This is part of a series of articles showcasing the Sax Institute members’ diverse range of research with implications for future health policy and practice.
National Drug and Alcohol Research Centre, UNSW Australia
An influential paper revealing that 5.5 million people worldwide have little or no access to opioid pain relief that was published in The Lancet earlier this year “hit at the right time” to broaden international discussion about the issue, says Professor Richard Mattick.
Professor Mattick, Professor of Drug and Alcohol Studies at the National Drug and Alcohol Research Centre (NDARC) at UNSW Australia and a member of the International Narcotics Control Board (INCB) which authored the paper, said its publication was significant in raising awareness of the issue of opioid access, in the lead up to the UN General Assembly reviewing its drug control conventions in April.
The INCB research team, including Professor Mattick, calculated the daily use of opioid analgesics for countries and regions globally over the period 2001 to 2013, compared the data against the prevalence of health conditions requiring pain relief and surveyed 214 countries about any impediments to availability of the medications.
They found that while use of common opioid painkillers such as codeine, morphine and oxycodone has more than quadrupled in Australia and doubled worldwide over the past decade, the majority of countries, particularly those in developing and poorer regions, have little or no access to basic pain medication and there has been little change over the decade.
Stark differences in opioid access
The bulk of the increase in opioid use occurred in high income western countries and regions including North America, Western and Central Europe and Australia and New Zealand, which together accounted for more than 95% of global opioid use. The needs of the ageing population for cancer pain and increased pain management for chronic non-cancer pain are thought to be the main drivers of the increase.
But people in nations including Central America and the Caribbean, Africa, South Asia, East Asia, South East Asia and Eastern Europe had little or no access to essential pain relief, the study found.
“The INCB is pushing strongly on the issue of availability and for the international community, including industry, to join in a careful way ‒ as happened with HIV medicines in Africa ‒ to enable appropriate access to affordable medicines,” Professor Mattick said. “We are quite serious about trying to bring about change in availability.”
Professor Mattick, who joined the INCB in 2015 and was recently re-elected for another five years, says there is no recognised level of appropriate opioid prescribing, so it is not known if use of the drugs in countries like Australia is excessive or appropriate. The INCB is now exploring what the adequate level of usage should be on a population basis, with the aim of setting a valid benchmark.
“It’s a complex question – it is influenced by a mix of medication education, doctors’ attitudes, government regulation and cultural issues,” he says. “But what is not appropriate is zero use, as happens in some countries.”
An agent for change
In April, the UN General Assembly reaffirmed its commitment to three international drug control conventions, one of which is a commitment to improve access to controlled substances for medical and scientific purposes. That includes addressing barriers to access to medications like opioids, including cost, regulations or laws prohibiting use, and a lack of training for healthcare professionals in prescribing such drugs.
Professor Mattick says the UN resolution will give agency to efforts by international organisations to push for better access to opioids, as well as creating a focus on the issue leading up to the next UN General Assembly in 2019.
“It is a clear statement of intent from agencies – they have to work together by 2019 to bring about a process that can cause change,” he says. “Doctors in countries can use these [resolutions] as a tool for advocacy.”
The Australian experience
Professor Mattick says NDARC is also focusing on the issue of opioid use locally, including investigating concerns about long-term use of the drugs.
The Centre plans to conduct a large-scale population study to look at how many people start and continue on opioids, with linkages to datasets on the subjects’ hospital usage as well as crime data.
“The question really is how many people commence on opioids and remain on them, which looks to be problematic. Combined with other work and reviews of the literature, the evidence for long-term prescribing of opioids is under question,” he says.
The Sax Institute’s unique organisational structure, with 47 members from public health and health services research groups and their universities, connects us with a powerful public health network and world‑leading research expertise.