Official measurements of “demand” do not reflect actual morphine needs

The actual need for painkilling medicines worldwide is not fully matched by figures measuring market demand. In particular, as most of the world’s population still has little access to painkilling medicines, the actual need for morphine remains largely unmet.

Official figures from the INCB show that just a handful of wealthy countries consume the significant majority of the global supply of poppy-based medicines. For instance, the United States, Canada, Europe, Japan, Australia and New Zealand, together representing less than 20% of the world’s population, accounted for more than 95% of the total morphine consumption in 2005. This indicates a significant underconsumption of morphine affecting the remaining 80% of the world’s population, whose combined morphine consumption represented less than 5% of the global total.

WHO efforts to increase prescription of poppy-based medicines Stressing the need for a balance between the obligations posed by UN conventions for fighting against the illegal narcotics, and the need to ensure and, in most cases, increase the availability of poppy-based medicines, the World Health Organisation (WHO) heavily promotes the prescription of poppy-based medicines for the treatment of pain, and includes morphine is on its list of essential medicines. Based on the known effectiveness of morphine and codeine, the WHO has created a three step pain ladder known as the WHO Analgesic Method for Cancer Pain Relief, designed to provide a scientific basis to encourage health professionals worldwide to use poppy-based medicines to treat pain. To help address the impediments that hamper the availability and use of poppy-based medicines particularly in less economically developed and emerging countries, at the request of the United Nations’ Economic and Social Council COSOC and the World Health Assembly, the WHO developed the Framework to the Access to Controlled Medications Programme in consultation with the INCB. Despite the World Health Organisation’s limited success in promoting poppy-based medicines for palliative care for cancer and HIV/AIDS in emerging countries, the sheer enormity of the global pain crisis demands ongoing sustained action by the WHO, governments and international regulatory boards. Moreover, given the increasing need for cancer and HIV/AIDS related palliative care, demand for poppy-based medicines is set to rise dramatically in the next few years.

Current per capita use of and global need for poppy-based medicines

Although the World Health Organisation has long acknowledged the existence of such an extensive un-met need, measuring the size of the un-met need for morphine is difficult. However, some measurements are available. A comparison of national per capita uses of morphine reveals glaring discrepancies in the use of morphine within individual countries, a reliable lower bound estimate of the amount needed can be obtained by calculating the morphine need for HIV and cancer treatment.

International comparisons of per capita consumption levels allow a quick assessment of the relative size of the global morphine shortage. An estimate of the global un-met pain needs in a number of global regions can be calculated under any given hypothesis on the required or attainable level of consumption.

This is done by calculating the quantities of morphine actually consumed per capita in various global regions (see Table 2), and then calculating the quantities of morphine needed to raise the per capita consumption rate of under-consuming regions to a given higher proportion of the average rate of those regions in which patients’ pain needs are largely being met (see Table 3).

Morphine “consumption” rate in most global regions does not reflect actual needs

In 2005, the average consumption of morphine was just 4.9 mg per person globally. However, this global rate clearly does not reflect uniform actual consumption of morphine around the world.



Rather, the majority of the global morphine supply was consumed in North America and in Western European countries, despite those regions accounting for just 17.2% of the world population. The per capita consumption rates of these regions (55.5 mg for North America and 24 mg for Western Europe) were significantly higher than the regional averages of Eastern Europe and Central Asia (1.4 mg), Latin America (1 mg), or Sub-Saharan Africa (0.3 mg).

Estimates of un-met morphine need through extrapolation of consumption needs

That the majority of the global populations’ morphine consumption rates are significantly lower than that of Western Europe indicates an extensive gap between the supplies of, and actual need for, essential poppy-based medicines. If patients suffering from pain in other global regions73 were to have used as much morphine per capita in 2005 as patients in Western Europe (24 mg), an extra 134 metric tons of morphine, (representing 1341 metric tons of opium) would have been needed (see table 3).

