed since 1991 has been uneven among regions. It has been driven mainly by North America, but also by 80. In Australia and New Zealand, consumption Europe and Oceania, the three major consumer regions increased, which influenced the trend for the whole (see figures 6-17). region. Chapter II. Narcotic DRUGS 15

Figure 6. Trends in consumption, by region, Figure 7. Trends in consumption for selected 2001-2013 subregions, 2001-2013

35 000 350 y y a

30 000 a d 300

d r North America Eastern and r e South America e

p South-Eastern

s Europe t 25 000 s

t 250 n n a t a i t i b b a

20 000 a 200 h h

n West Asia i n

East and n n o South-East Asia i o l 15 000 i 150 l l i l i m

r r e e

p 10 000 100

p Western and D

D Central America D Central Europe Oceania D and the Caribbean 5 000 50 S- D S- D Africa Other regions South Asia 0 0 2001-2003 2007-2009 2011-2013 2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board. Source: International Narcotics Control Board.

Figure 8. Average consumption of opioid analgesics, all regions, 2001-2003, 2007-2009 and 2011-2013

35 000 400

350 30 000 y a d

e 300 p

s 25 000 t n a t i

b 250 a h n

i 20 000

n o i l

l 200 i m

e 15 000 p

D 150 D

S- D 10 000 100

5 000 50

0 0 North Western and Oceania South Eastern and West Asia East and Central Africa South Asia America Central Europe America South-Eastern South-East America and Europe Asia the Caribbean

2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board.

Figure 9. Average consumption of opioid analgesics in African countries and territories with higher levels of consumption, 2001-2003, 2007-2009 and 2011-2013 600 y a d

e 500 p

s t n a t i

b 400 a h n i

n o i

l 300 l i m

r e p

D 200 D S- D 100

0 a s a a a s d t a a e e a a i o e a ic le si i n u n p ri y w d i d w c p n r l i ib a ti a y e b b r b n la c i a f e n ri l g g Li a e m a a o c h A h u m sw u Is E l V a g r in G h c T a t a A b o Z U M o r t y N o n m b M P u e B M io i a d o S s Z C n S n a ce e s m A o T o a S 2001-2003 2007-2009 2011-2013 Source: International Narcotics Control Board. Note: Red lines: levels less than 200 S-DDD are considered inadequate; levels less than 100 S-DDD are considered very inadequate. For further information on inadequate and very inadequate levels of consumption as identified by the Board, see paragraph 46, above. 16 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS

Figure 10. Average consumption of opioid analgesics in African countries with lower levels of consumption, 2001-2003, 2007-2009 and 2011-2013

14 y a d

e 12 p

s t n a t

i 10 b a h n i 8 n o i l l i

m 6

r e p

D 4 D S- D 2

0 l i in d la n e n a o o e a r l n a o o u o g g s ir re ca a e h g b iq ep. a o e ep. o o a o it s M B C n a R i r n R g T F v r a A G b n e e n a E g m a m S o n d’I a a z a i e d z n C em. C rk t a o nitedT a D e u ô M U f th B C M o f o

2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board.

Figure 11. Average consumption of opioid analgesics in Central America and the Caribbean, 2001-2003, 2007-2009 and 2011-2013

3 000 y a d

2 500 r e p

s t

n 2 000 a t i b a h n

i 1 500

n o i l l i

m 1 000

r e p

D 500 S- D

0 a a

Haiti Cuba Belize Panama Jamaica Grenada Anguilla Curaçao BahamasBarbados Dominica Honduras Costa Rica Guatemala El Salvador Montserrat Nicaragua Sint Maarten Cayman Islands

British Virgin IslandsTrinidad and Tobago Dominican Republic

St. Vincent and the Grenadines 2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board. a The Netherlands Antilles was dissolved on 10 October 2010, resulting in two new constituent entities, Curaçao and Sint Maarten. Chapter II. Narcotic DRUGS 17

Figure 12. Average consumption of opioid analgesics in South America, 2001-2003, 2007-2009 and 2011-2013

1 000

900 y a 5 381 2 909 2 669 d

r 800 e p

t 700 n a t i

b 600 a h n i

500 n o i l l

i 400 m

e 300 p

D 200 S- D 100

Chile Brazil Peru Uruguay Guyana Ecuador Argentina Colombia Paraguay Suriname Venezuela Falkland(Malvinas) Islands (Bolivarian Rep. of) State of) Bolivia (Plurinational 2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board. Note: Red lines: levels less than 200 S-DDD are considered inadequate; levels less than 100 S-DDD are considered very inadequate. For further information on inadequate and very inadequate levels of consumption as identified by the Board, see paragraph 46, above.

