A first comparison between the consumption of and the need for opioid analgesics at country, regional, and global levels

The objective of this study was to propose a rough but simple method for estimating the total population need for opioids for treating all various types of moderate and severe pain at the country, regional, and global levels. We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world's population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access. Policies should seek a balance between maximizing access for medical use and minimizing abuse and dependence. Countries should aim to increase the medical consumption to the magnitude needed to address the totality of moderate and severe pain.     

A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country,Regional, and Global Levels

ABSTRACT

The objective of this study was to propose a rough but simple method for estimating the total population need for opioids for treating all various types of moderate and severe pain at the country, regional, and global levels. We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world's population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access. Policies should seek a balance between maximizing access for medical use and minimizing abuse and dependence. Countries should aim to increase the medical consumption to the magnitude needed to address the totality of moderate and severe pain.     

What do different databases tell about the use of opioids in seven European countries in 2002?

Objective: The objective of this paper was to analyse opioid consumption in a number European countries using different sources of data. Methods: Data were extracted from the United Nations’ International Narcotics Control Board Report (INCB) 2003 and from the registers of the national health authorities in seven countries where data were available for 2002. The amount of opioid used was calculated as daily defined doses per 1000 inhabitants per day (DDD/1000/day). Danish Register of Medicinal Products Statistics was further explored for characteristics of opioid consumption (age, gender, type of opioids consumed) by patients in primary care. Total opioid consumption and consumption of 11 selected opioids (7 strong and 4 weak) were analysed. The amount of opioids consumed by outpatients was also examined. Results: There were considerable differences in the number of opioids reported and significant discrepancies in the amounts of opioids consumed between the national data and the INCB report. The source of data for the national registers on drug consumption varied (pharmacies or wholesale). The INCB data provide information on opioid import and estimated need rather than on medical consumption. Conclusions: Caution is required when interpreting the data on opioid consumption between countries because of differences in the collection and reporting of data. Better recording of opioid consumption is needed for meaningful analysis of opioid consumption and its possible effect on pain management in different countries. Data on opioids consumed for cancer‐related pain in comparison with chronic non‐malignant pain are needed. A uniform method of collection of data on analgesic consumption should be established for all European countries.     

Postoperative Pain Management in Spanish Hospitals: A Cohort Study Using the PAIN-OUT Registry

Pain after surgery remains a problem worldwide, although there are no published data on postoperative outcomes in Spain. We evaluated 2,922 patients on the first day after surgery in 13 tertiary care Spanish hospitals, using the PAIN-OUT questionnaire. The aims were to: assess postoperative outcomes and anesthetic/analgesic management in Orthopedics (ORT) and General Surgery (GEN) patients; explore the influence of the analgesic therapy on outcomes and opioid requirements; evaluate and compare outcomes and analgesic management according to surgical procedure. Mean worst pain and percentage of patients in severe pain were 5.6 (on a numeric rating scale of 0–10) and 39.4%, respectively, slightly lower than those reported in Western countries (range, 5.0–8.4 and 33–55%). Patients’ pain assessment (83.1%) and information were high (63.3%), but participation in decision-making (4.8) was lower than in the United States (7.0) and Europe (Germany, France, Norway, and Denmark; mean, 5.9). Patients after orthopedic surgery had the worst outcomes. General anesthesia was more frequent in GEN patients, whereas regional (central and peripheral) was more frequent in ORT surgery patients. Mean opioid consumption (20.2 mg per patient per 24 hours, oral morphine equivalents), was lower than reported and decreased >50% after regional analgesia. Intravenous morphine patient-controlled analgesia was seldom used (6.2%). Acute opioid treatments were associated with worsened outcomes whereas multimodal analgesia (mainly antipyretic analgesics–nonsteroidal anti-inflammatory drugs–opioids) were associated with improved results. Epidurals in abdominal surgery (16.7%) were also associated with better outcomes. Presurgical chronic pain (>7) and/or chronic opioid consumption, were associated with worsened pain outcomes; the latter with a 50% increase in postoperative opioid requirements. Tibia/fibula and foot surgeries (ORT), and gastric, small intestine, and anterior abdominal wall procedures (GEN) were the most painful. Rigorous control of chronic pain before surgery, and combining opioids with adjuvants and other analgesics perioperatively, might improve postoperative outcomes.

Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life, and analgesia

Effective management of chronic pain has become an increasingly critical issue in health care. Opioid agonists are among the most effective analgesics available for reducing pain perception; however, their chronic use is controversial. This is primarily due to regulatory barriers, misunderstandings about pain management among primary caregivers, fear of adverse side effects, and misconceptions about the potential risks of addiction. Short-acting opioids provide effective analgesia for acute pain but should be avoided as primary analgesics for chronic pain management. Long-acting opioids have greater utility than short-acting opioids in treating chronic pain in patients with consistent pain levels. Results of studies show that improved quality of life is directly related to the use of long-acting opioids in patients with chronic pain of both cancer and noncancer etiology. Short-acting opioids may be used during the initial dose titration period of long-acting formulations and as rescue medication for episodes of breakthrough pain. Clinical experience reveals that selection of an effective pain regimen for the patient with chronic pain, combined with aggressive management of side effects, leads to improved overall functioning and quality of life.     

Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids

Physicians involved in cancer pain management treat thousands of patients with opioids, whose effective analgesia improves overall functioning. Side effects generally are tolerable, and treatment can be maintained with stable doses for long periods. Problems with addiction are infrequent. Many physicians, however, assume that opioids should be used only for chronic malignant pain. Research and clinical experience have demonstrated that opioids can safely and effectively relieve most chronic moderate to severe nonmalignant pain. Fears of addiction, disciplinary action, and adverse effects result in ineffective pain management. With current information on the use of opioids in chronic nonmalignant pain, primary care physicians can overcome these obstacles. Guidelines must clearly define the role of the primary care physician in the proper management of pain and the integration of opioid therapy. Used appropriately, opioids may represent the only source of relief for many patients.     

癌性疼痛的控制及护理

目的：探讨癌症患者疼痛及护理对策。方法：对100例癌症患者采用线性视觉模拟评估疼痛的程度。结果：本组100例,75例得到有效控制,24例未能得到有效控制。其中轻度疼痛占43.9%,中度疼痛占40.1%,重度疼痛占16.0%。在重度疼痛中,强阿片类药物应用仅达52.1%,在中度疼痛中,弱阿片类药物应用仅达52.2%。结论：实施心理护理、疼痛控制、营养支持等优质护理是改善患者生活质量,延长寿命的关键。     

Personal past experience with opioid consumption affects attitudes and knowledge related to pain management

The personal past experience with opioid consumption by hospital health care providers was examined for its influence on their attitudes toward and knowledge of pain management. Data were collected through a questionnaire that elicited demographic information, attitudes toward pain management, barriers to pain relief, and self-assessment of pain management knowledge. The sample ( N = 163) was divided into two groups according to past experience with opioids: 52% of participants had used opioids (UO) for pain relief in the past, and the rest had never done so (NO). UO participants noted that pain control treatment was not sufficient for pain relief, in contrast to NO participants ( p = .013). Pain management was considered a low priority relative to overall treatment by the UO group compared with the NO group ( p = .016). The former group also attributed major responsibility for inappropriate pain relief to the clinical staff (12% of the UO group vs. 1.4% of the NO group; p = .048) rather than to the patients (22.9% of the UO group vs. 32.9% of the NO group; p = .019). UO participants felt extremely competent in their ability to manage several aspects of pain therapy ( p < .05). These aspects included assessing cause of the pain (42.9% of the UO group vs. 29.3% of the NO group), selecting a starting dose for opioid therapy (26.9% of the UO group vs. 13.3% of the NO group), and using opioids intravenously (20.5% of the UO group vs. 8.3% of the NO group). Personal past experience regarding analgesic use is an important factor in evaluating attitudes toward pain and achieving optimal pain management outcomes.     

State medical board members' beliefs about pain, addiction, and diversion and abuse: a changing regulatory environment.

Three national surveys were conducted in 1991, 1997, and 2004 to evaluate state medical board members' knowledge and attitudes about prescribing opioid analgesics for pain management. Topics addressed include perceived legality of prolonged opioid prescribing, characteristics of addiction, prevalence of medication abuse and diversion, and perceived importance and influence of medical board policy. Questions were added in 2004 to determine board members' views about law enforcement involvement in physician investigations and prosecutions. This study assesses medical regulators' current beliefs and compares the 2004 responses with previous responses to determine how knowledge and attitudes about prescribing opioids have changed in recent years. Survey results show that board members have a greater understanding of pain management issues, particularly regarding characteristics of addiction and the legality of prolonged opioid prescribing for chronic noncancer pain. During the last 15 years, there has been substantial regulatory policy development, with medical boards adopting regulations, guidelines, or policy statements to provide guidance to licensees about using opioids to treat pain. However, many board members believe that federal and state law enforcement agencies have increased criminal investigations and prosecutions of physicians. We discuss appropriate regulatory and law enforcement responses to opioid prescribing violations, and suggest crucial next steps. PERSPECTIVE: The authors examine the evolution of state medical board members' knowledge and attitudes about prescribing opioid analgesics to treat chronic pain, demonstrate that medical regulators believe that there have been increased criminal investigations and prosecutions of physicians for their prescribing practices, and suggest ways to avoid unwarranted criminal prosecutions.     