For sub-Saharan Africa alone, 17.6 metric tons of morphine would be needed if patients there were to consume morphine at the same rate as patients in Western Europe. Moreover, because Sub-Saharan Africa bears the world’s largest HIV/AIDS burden, the region’s need for pain-medicines is likely to be significantly higher than that in Western Europe.

A further 84 metric tons of morphine, representing the equivalent of 844 metric tons of opium, would have been needed, for all patients in Asia and Pacific to be able to consume morphine at the same rate as patients in Western Europe in 2005. Even if patients in Latin America, Eastern Europe and Central Asia, Asia and Pacific, North Africa and Middle East, and sub-Saharan Africa had used just half as much morphine as patients in Western Europe did in 2005, an extra 65 metric tons of morphine, (representing 650 metric tons of opium) would have been needed.

Extensive morphine shortage for pain associated with cancer and HIV/AIDS

A reliable estimate of a significant part of the global morphine shortage can be calculated using measurements of the pain needs of end-stage cancer and HIV/AIDS patients in the world. The un-met pain needs of specific sets of patients in a given country can be reliably assessed through a method based on the use of morphine for the treatment of pain. A disease-specific need for morphine can be calculated using the prevalence or mortality rate linked to that disease and the corresponding treatment average requirements.

The extent of the 2005 global shortage of pain-medicines for end-stage cancer and HIV/AIDS can be measured using the calculations employed by researchers from the University of Toronto. Estimates for various global regions and for the world are shown in a table (Table 4). These results provide consistent lower bound approximations of the overall need for poppy-based medicines.

Palliative care needs to increase in the future Pain relief experts predict the global need for pain medication will increase. By 2020, there will be a significant ageing population in Europe, North America, East Asia and Latin America. HIV/ AIDS projections in 53 African countries suggest that mortality due to HIV will increase by a factor of five, while global cancer rates will increase by 50% from 10 million in 2002 to 15 million in 2010. Furthermore, 50% of new cancer cases are now occurring in developing countries.

In 2005 end-stage cancer and HIV/AIDS patients in Eastern Europe and Central Asia needed a total of 9.5 metric tons of morphine; yet according to the INCB, the total quantity of morphine consumed in this region that year amounted to less than 600 kg. Thus, a further 8.9 metric tons of morphine, equivalent to 89 metric tons of opium, would have been needed. In other global regions, the gap between the actual need and annual use is even wider. In Africa in particular, the need for essential poppy-based pain medicines remains mostly un-met. The 2 million people who died of HIV/AIDS and cancer in sub-Saharan Africa in 2005 consumed less than 1% of the quantity of morphine that was required (76.5 metric tons). Likewise, Asia’s need for poppy-based pain-killing medicines is far from being met. In 2005, 98% of the pain needs of dying HIV/AIDS and cancer patients in Asia were not met.

These figures show that significant levels of pain medicine needs are going un-met around the world. Furthermore, it should be noted that the above figures only represent the un-met needs of HIV/AIDS and cancer patients for morphine, while other patients suffering from post-operative and chronic pain are not taken into account. Thus it is likely that the pain-medicine deficits in these regions would be even more alarming once all the poppy-based medicines needs of patients are factored in. Equally, pain medicine needs are set to rise in the future, as palliative care becomes more necessary.

Afghan morphine needed to meet actual global need for painkillers The global need for poppy-based medicines far outweighs their current availability. Even in the world’s six richest countries, which include the United States and the Western Europe, only 24% of patients’ pain needs are being met. In 2006, Afghanistan produced 6,100 metric tons of opium. Yet even this huge quantity would be insufficient to meet the world’s current actual morphine needs, which in 2005 were estimated to be equal to 6,152 metric tons of opium. The licensing of Afghan poppy crops would go a long way towards improving the quality of life for those suffering severe pain, especially in transitional and emerging countries where the availability of poppy-based medicines is at its lowest. The potential market for the affordable medical morphine that Afghan Poppy for Medicine projects could fill is considerable.