Figure 13. Average consumption of opioid analgesics in Asian countries and territories with higher levels of consumption, 2001-2003, 2007-2009 and 2011-2013

2 500 y

a 2 000

r e p

s t n a t i 1 500 b a h n i

n o i l l

i 1 000 m

r e p

D D 500 S- D

0 l a n n y n e it n a a n a e e a a e i r a a i n o m i ra r p t k ra o d b i n la ys s o a u r h p w r ra h a a a I K J h Tu a a u Jo A C b s l f B B g K i , e s a o in d o L ru M . S u ca a p a a e S i D R M e n ru B 2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board. 18 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS

Figure 14. Average consumption of opioid analgesics in Asian countries and territories with lower levels of consumption, 2001-2003, 2007-2009 and 2011-2013

200 180 y a d

160 r e p

s 140 t n a t i

b 120 a h n i

100 n o i l l

i 80 m

r e

p 60

D D 40 S- D 20 0 r a n a n ) a a d a a a a n s s a a n n n l h n a q n n ta n a ri a f i n n m li i e k a e e si i a a a a s e i a a a a i y t o rg i a a o n r n t n iv e d ij t t p e d Ir t t h m S s o h il N g e o a s i d In a is is e d m Rep. o is is Q C O h e C a t n m K L yz p l n b n k N a e b k k , k ep. h ie o r f i g ip a o r e e l Y m a ji g a R G T A o r r il d e b g em. a P a Emiratesn z V M S y h M In z m z n C T b o a K P A rk U a ra K K ep. u B A g T d n Islamic e o ( it H n eople’s D n a P U Ir o People’s R La em. D 2001-2003 2007-2009 2011-2013

Figure 15. Average consumption of opioid analgesics in European countries and territories with higher levels of consumption, 2001-2003, 2007-2009 and 2011-2013

25 000 y a 20 000 d

r e p

s t n a t i 15 000 b a h n i

n o i l l i 10 000 m

r e p

D D 5 000 S- D

0 r y ia m rk a d s in y rg n d e d d m ia ry ic ly e ia n tr u a lt n d a a u e n c n n o n a l a c k a s i a la n p w o d la n la la d e g b It e a m u lg m r r la S r e e ra n e g v n u re v r e n b e r o b w c F i Ir n o u p G o e A B e i z e N m S I F i l e l G D G it h e K S H R S w t x d h S e u e c N L it e n z U C 2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board. Chapter II. Narcotic DRUGS 19

Figure 16. Average consumption of opioid analgesics in European countries with lower levels of consumption, 2001-2003, 2007-2009 and 2011-2013

3 000

2 500 y a d

r e p 2 000 s t n a t i b a h n

i 1 500

n o i l l i m

r e 1 000 p

D D S- D 500

0 a a l d o s a a a a a a a s n a e ti rr a n r u i i i i i ri lt u o v n ia a o g a g r rb n tv n n a a r ti o i n o d tu l e p e a a a to g la a ld a ra a r n r o n y S u L m s l M e r o i k b C A o P te C th o E u B e n U l P n Li R B d M ugoslavo A o Fe f d o ce M Herzegovina n . a d ia p n s e M a s R f u o ia R sn The formerep. Y o R B

2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board.

