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Global Need for Morphine

1. Demand and supply: the current poppy-based medicines production system

2. The global un-met need for morphine


Summary

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Poppy-based medicines such as morphine play a fundamental role in the treatment of pain, and the overall worldwide need for adequate and sustained pain relief is increasing. Research shows that in more than 150 countries, containing about 80% of the world’s population, only a tiny minority of the patients in need of morphine treatment actually receives this morphine. Millions of people, particularly cancer and HIV/AIDS sufferers in emerging countries, live and die in unnecessary pain because their needs for essential morphine medicines are not being met.

Principles of the current system

The production, international trade and use of poppy-based medicines such as morphine are strictly controlled under international law through an elaborate system of estimates and statistical returns.

The 1961 Single Convention on Narcotic Drugs governs the annual international trade of opiates raw materials used for scientific and medical purposes. Adherence to the rules and regulations of this Convention is overseen by the International Narcotics Control Board (INCB). National governments must submit to the INCB quarterly and annual statistical reports on the manufacture, use, import and export of poppy-based medicines to ensure that the worldwide supply of these medicines does not greatly exceed demand, nor fall significantly below the prescribed targets. As such, the international supply of raw materials used to make morphine depends almost entirely on the estimated global demand for these raw materials, as measured through the INCB-administered system.

Providing for the strict control of the raw poppy materials used in the production of medicines, this system can be described as an almost perfect closed, planned economy. Importantly, under article 21 of the 1961 Single Convention on Narcotic Drugs, the quantity of essential opium-based medicines manufactured in, or imported into, a country must never exceed the official estimate which that country had submitted to the INCB. These statistical reports constitute a country’s official requirements of narcotic drugs for the following year; once validated by the INCB, the estimates become binding for governments. Supply countries are only legally allowed to produce as much as is necessary to meet the total estimated global requirements. Thus the availability of morphine around the world in any one year is in effect dependent on the total use of primary materials from two years previous.



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Stocks within the system

Although significant stocks of raw poppy materials currently exist in several countries, these stocks do not represent a global over-supply. Stocks appear within the current poppy-based medicine supply system for two main reasons:

1. Because INCB-administered commodities constitute the raw materials for a range of essential medicines, consumer countries often build up strategic reserves to be able to cope with future shortage;
2. Producing countries build stocks to both smooth price trends over time, and to compete effectively with other producing countries.

Typically, stocks of agricultural commodities are at levels sufficient to cover several years of consumption. In comparison, current stocks of raw poppy materials are relatively low. Moreover, because these stocks are created and managed within the current supply system, they can not be used to supply needs un-accounted for by the INCB-administered system.

Current system provides for “market” demand, not actual need

The INCB administered system is designed to identify market demand for raw poppy materials and to manage the related supply. The INCB has proven efficient administrating this highly regulated market. It does not, however, state the actual need for poppy-based medicines.

In less economically developped and emerging countries, patients’ demands for morphine and other poppy-based medicines are currently significantly underestimated because of a selfperpetuating cycle of medical under-prescription and restrictive regulations which inhibit countries’ ability to import morphine. Given that demand is measured - under the current supply system - by actual consumption the previous year, demand from less economically developed nations remains structurally low and systematically understates the actual need. As such, many countries, most of the less economically developed and emerging countries, but also even highly industrialised countries, are caught in a cycle that deprives patients of the essential medicines necessary to ease the global pain crisis. Furthermore, in a number of countries the system to assess and submit estimates to INCB does not function well.

Un-met need for painkillers in Latin America

The consumption of poppy-based medicines in Latin America is extremely low, despite its large population and increasing cancer and HIV/AIDS burdens. Latin America accounts for less than 1% of the global consumption of morphine, due to under-prescription by medical staff untrained in poppy-based medicines, overly restricted laws and the high cost. In most countries consumption is below the global mean of 6.2 mg of poppy-based medicines per capita, although some countries have increased. In 2005 the entire population of Argentina (39.9 million) used just 96 kg of morphine, what represent 2.4 mg per capita. This only represents one tenth of the morphine consumption per capita rate in Germany, which in 2005 was 24.5 mg.

Only 5–10% of patients in Latin America in need of palliative care receive it, and 97% of palliative care provision is available in large cities. In 2005, to meet the pain needs of the end-stage HIV/AIDS and cancer patients in Latin America, 7.1 metric tons of morphine would have been needed, but just 600 kg of morphine was actually used, leaving 91% of these patients’ pain needs un-met.

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Low estimates of a country’s demand for morphine are a result of a number of factors, including doctors’ reluctance to prescribe medicines their patients will not be able to actually purchase; the relatively high cost of these medicines; dysfunctional bureaucracies that impose overly restrictive regulations which limit the number of pharmacies that stock the medicines, thereby further limiting patients’ access to these medicines and constraining doctors’ prescribing practices; and cultural misunderstandings related to the effects of poppy-based medicines. This in turn results in an inadequate supply of poppy-based medications, leaving countries such as those in Latin America with a great disparity between need and supply (see box).

For those countries whose bureaucracies and health system are able to identify and supply a demand corresponding to the essential need of their population, the current international system of supply functions adequately. Nevertheless, the INCB has admitted that “Most developing countries lack the resources and expertise required for determining medical needs and adjusting drug supply to meet those needs.” The existence and perpetuation of an un-met need outside the market demand is an alarming fact that calls for watchful analysis and swift action.