Clinical Consumption of Opioid Analgesics in China: A Retrospective Analysis of the National and Regional Data 2006–2016

ContextThe annual consumption of opioid analgesics in the U.S. was more than 10 times the world average, whereas that in China was at a moderate level within Asia but much lower than the worldwide average. The opposite situations of opioid use in the U.S. and China revealed totally different problems in the developed versus developing world, that is, overuse versus underuse of opioids.ObjectivesThis study analyzed the clinical consumption, estimated the needs of pain treatment, and evaluated the adequacy of opioid analgesic consumption in mainland China and its seven regions.MethodsA retrospective analysis of the national and regional consumption of opioid analgesics in mainland China during 2006–2016 was conducted. The adequacy of consumption measure was used to gauge the overall adequacy of opioid analgesic consumption in morphine equivalents (MEs) for the treatment of moderate-to-severe pain in mainland China and compared with international data. Annual per capita consumption was adopted to measure the clinical consumption of opioid analgesics in MEs at a national level and across seven regions of mainland China. Needs of morphine for cancer pain treatment in mainland China and in its seven regions were estimated and compared with the clinical consumption of opioid analgesics in MEs.ResultsThe adequacy of consumption measure of mainland China ranged from 0.0041 to 0.0088 during 2006–2016, which was less than 1% of that in the reference countries. The poor North East region had only 10.85% of the cancer pain morphine needs fulfilled. The highest fulfillment rate was 36.02% in rich Southern China, which was 25.9% at the national level.ConclusionThe clinical consumption of opioid analgesics for the treatment of moderate-to-severe pain in mainland China was far below the international level. The annual per capita of clinical consumption was lower, and the adequacy of cancer pain treatment was poorer in less developed areas. All these findings call for actions to strengthen pain management.     

Management of chronic pain in the acute care setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.     

Using a Morphine Equivalence Metric to Quantify Opioid Consumption: Examining the Capacity to Provide Effective Treatment of Debilitating Pain at the Global,Regional, and Country Levels

ContextMorphine has been considered the gold standard for treating moderate-to-severe pain, although many new opioid products and formulations have been marketed in the last two decades and should be considered when examining opioid consumption. Understanding opioid consumption is improved by using an equianalgesic measure that controls for the strengths of all examined opioids.ObjectivesThe research objective was to use a morphine equivalence (ME) metric to determine the extent that morphine consumption relates to the total consumption of all other study opioids.MethodsAn ME metric was created for morphine and the aggregate consumption of each study opioid (Total ME), adjusted for country population to allow for uniform equianalgesic comparisons. Graphical and statistical evaluations of morphine use and Total ME consumption trends (between 1980 and 2009) were made for the global and geographic regional levels and selected developed and developing countries.ResultsGlobal morphine consumption rose dramatically in the early 1980s but has been significantly outpaced by Total ME since 1996. As expected, the extent of morphine and Total ME consumption varied notably among regions, with the Americas, Europe, and Oceania regions accounting for the highest morphine use and Total ME in 2009. Developing and least developed countries, compared with developed countries, demonstrated lower overall Total ME consumption.ConclusionGenerally, worldwide morphine use has not increased at the rate of Total ME, especially in recent years. Examining a country's ability to effectively manage moderate-to-severe pain should extend beyond morphine to account for all available potent opioids.     

End‐of‐Dose Pain in Chronic Pain: Does it Vary with the Use of Different Long‐Acting Opioids?

A large percentage of patients with chronic pain on around‐the‐clock (ATC) opioids may experience increased pain occurring at the end of a scheduled dose, also known as end‐of‐dose pain. Despite the significant prevalence and impact of end‐of‐dose pain in patients using extended‐release (ER) opioids, there are no detailed analyses examining how the frequency of end‐of‐dose pain is linked to the formulations of long‐acting opioids. Consequently, we performed a systematic review to evaluate how many published studies on patients with chronic cancer or noncancer pain identified end‐of‐dose pain. As only a few studies mentioned end‐of‐dose pain explicitly, we used breakthrough pain (BTP) as a surrogate parameter. We determined if any opioid formulation had a greater association with the frequency of BTP, the use of rescue medication for BTP, and the frequency of end‐of‐dose pain. Of the 39 studies entered in the final analysis, 14 studies across different formulations showed that ER opioids were effective in the prevention of BTP. The opioids most frequently studied were hydromorphone (26%), followed by morphine (23%), and transdermal buprenorphine (23%). Only 5% of the studies used immediate‐release preparations. Overall, most studies showed that patients using ER preparations experienced fewer episodes of BTP compared with patients on placebo or an active comparator. This could reflect the favorable duration of action of these opioids compared with short‐acting formulations. Future studies should examine the incidence of end‐of‐dose pain and use of rescue medicine in a longitudinal manner in patients with chronic pain taking short‐ vs. long‐acting ATC opioids.