Figure 17. Average consumption of opioid analgesics in Oceania, 2001-2003, 2007-2009 and 2011-2013

3 500 y a

d 3 000

r e p

s t 2 500 n

a t i b

a 2 000 h n i

n o

i 1 500 l l i m

e 1 000 p

D D 500 S- D

0 a d d a a u d s a a u a ji a u u li n n i i a n d i e r g i o l t a a a n s l a n s n u n F a a tr l l o e a l a e i a o m v u s Is a d yn P Is l n u N T a Tu n u e le l s Is ro G S a A lk Z a o a k c V o w C P a Islands i w rf e n m o M e o w ch tu t o N N e n u is C a N N e F r u r d h p F n C a a P is ll a W 2001-2003 2007-2009 2011-2013

Source: International Narcotics Control Board. 20 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS

(c) Overconsumption and prescription misuse shows a high prevalence of misuse of opioids in drug abuse some countries. This is reported by high-income coun- tries40 such as Australia, Canada and the United States and 81. While inadequate access to opioid analgesics in by lower-middle-income countries such as Nigeria and some regions is a matter of concern, it is important to Pakistan, which have the lowest per capita consumption of also consider that in regions with high levels of consump- opioids for medical purposes (see figures 18-19).41 tion there are growing public health concerns regarding According to UNODC, that suggests that the misuse of the abuse of prescription drugs, which in some countries prescription opioids does not necessarily follow from mak- has outpaced the abuse of illegal drugs. ing opioids accessible or available for medical purposes.42

82. Many factors are contributing to this development, but the main ones are the widespread availability of prescription drugs and the erroneous perception that they are less susceptible to abuse than illicit drugs. The non- prescription use of prescription drugs for self-medication has further exacerbated the problem.

83. A comparative analysis by UNODC39 of the con- 40 Based on the World Bank classification of income levels and sumption of opioid analgesics and the prevalence of their development. 41 The annual prevalence of misuse of prescription opioids is as follows: Australia, 3.1 per cent; Canada, 1 per cent; Nigeria, 3.6 per cent; 39 World Drug Report 2014, United Nations publication, Sales No. Pakistan, 1.5 per cent; and United States, 5.2 per cent. E.14.XI.7. 42 World Drug Report 2014.

Figure 18. Per capita consumption of opioid analgesics, 2011

800

700 a t i p a c

e 600 p / g m

i 500

t n e l a v i 400 u q e

e n i

h 300 p r o M 200

100

0 l l a s ia d y d d m s d e ia ic ia ia ia d a ia le a a y i ia n f) n n ia d te l n n n n o iu n a k l r n b n ic g i in ic a z s ta o ta ta r a a ra la a la la d it la r a b a o r la fr r h t R u ra i s s s e n t t r m a e g r n Is v u lg t e o A o C n a g B n h i i ig a S s e r e Ir n u i lo p u s S P e e t ru u k n k N C d u tz e Z i a F e E th G rg s U T a tate a a e A i G K M S R B u o z S h P it w w d h o A C a fg n S e e c K A N it e S U n z U C

lurinational P ( a vi li o B

Source: UNODC. Chapter II. Narcotic DRUGS 21

Figure 19. Prevalence of misuse of prescription opioids in the general population, 2013 or latest available data

5 ) e g a t n

e 4 c r e p (

e c

n 3 e l a v e r p

l 2 a u n n A 1

0 a s a y s l a c a a a a a e a a y l a ) a e i d n d d m d e i li i i i d c i l c a zi i n f n n i d t l n n n o iu n a k r n b n i g i in i a s ta o ta ta r a a ra la a la la d it la r a b a o r la fr r h t R u r i s s s e n t t r m a e g r n Is v u lg t e o A o C n a g B n h i i ig a S s e r e Ir n u i lo p u s S P e e t ru Tu k tate n k N C d u tz e Z i a F e B E th G rg s U a S a a e A i G K M S R u A o z h P it w w d h o C a fg n S e e c K A N it e S U n z U C lurinational P ( a vi li o B

Source: UNODC.

