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Millions of cancer patients, almost entirely in low- and middle-income countries, lack access to essential pain medicines.

Essential medicine lists of the World Health Organization and many countries include opioid analgesics, such as morphine. The moderate or severe pain experienced by approximately 80% of people with advanced cancer cannot be relieved without them.

But access to opioid analgesics is limited in low- and middle-income countries, where 85% of the world’s population consumes just 7% of the medicinal opioids. (Figure 1, 2) Legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of healthcare providers, poorly functioning markets, weak health systems, and concern about addiction and non-medical use all contribute to limited access, even though morphine, the most effective treatment for severe pain, is safe, effective, inexpensive, and easy to use.

Improved access to oral morphine is mandatory for the treatment of moderate to severe cancer pain, suffered by over 80% of cancer patients in terminal phase.

World Health Organization

Figure 1. Untreated deaths in pain due to HIV and cancer, 2016. 651,867 untreated deaths in pain occurred in China. 513,278 untreated deaths in pain occurred in India. 190,269 untreated deaths in pain occurred in Russian Federation. 130,984 untreated deaths in pain occurred in Nigeria. 122,142 untreated deaths in pain occurred in Indonesia. 96,333 untreated deaths in pain occurred in Pakistan. 77,455 untreated deaths in pain occurred in Bangladesh. 59,569 untreated deaths in pain occurred in Philippines. 47,872 untreated deaths in pain occurred in Mozambique. 40,941 untreated deaths in pain occurred in Egypt.

Three quarters of untreated deaths in pain occur in just ten countries.

Figure 2. Total cancer and HIV deaths in pain and those treated for pain, by income level, 2016. In High income countries, 99.9% of 2,094,499 Deaths in pain due to cancer or HIV receive pain treatment. In Middle income countries, 57% of 5,306,664 Deaths in pain due to cancer or HIV receive pain treatment. In Low income countries, 17% of 447,538 Deaths in pain due to cancer or HIV receive pain treatment.

Meanwhile, some high-income countries are dealing with a very different challenge related to pain relief, as rates of addiction continue to rise due to harmful and non-medical use of opioids.

Worldwide, the number of cancer patients in need of pain relief is projected to increase 48% from 2018 to 2035, but the increase is likely to be considerably higher in the regions with more rapidly increasing cancer rates and with the lowest access to pain relief, including South-Eastern Asia (projected 54% increase in cancer cases) and Africa (72% increase), where consumption of pain relief is sufficient to cover less than 25% of deaths in pain. (Figure 3) A balanced approach to access to opioids with sufficient measures to prevent harmful and non-medical use has been achieved by many Western European countries and in some low- and low-middle income countries.

Figure 3. Untreated deaths in pain by region, 2016. Of untreated deaths in pain in 2016, 35% or 921,434 deaths were in East Asia and the Pacific; 27% or 714,069 deaths were in South Asia; 22% or 577,758 deaths were in sub-Saharan Africa; 9% or 240,959 deaths were in Europe and Central Asia; 4% or 109,478 deaths were in Latin America and the Caribbean; and 4% or 94,561 deaths were in the Middle East and North Africa.


The Pain-Free Hospital Initiative, a one-year hospital-based health worker training initiative designed to improve the quality of pain assessment and treatment, resulted in a tripling of the use of essential pain medications and a 25% decrease in average pain scores in the oncology unit after being implemented at Kenyatta National Hospital in Nairobi, Kenya.

Deaths in pain:
World Health Organization (12 Sept 2018) http://www.who.int/news-room/fact-sheets/detail/cancer

Access creates progress:
O’Brien M, Schwartz A, Plattner L. Treat the Pain Program. J Pain Symptom Manage. 2018;55(2):S135-S139.

United Nations International Narcotics Control Board. Narcotic Drugs: Estimated World Requirements for 2018 – Statistics for 2016. 2017. Report No.: E/INCB/2017/2. Available from: https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2017/Narcotic_drugs_technical_publication_2017.pdf

United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2017 Revision, custom data acquired via website. 2017. Available from: https://population.un.org/wpp/DataQuery/

World Health Organization. Global Health Observatory Data Repository. 2018. Available from: http://apps.who.int/gho/athena/data

World Bank. World Bank country and lending groups. 2018. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-worldbank-country-and-lending-groups

International Agency for Research on Cancer. GLOBOCAN 2018: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2018 [Internet]. [cited 2018 Oct 25]. Available from: http://gco.iarc.fr/today/home

Map and all figures:
Population: World Health Organization, http://apps.who.int/gho/data/

World Bank regions and income levels: World Bank, https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups

Deaths from HIV: UNAIDS, http://aidsinfo.unaids.org/

Deaths from cancer: World Health Organization International Agency for Research on Cancer GLOBOCAN 2018, http://gco.iarc.fr/today/home

Consumption of narcotics: International Narcotics Control Board, unpublished data