Background & Aims

The WHO and others identified global inequities in access to morphine, called for action for improvement worldwide, and called attention to regulatory and legal barriers, attitude and knowledge barriers, and economic and procurement impediments (1). Despite integration of palliative care and pain management into national healthcare systems having been identified as imperative to facilitate availability of morphine and other critical pain medications, the “access abyss” between high- and low- and middle-income countries (LMICs) remains a tragic reality (2). International collaborations in the study of opioid availability and accessibility have advanced efforts in advocacy, education, regulatory reform, and suppliers engagement (3,4).
In this scoping review of global opioid legislation in health care systems in LMICs, we focused on identifying restrictive legislative domains that may influence access to adequate pain management and palliative care resources.

Methods

A PubMED search using the MeSH terms “(Global AND Opioid AND Policy AND Initiative)” returned 74 results, which were narrowed down to publications about legislation, policy, or restrictive practices in LMICs. The distribution of factors restricting access to opioids was evaluated in specific domains. Human Development Index (HDI) and Quality of Death Index were explored. Models of success in facilitating access to opioids and developing palliative care programs were investigated.

Results

The analysis of healthcare legislation from 104 countries or regions revealed 12 restrictive opioid-related domains (range, 5-12): eligibility restriction for outpatient, inpatient, or hospice, respectively (always vs. only with special authorization vs. never), maximum days opioids prescribed (range, 2-60, or at physician’s discretion), physician prescriber restriction (yes/no), emergency prescription by fax/phone or non-medical prescriber (yes/no), limited prescription duration (yes/no), pharmacist authority to correct prescription (yes/no), increased prescription bureaucratic burden (yes/no), restricted dispensing sites (yes/no), access to dispensing pharmacy (usually, half the time, occasionally, almost never), negative language in laws (yes/no).
Essential opioids were mentioned in the legislative content (range of 1-7): codeine, immediate-release and controlled-release morphine, injectable morphine, immediate-release oxycodone, oral methadone, and transdermal fentanyl.

Conclusions

While analyses of associations of restrictive domains and HDI and QDI are ongoing and results are pending, this scoping review preliminarily calls attention to the specific restrictive domains of the legislative language that may negatively influence access to quality pain management.
Individual models of success in facilitating access to opioids and developing palliative care programs were identified in Nepal, Mongolia, and Uganda.

References

1.WHO Report. Left behind in pain: Extent and causes of global variations in access to morphine for medical use and actions to improve safe access. June 15, 2023.

2.Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X et al. Alleviating the access abyss in palliative care and pain relief – an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018;391(10128):1391–454.

3.Cherny NI, Cleary J, Scholten W, Radbruch L, Torode J. The Global Opioid Policy Initiative (GOPI) project to evaluate the availability and accessibility of opioids for the management of cancer pain in Africa, Asia, Latin America and the Caribbean, and the Middle East: introduction and methodology. Ann Oncol. 2013 Dec;24 Suppl 11:xi7-13. doi: 10.1093/annonc/mdt498. PMID: 24436961.

4.Cleary J, Powell RA, Munene G, Mwangi-Powell FN, Luyirika E, Kiyange F, Merriman A, Scholten W, Radbruch L, Torode J, Cherny NI. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI). Ann Oncol. 2013 Dec;24 Suppl 11:xi14-23. doi: 10.1093/annonc/mdt499. PMID: 24285225.

Presenting Author

Doralina L. Anghelescu

Poster Authors

Doralina L. Anghelescu

MD

St Jude Children's Research Hospital

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Jacob McArthy

St. Jude Children's Research Hospital

Lead Author

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Christopher Austreng

St. Jude Children's Research Hospital

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Tienne Anderson

St. Jude Children's Research Hospital

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Jane Hankins

St. Jude Children's Research Hospital

Lead Author

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Ombeni Idassi

St. Jude Children's Research Hospital

Lead Author

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Michael McNeil

St. Jude Children's Research Hospital

Lead Author

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Topics

  • Economics, Ethics, and Law

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