84. To address this problem, countries need to develop Commission on Narcotic Drugs. Accordingly, in March a comprehensive strategy aimed at tackling the root 2013 the Commission adopted resolution 56/8, on pro- causes of the excessive supply of prescription drugs, moting initiatives for the safe, secure and appropriate including overprescribing by medical professionals, “doc- return for disposal of prescription drugs, in particular tor shopping” and inadequate controls on the issuing and those containing narcotic drugs and psychotropic sub- filling of prescriptions. In addition, public health officials stances under international control. identified the presence in households of prescription drugs that are no longer needed or used for medical pur- 87. In that resolution, the Commission encouraged poses as one of the main sources of prescription drugs States to consider the adoption of a variety of courses of diverted from licit channels for abuse. Surveys of the action to address prescription drug abuse, in cooperation prevalence of abuse undertaken in several countries have with various stakeholders such as public health officials, revealed that a significant percentage of individuals abus- pharmacists, pharmaceutical manufacturers and distribu- ing prescription drugs for the first time had obtained the tors, physicians, consumer protection associations and drug from a friend or family member who had acquired law enforcement agencies, in order to promote greater them legally. awareness of the risks associated with the non-medical use of prescription drugs, in particular those containing 85. Among the measures increasingly being used to narcotic drugs or psychotropic substances. address this problem are mechanisms to ensure the safe return and disposal of medications possessing psycho active properties, particularly those containing narcotic (d) Consumption of opioid analgesics and drugs or psychotropic substances, including through the need for palliative care prescription drug take-back days. The setting up of such initiatives in many jurisdictions has yielded significant 88. The patterns of consumption of opioid analgesics results at a relatively low cost. expressed in S-DDD or in milligrams per capita tell only part of the story. In order to ascertain if the level of con- 86. The importance of these measures has been recog- sumption is appropriate, it is important to measure it in nized by the international community, including by the relation to the prevalence of health conditions requiring 22 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS

Figure 20. Deaths from diseases requiring Figure 21. Distribution of adults in need of palliative care at the end of life, by type of palliative care at the end of life by income disease, 2011 group and disease category, 2011

100 6% 90

28% 60

66% 10

0 High income Upper middle Lower middle Low income income income HIV/AIDS Cancer PNMD Source: World Health Organization and Worldwide Palliative Care HIV/AIDS Cancer (malignant neoplasm) PNMD Alliance, Global Atlas of Palliative Care at the End of Life (Worldwide Palliative Care Alliance, 2014). Source: World Health Organization and Worldwide Palliative Care Alliance, Global Atlas of Palliative Care at the End of Life (Worldwide Palliative Care Alliance, 2014). palliative care, which include not only cancer but also care cases in low-income countries, but remains below 10 other conditions. Also, while consumption of opioid anal- per cent in countries with higher income levels. gesics is concentrated in a few countries, the prevalence of conditions requiring their use is much more 91. The latest data available from the International widespread. Agency for Research on Cancer, the specialized cancer research agency of WHO, show that the global burden of 89. Information from the Global Atlas of Palliative Care cancer has risen to 14.1 million new cases and 8.2 mil- at the End of Life,43 prepared by WHO and the Worldwide lion cancer deaths in 2012, compared with 12.7 million Palliative Care Alliance, indicates that cancer is respon- new cases and 7.6 million deaths in 2008. Prevalence esti- sible for 28 per cent of adult deaths requiring palliative mates for 2012 show that there were 32.6 million people care. The majority (66 per cent) of deaths requiring such alive and over the age of 15 years who had been diagnosed care are related to progressive non-malignant diseases with cancer in the previous five years (see figure 22). (PNMD).44 The remaining 6 per cent are due to AIDS According to projections based on estimates presented by (see figure 20). the GLOBOCAN project for 2012, a substantial increase in new cancer cases to 19.3 million per year by 2025 is 90. In all but low-income countries, the share of adults expected, owing to the expected increase and ageing of in need of palliative care for cancer remains more or less the global population. constant at around 33-38 per cent; that share drops to around 23 per cent in low-income countries (see 92. More than half of all cancer cases (56.8 per cent) figure 21). Progressive non-malignant diseases continue and cancer deaths (64.9 per cent) in 2012 occurred in to comprise the majority of cases in all regions. The need less developed regions of the world. Those proportions for AIDS palliative care comprises one third of palliative will increase further by 2025. Cancer is often presented as a disease of wealthy or developed populations. In real- ity, over 70 per cent of cancer deaths occur in low- and 43 World Health Organization and Worldwide Palliative Care middle-income countries. Without sustained action, the Alliance, Global Atlas of Palliative Care at the End of Life (Worldwide Palliative Care Alliance, 2014). incidence of cancer is projected to increase further in 44 Progressive non-malignant diseases among adults are considered to low- and middle-income countries by 2030. Cancer is be Alzheimer’s disease and other dementias, cardiovascular diseases present throughout the world, but countries that lack the (excluding sudden deaths), chronic obstructive pulmonary diseases, health infrastructure to cope with the increasing num- cirrhosis of the liver, Diabetes mellitus, multiple sclerosis, kidney diseases, Parkinson’s disease, rheumatoid arthritis and tuberculosis (multidrug- ber of people suffering from the disease are particularly resistant tuberculosis and extensively drug-resistant tuberculosis only). affected. Chapter II. Narcotic DRUGS 23

Figure 22. Prevalence of cancer diagnoses 94. Plotting the level of consumption of opioid analge- within the previous five years, per 100,000 sics against the cancer age-standardized rate45 confirms the population, 2012 global imbalance in the consumption of such substances, with the United States, Canada, Australia, New Zealand 2 000 and Western and Central European countries registering

1 500 high levels of consumption, with a corresponding high cancer age-standardized rate. A global comparison is dif- 1 000 ficult owing to the fact that most countries are clustered together in the lower levels as a result of the high level of 500 consumption in a few countries (see figure 23). If the patterns in each region are examined in detail, it is possible 0 North Oceania Europe World Latin Asia Africa to gain a better idea of the global variations. America America and the Caribbean 45 GLOBOCAN presents cancer data in an age-standardized rate, Source: GLOBOCAN database. which is a summary measure of the rate that a population would have if it had a standard age structure. Standardization is necessary when comparing several populations that differ with respect to age because age has a powerful influence on the risk of cancer. The age-standardized rate is a 93. In low- and middle-income countries, where there weighted mean of the age-specific rates; the weights are taken from the is limited capacity with regard to prevention and early population distribution of the standard population. The most frequently used standard population is the World Standard Population. The calcu- detection of cancer, the disease is mostly discovered when lated incidence or mortality rate is then called age-standardized incidence it is at an advanced stage. By then, there are not many or mortality rate (world), and is expressed per 100,000 people. The age- treatment options and palliation is required. Opioid analge standardized rate is calculated using 10 age groups (0-14, 15-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74 and 75+). The result may be sics for cancer treatment are therefore are indispensable slightly different from that computed using the same data categorized in these countries. using the traditional five-year age bands.

Figure 23. Relationship between cancer incidence, 2012, and consumption of narcotic drugs, 2011-2013

45 000

40 000 y a d

r 35 000 e p

s t

n 30 000 a t i b a

h 25 000 n i

n o i l

l 20 000 i m

r e p

15 000 D D

S- D 10 000

5 000

0 0 50 100 150 200 250 300 350 400 Cancer (age -standardized rate)

Africa Asia Eastern Europe Western Europe Oceania Americas United States

Source: GLOBOCAN database and International Narcotics Control Board. 24 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS

95. In the North America region, there is a considerable a number of countries exceeding it while the consump- gap between Mexico on the one hand, and the United tion of opioid analgesics remains well below the level of States and Canada on the other hand (see figure 24). 200 S-DDD per million inhabitants per day (see figure 26). 96. In Central and South America and the Caribbean, the distribution of the countries seems to indicate that 98. In Asia, the level of consumption in S-DDD per mil- South American countries have increased their consump- lion inhabitants per day is higher, but this corresponds tion of opioid analgesics and that this is the result of an to higher cancer rates. In Western Europe, consumption increasing rate of cancer (see figure 25). In Central America is high and seems to match the level of cancer prevalence. and the Caribbean, there are countries with relatively In Eastern and South-Eastern Europe, cancer rates are higher rates of cancer, but their consumption of narcotic similar to Western Europe but the level of consumption drugs for palliative care is below the adequate level. of pain relief drugs is considerably lower. Australia and New Zealand have very high levels of consumption, while 97. In Africa, there seems to be a concentration of other, smaller countries in Oceania have much lower lev- countries with a cancer age-standardized rate of 100, with els (see figures 27-30).

Figure 24. Relationship between the cancer Figure 25. Relationship between the cancer age-standardized rate, 2012, and consumption age-standardized rate, 2012, and consumption of narcotic drugs, 2011-2013, North America of narcotic drugs, 2011-2013, Central and South America and the Caribbean 50 000 y a d

r 1 000 a e d

40 000 r 900 s e t p n

s a 800 t t i n b a 700 a 30 000 t i h b n a i 600

h n n o i i 500 l l 20 000 n i o

i 400 m l

l r i e

m 300

10 000 e D

p 200 D

D 100 S- D 0

S- D 0 0 100 200 300 400 0 100 200 300 400 Cancer (age-standardized rate) Cancer (age-standardized rate) Central America and the Caribbean South America Source: GLOBOCAN database and International Narcotics Control Source: GLOBOCAN database and International Narcotics Control Board. Board.

Figure 26. Relationship between cancer Figure 27. Relationship between cancer incidence, 2012, and consumption of narcotic incidence, 2012, and consumption of narcotic drugs, 2011-2013, Africa drugs, 2011-2013, Asia

200 5 000 y y a a d d

r r e e

p 4 000 p

150 s t t n n a a t t i i b b

a 3 000 a h h n n i i 100

n n o o i i l l l

l 2 000 i i m m

r r e e

p 50 p

D 1 000 D D S- D S- D 0 0 0 100 200 300 400 0 100 200 300 400 Cancer (age-standardized rate) Cancer (age-standardized rate)

Source: GLOBOCAN database and International Narcotics Control Source: GLOBOCAN database and International Narcotics Control Board. Board. Chapter II. Narcotic DRUGS 25

Figure 28. Relationship between cancer 99. Palliative care is also required for AIDS. A compar- incidence, 2012, and consumption of narcotic ison among the various WHO regions in the Global Atlas drugs, 2011-2013, Western Europe of Palliative Care at the End of Life shows that the percentage of adults in need of palliative care in relation to 25 000 y a

d AIDS is larger in low-income countries, particularly in

r e p

20 000

s Africa, than in countries in other income groups. t n a t

i Expanded access to antiretroviral therapy and a declining b 15 000 a h

n incidence of HIV infection have led to a steep fall glob- i

n o i

l 10 000 ally in the number of adults and children dying from l i m

r HIV-related causes. The drop in HIV-related mortality is e p 5 000 D

D especially evident in the regions with the greatest burden

S- D 0 of HIV infection, including the African region, which was 0 100 200 300 400 home to about three in four people who died from HIV- Cancer (age-standardized rate) related causes in 2013. However, HIV and AIDS preva- Source: GLOBOCAN database and International Narcotics Control lence remains high in low-income countries, and the Board. availability of antiretroviral therapy is still limited, despite efforts made in that regard by UNAIDS and the broader Figure 29. Relationship between cancer international community. The inadequate availability of opioid analgesics to manage AIDS-related pain is a major incidence, 2012, and consumption of narcotic problem for an even larger percentage of the population drugs, 2011-2013, Eastern and South-Eastern in low-income countries. Europe

3 000 100. When comparing the estimated number of AIDS y

a 46 d

deaths in 2013 with the level of consumption of opioid r 2 500 e p

s analgesics, expressed in S-DDD per million inhabitants t n

a 2 000 t i per day, the countries with highest number of deaths and b a h n

i lowest levels of consumption were in sub-Saharan Africa

1 500 n o i l

l and Asia (see table 1). Nigeria, with an estimated 210,000 i

m 1 000

e AIDS deaths in 2013, reported no consumption of opi- p

D 500 oid analgesics to INCB. India had an estimated 130,000

S- D AIDS deaths and just 11 S-DDD per million inhabitants 0 0 100 200 300 400 per day. Mozambique, with only 5 S-DDD per million Cancer (age-standardized rate) inhabitants per day, had an estimated number of deaths in 2013 of 82,000. The United Republic of Tanzania had Source: GLOBOCAN database and International Narcotics Control Board. the same level of S-DDD and 78,000 estimated deaths. Zimbabwe had 64,000 estimated deaths and only 35 S-DDD. Uganda had only 30 S-DDD and 63,000 esti- Figure 30. Relationship between cancer mated AIDS-related deaths. South Africa had 338 S-DDD, incidence, 2012, and consumption of narcotic but the estimated number of AIDS-related deaths was drugs, 2011-2013, Oceania 200,000.

14 000 y a d 12 000 r e p

s t 10 000 n a t i b

a 8 000 h n i

n o

i 6 000 l l i m

r 4 000 e p

D 2 000 S- D 0 0 100 200 300 400

Cancer (age-standardized rate) Source: GLOBOCAN database and International Narcotics Control Board. 46 World Health Organization, Global Health Observatory. 26 AVAILABILITY OF INTERNATIONALLY CONTROLLED DRUGS

Table 1. Estimated number of AIDS deaths, and dispense such substances through appropriate palli- 2013, compared with the level of consumption ative care services. In the Global Atlas of Palliative Care of opioid analgesics, 2011-2013 at the End of Life, WHO and the Worldwide Palliative Care Alliance classified countries in relation to the development of the level of palliative care services in six S-DDD per million Estimated AIDS inhabitants per categories: Country deaths in 2013 day, 2011-2013 • Level 1: no known activity Nigeria 210 000 0 • Level 2: capacity-building activity South Africa 200 000 338 • Level 3a: isolated provision India 130 000 11 • Level 3b: generalized provision Mozambique 82 000 5 • Level 4a: preliminary health system integration United Republic of 78 000 5 • Level 4b: advanced health system integration Tanzania Zimbabwe 64 000 35 103. By looking at the map illustrating the different lev- Uganda 63 000 30 els of palliative care services (see map 3) and comparing Kenya 58 000 0 it with the map illustrating the levels of consumption of Malawi 48 000 26 opioid analgesics expressed in S-DDD (see map 4), it is Ethiopia 45 000 0 possible to see that, even though there is generally a Cameroon 44 000 4 positive direct correlation between high levels of consumption and high levels of development of palliative Democratic Republic 30 000 2 of the Congo care services, there are some inconsistencies. Indonesia 29 000 16 104. In East and Southern Africa, for example, there are Côte d’Ivoire 28 000 1 a number of countries at level 4a (Kenya, Malawi, South Zambia 27 000 32 Africa, United Republic of Tanzania, Zambia and Zimbabwe) or level 4b (Uganda), but in all of these coun- Source: International Narcotics Control Board and WHO Global Health Observatory. tries (except South Africa) the reported consumption of opioid analgesics is fairly low.

101. Even though the table above confirms that AIDS 105. In South America (with the exception of Chile and is a major health condition requiring palliation, the dis- Uruguay, which are considered to be at level 4a, and eases classified as progressive non-malignant diseases are Argentina, which is rated as level 3b), most countries are the major reasons for the demand for palliative care in rated at level 3a (Brazil, Colombia, Ecuador, Guyana, all regions. However, reliable prevalence rates for these Paraguay and Peru) or level 2 (Bolivia (Plurinational State diseases are not available at the global level, making it of) and Suriname). Nevertheless, levels of consumption impossible to compare them with levels of consumption are relatively high in the region. The apparent inconsist- of opioid analgesics. ency with the level of palliative care services may be an indication that consumption is high but concentrated in limited or privileged areas. (e) Consumption of opioid analgesics and the level of development of palliative care 106. The development of palliative care services is important to ensure that, when opioid analgesics are 102. An important aspect of the availability of opioid made available, they can actually be efficiently and ration- analgesics is the capacity of health systems to prescribe ally prescribed. Chapter II. Narcotic DRUGS 27

Map 3. Global levels of palliative care, 2014

Levels of palliative care development Level 1: no known activity 4 Level 2: capacity- building activity Level 3a: isolated provision Level 3b: generalized provision Level 4a: preliminary 5 health system The boundaries and names shown and the designations used on this map do not imply officialendorsement integration or acceptance by the United Nations. The final boundary between South Sudan and the Sudan has not Level 4b: advanced yet been determined. The dotted line represents approximately the Line of Control in Jammu and Kashmir health system inte- agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by gration the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain Not applicable and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas).

Source: World Health Organization and Worldwide Palliative Care Alliance, Global Atlas of Palliative Care at the End of Life (Worldwide Palliative Care Alliance, 2014).

Map 4. Consumption of opioids for pain management, 2011-2013

Consumption in S-DDD per million inhabitants per day < 1 1-100 101-200 201-2,000 The boundaries and names shown and the designations used on this map do not imply officialendorsement or acceptance by the United Nations. The final boundary between South Sudan and the Sudan has not 2,001-5,000 yet been determined. The dotted line represents approximately the Line of Control in Jammu and Kashmir 5,001-10,000 agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain > 10,000 and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas).