The Single Convention on Narcotic Drugs- Implementation in Six Countries: Albania, Bangladesh, India, Kyrgyzstan, Sri Lanka, Ukraine

Transcription

1 The Single Convention on Narcotic Drugs- Implementation in Six Countries: Albania, Bangladesh, India, Kyrgyzstan, Sri Lanka, Ukraine A MONOGRAPH PREPARED FOR: International Pain Policy Fellowship Training Madison, Wisconsin, USA 6-10 August 2012 University of Wisconsin Pain & Policy Studies Group Carbone Cancer Center World Health Organization Collaborating Center for Pain Policy and Palliative Care 1300 University Ave, 6152 MSC Madison, Wisconsin USA Not for further distribution. Supported by: LIVESTRONG Open Society Foundations

2 Citation: Pain & Policy Studies Group. The Single Convention on Narcotic Drugs - Implementation in Six Countries: Albania, Bangladesh, India, Kyrgyzstan, Sri Lanka, Ukraine. University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center for Pain Policy and Palliative Care; Madison, Wisconsin, USA (Monograph)

3 Table of Contents I. ABOUT THE PAIN & POLICY STUDIES GROUP... 1 II. INTRODUCTION: INTERPRETING INFORMATION IN THIS MONOGRAPH A. Why are opioid consumption statistics important?... 2 B. Governments are the source of required reports to the INCB... 3 C. Competent national authorities... 4 D. Status of adherence to conventions, receipt of statistics and estimates... 4 III. OVERVIEW OF OPIOID CONSUMPTION A. Global Consumption... 4 B. Regional Consumption... 5 C. National Consumption... 5 D. Morphine Equivalence: Global and National Trends, IV. TABLE 1. COMPETENT NATIONAL AUTHORITIES... 7 V. TABLE 2. STATUS OF ADHERENCE TO CONVENTIONS, RECEIPT OF STATISTICS, AND ESTIMATES... 8 VI. GLOBAL CONSUMPTION TRENDS, Graph 1. Morphine, oxycodone, pethidine, methadone... 9 Graph 2. Fentanyl, hydromorphone VII. GLOBAL CONSUMPTION, Graph 3 and Table 3. Morphine Graph 4 and Table 4. Fentanyl Graph 5 and Table 5. Hydromorphone Graph 6 and Table 6. Oxycodone Graph 7 and Table 7. Pethidine Graph 8 and Table 8. Methadone VIII. REGIONAL CONSUMPTION, Graphs AFRO Graphs AMRO Graphs EMRO Graphs EURO Graphs SEARO Graphs WPRO IX. NATIONAL CONSUMPTION TRENDS, Graphs Albania Graphs Bangladesh Graphs India Graphs Kyrgyzstan Graphs Sri Lanka Graphs Ukraine X. MORPHINE EQUIVALENCE: GLOBAL AND NATIONAL TRENDS, Graph 81 and Table 9. Global Graph 82 and Table 10. Albania Graph 83 and Table 11. Bangladesh Graph 84 and Table 12. India Graph 85 and Table 13. Kyrgyzstan Graph 86 and Table 14. Sri Lanka Graph 87 and Table 15. Ukraine

4 I. ABOUT THE PAIN & POLICY STUDIES GROUP The Pain & Policy Studies Group (PPSG), a global research program at the University of Wisconsin Carbone Cancer Center, is committed to promoting pain relief through effective public policy, communications, and outreach efforts. The PPSG mission is to improve global pain relief by achieving balanced access to opioids worldwide. Much of its work focuses on improving the appropriate medical use of opioid analgesics (such as morphine), which are essential for palliative care, by identifying and addressing legislative and regulatory barriers. Over the last two decades, PPSG has developed an abundance of experience, and expertise, which it uses to provide policy and research resources to colleagues around the world. The PPSG s efforts have focused historically on researching and disseminating information about global under-treatment of pain, disparities in global opioid consumption, methods to identify and address policy barriers at the national level, and providing ongoing technical assistance to colleagues to help them improve availability and access to opioids in their country. Most recently, the PPSG has developed interactive opioid consumption maps, which gives an immediate visual image of the variation in consumption of opioids across the world; and interactive graphs for exploring opioid consumption trends allowing users to explore relationships over time between opioid consumption and other country characteristics, such as Gross Domestic Product or Human Development Index. The PPSG is nationally and internationally recognized for its work and leadership to improve availability of opioid pain medicines, having been at the forefront of such efforts since its creation in

5 II. INTRODUCTION: INTERPRETING INFORMATION IN THIS MONOGRAPH A. Why are opioid consumption statistics important? In 1986, the WHO concluded that most pain due to cancer could be relieved using a simple analgesic method and that every national government should institute a cancer pain relief programme. 1 The WHO analgesic method has also been endorsed for relief of pain due to HIV/AIDS. 2 The analgesic method depends on the availability of, and patient access to, medicines that can relieve severe pain, such as morphine and other opioids. Recognizing that opioids are controlled strictly as narcotic drugs because of a potential for abuse and drug dependence, WHO recommended that governments (a) evaluate their drug control policies and practices to ensure that patients receive the opioid medications that are necessary for pain relief, and (b) encourage health care workers to report to the appropriate authorities any instance in which oral opioids are not available for cancer patients. Indeed, the fact that opioids are narcotic drugs regulated by governments is why those interested in pain relief and palliative care for HIV/AIDS and cancer must learn about the drug regulatory system and prepare to work with governments. For nearly three decades there has been clear guidance from United Nations (UN) health and regulatory agencies regarding the need for governments to address opioid availability and accessibility. These high-level bodies have repeatedly called on governments to identify and remove barriers that block patient access to opioid analgesics. At a recent meeting of the UN Commission on Narcotic Drugs in March 2010, there was a resolution adopted called Promoting adequate availability of internationally controlled licit drugs for medical and scientific purposes while preventing their diversion and abuse, 3 noting the concern that some governments need to take specific measures to ensure adequate access to opioid analgesics in line with the international drug control conventions. In September 2011, the UN General Assembly called attention to the growing international epidemic of non-communicable diseases (NCDs) (including cancer) by holding a high-level Meeting on the Prevention and Control of NCDs. The resulting Political Declaration acknowledges the importance of providing palliative care for people with NCDs, and calls for the use of affordable medicines (including generics) for palliative care. 4 Additionally, non-governmental professional and advocacy groups have made numerous declarations over the years calling on healthcare professionals and governments to improve pain and palliative care, by addressing barriers to the availability of opioids to manage pain. A notable example of such efforts is the World Cancer Declaration from 2008 in which the 1 World Health Organization. Cancer pain relief. Geneva, Switzerland: World Health Organization; World Health Organization HIV-AIDS. Palliative Care. Geneva, Switzerland: World Health Organization; United Nations Economic and Social Council. Promoting adequate availability of internationally controlled licit drugs for medical and scientific purposes while preventing their diversion and abuse; Resolution 53/4. Report on the fifty-third session of the Commission on Narcotic Drugs; 8-12 March 2010; Agenda item 9; Implementation of the international drug control treaties United Nations General Assembly. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Draft resolution submitted by the President of the General Assembly at the sixty-sixth session; Agenda item 117; September New York, NY, United Nations. 2

6 Union for International Cancer Control called for effective pain control measures to be available universally to all cancer patients when needed. 5 Consumption statistics for opioids are one indicator of the capability of a country to treat moderate to severe pain. Opioid consumption statistics can also be used to evaluate the outcomes of efforts to improve opioid availability. Morphine is frequently used as a principal indicator because morphine is the most widely available opioid analgesic for moderate to severe pain. Fentanyl, hydromorphone, methadone and oxycodone are included in this publication because they are appropriate to treat moderate to severe pain, and they have become increasingly available globally over the last decade. Consumption trends for pethidine are included in this monograph because (1) although pethidine is no longer recommended for chronic pain, it is still widely used; and (2) since pethidine is subject to the same legal controls as other strong opioids, its consumption is an indication that, from a legal standpoint, the country should be able to obtain other opioids for severe pain, such morphine, fentanyl or oxycodone. Finally, other opioids such as tramadol and codeine are not included because they are not capable of relieving severe pain. B. Governments are the source of required reports to the INCB The International Narcotics Control Board (INCB) is the international narcotic regulatory authority for the United Nations; it monitors national governments implementation of the 1961 Single Convention on Narcotic Drugs. This treaty, to which most governments are party, governs the cultivation, movement and availability of narcotic drugs for medical purposes in the world. According to the Single Convention, narcotic drugs are indispensable for the treatment of pain and suffering, and governments should ensure their adequate availability for all medical and scientific purposes, while preventing diversion and abuse. Governments must annually provide INCB an estimate of the amounts of opioids that will be required to satisfy all medical and scientific needs in the next year. Although INCB confirms the estimate as the amount authorized to be used in the country, the estimate itself is determined and submitted by the government. The INCB does not reduce governments estimates to less than is needed. In fact, if unanticipated needs arise during the year, the INCB encourages governments to submit a supplemental request, which it can confirm in a short amount of time. Recently, in 2012, INCB and WHO published a Guide for governments on estimating requirements for controlled substances, including opioids. 6 Governments also report prior year opioid consumption statistics to the INCB which compiles them into annual statistical reports. 7 Consumption refers to the amounts distributed to the retail level in a country, i.e., to those institutions and programs that are licensed to dispense to patients. Consumption is reported by anhydrous weight of the active drug, not including the salt; 5 Union for International Cancer Control. World Cancer Declaration International Narcotics Control Board, World Health Organization. Guide on Estimating Requirements for Substances under International Control. Vienna: United Nations, International Narcotics Control Board. Narcotic Drugs: Estimated World Requirements for Statistics for New York, NY: United Nations;

7 for example, the amount reported for morphine does not include the weight of the salt (sulfate or chloride), just the morphine base. Some countries do not report consumption statistics. In addition, INCB does not publish reports of consumption less than 0.5 kilogram. However, the PPSG obtains complete annual data from the INCB and makes them available because there are many countries where small amounts are important and because any amount of morphine consumed demonstrates that the government approved its use. C. Competent national authorities Each government that is party to the Single Convention designates an office that is responsible for carrying out required functions, including making estimates and reporting consumption statistics. 8 Table 1 provides a list of the names and contact information for the National Competent Authority in the 6 Fellows countries. These offices may be located in the Ministry of Health in the pharmaceutical department or in the national food or drug control agency. They are the principal national authority for ensuring that opioid analgesics are adequately available for medical and scientific purposes and for submitting the required documents to the INCB. These offices receive reports from the INCB, including technical reports that encourage all governments to examine national policies and administrative procedures for barriers and to consult with health professionals in formulating realistic estimates. However, sometimes these offices do not have adequate personnel to administer these and other important responsibilities in the area of drug control and availability. D. Status of adherence to conventions, receipt of statistics and estimates Table 2 presents information that the INCB compiles annually in an effort to inform the public about whether national governments are adhering to their obligations under the Single Convention. Information is provided for the 6 Fellows countries. From these data, it can be seen that all 6 governments are parties to the Single Convention, 1961, and as amended in 1972, and submitted all required reports for the most recent report. III. OVERVIEW OF OPIOID CONSUMPTION A. Global Consumption Trend in kilograms Graphs 1-2 provide the global consumption trends for morphine, fentanyl, hydromorphone, oxycodone, pethidine and methadone for which presents the big picture of the consumption of opioid analgesics. Prior to 1986, the consumption of morphine throughout the world was low and stable. After 1986, the total global consumption of morphine began to increase as some national governments and health professionals adopted the WHO analgesic method and as new opioid products became available more widely. The consumption of 8 United Nations. Competent national authorities under the international drug control treaties, New York, NY: United Nations;

8 pethidine exceeded that of morphine, but has slowly declined as other opioids have become more widely used. Recently, there are indications that consumption of morphine is being offset in some countries by the advent of other opioid analgesics such as fentanyl, hydromorphone, methadone and oxycodone. Although some countries use morphine mainly for cancer pain, morphine may be used for other pain, including acute, post-operative, AIDS, and for chronic non-cancer conditions. In addition, some countries may use strong opioids including morphine and methadone for substitution treatment of drug dependence. 2010, in milligrams per capita Graphs and corresponding Tables 3-8 present global 2010 consumption statistics in milligrams per capita (dividing the total amount of drug consumed in kilograms, by the country population [in millions] of the country) for morphine, fentanyl, hydromorphone, oxycodone, pethidine and methadone. This provides a population-based statistic that allows for comparisons between countries and in relation to the global mean. The consumption of opioids varies greatly from country to country. Fellows countries that reported statistics are highlighted. The vast majority of morphine is consumed in industrialized countries which represent a small part of the world s population. The remaining countries of the world (a number of developed countries and all of the developing countries) consumes comparatively little for In a recent report, the INCB stated, "Global consumption of opioid analgesics for the treatment of moderate to severe pain...increased by more than two and one half times during the past decade...the global figures hide large and enduring disparities in the consumption of opioid analgesics among countries. In 2008, Australia, Canada, New Zealand, the United States and the member States of the European Union together accounted for more than 96 per cent of global consumption of fentanyl, 90 per cent of global consumption of morphine and 98 per cent of global consumption of oxycodone. Although there is sufficient supply of opiate raw materials worldwide, access to opioid analgesics is non-existent or almost non-existent in many countries and in entire regions." (p. 19) 9 B. Regional Consumption Graphs 9-44 present the WHO regional pictures of the consumption of morphine, fentanyl, hydromorphone, oxycodone, pethidine and methadone in milligrams per capita for the WHO Regional Office for Africa (AFRO), WHO Pan American Health Organization (AMRO/PAHO), WHO Regional Office for the Easter Mediterranean (EMRO), WHO Regional Office for Europe (EURO), WHO Regional Office for South-East Asia (SEARO), and WHO Western Pacific Region (WPRO) regions respectively. C. National Consumption Graphs present morphine, fentanyl, hydromorphone, oxycodone, pethidine and methadone consumption trends for the 6 Fellows countries: Albania, Bangladesh, India, Kyrgyzstan, Sri Lanka, Ukraine. These data are expressed in milligrams per capita. A value of 0 indicates that 9 International Narcotics Control Board. Report of the International Narcotics Control Board for New York, NY: United Nations;

9 no report was received by the INCB for that year. D. Morphine Equivalence: Global and National Trends, Historically, the WHO has considered a country s annual consumption of morphine to be an indicator of the extent that opioids are used to treat severe cancer pain and an index to evaluate improvements in pain management. However, over the past 20 years additional opioid analgesic medications and formulations, such as the fentanyl patch, hydromorphone, and sustained-release oxycodone, have been introduced in global and national markets and should be considered when studying opioid consumption in a country, region, and globally. Using the INCB data it receives annually, and applying conversion factors from the WHO Collaborating Center for Drugs Statistics Methodology, PPSG developed a Morphine Equivalence (ME) metric, adjusted for population, for 6 principal opioids used to treat moderate to severe pain: fentanyl, hydromorphone, methadone, morphine, oxycodone, and pethidine. The ME allows for equianalgesic comparisons between countries of the aggregate consumption of these principal opioids (total ME), thereby providing a more complete picture of a country s capability to treat moderate to severe pain than is possible by analyzing morphine consumption alone. Graph 81 presents the Global ME opioid consumption trend from in milligrams per person, with the corresponding Table 9. The ME trend graph illustrates that the ME consumption of fentanyl, oxycodone, and methadone has been higher than morphine since the early 1990s. Graphs and corresponding tables present the ME opioid consumption trend data ( ) for each of the Fellows' countries. 6

10 IV. TABLE 1. COMPETENT NATIONAL AUTHORITIES ALBANIA Ministry of Health Department of Pharmacy Tirana Albania Phone: FAX: BANGLADESH Department of Narcotics Control (DNC) Ministry of Home Affairs Wage Earners Hostel Complex (Level 8) 71-72, Old Elephant Road (Eskaton Garden), Ramna Dhaka 1000, Bangladesh Phone: Fax: dgdnc@bttb.net.bd INDIA Central Bureau of Narcotics Ministry of Finace 19, The Mall Morar Gwalior Madhya Pradesh India Phone: Phone: Phone: Fax: Fax: narcom@sancharnet.in KYRGYZSTAN State Service on Drugs Control of the Kyrgyz Republic 80 Toktogula Street Bishkek The Kyrgyz Republic Phone: Fax: Web: SRI LANKA Medical Supplies Division 357, Deans Road Colombo 10 Sri Lanka Phone: Fax: UKRAINE State Service on Drugs Contol Prospect Chervonozoryanyi Kiev Phone: Fax: info@narko.gov.ua Web: 7

11 V. TABLE 2. STATUS OF ADHERENCE TO CONVENTIONS, RECEIPT OF STATISTICS, AND ESTIMATES Adherence Consumption Statistics Estimated requirements Single Convention 1961 As amended 1961/72 for 2010 for 2012 Albania Bangladesh India Kyrgyzstan Sri Lanka Ukraine = report received 8

12 VI. GLOBAL CONSUMPTION TRENDS Graph 1. Global Consumption of Morphine, Oxycodone, Pethidine and Methadone, Kilograms Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

13 Graph 2. Global Consumption Fentanyl and Hydromorphone, Kilograms Source: International Narcotics Control Board By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

14 VII. GLOBAL CONSUMPTION, 2010 Graph 3. Global Consumption of Morphine, 2010 mg/capita 152 countries **Austria s consumption includes use of morphine for substitution therapy Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

15 TABLE 3: Global Morphine Consumption, 2010: (mg/capita) Note: Countries not listed either did not report, or reported an amount of zero (0) for morphine consumption, to the INCB for Austria Cayman Islands Kenya United States of America Colombia Kuwait United Kingdom Andorra Philippines Denmark Jamaica Venezuela Canada Brunei Darussalam Montenegro Australia Trinidad and Tobago Cape Verde Switzerland Lebanon Kazakhstan Iceland Georgia Dominica France Singapore Egypt New Zealand Cuba Ecuador Slovenia Bahamas Montserrat Norway Saint Lucia United Arab Emirates Sweden Republic of Korea Madagascar Germany Cook Islands Nepal Belgium Republic of Moldova Mozambique Netherlands Thailand Algeria South Africa Macao Uzbekistan Spain Albania Syrian Arab Republic Malta Hungary Mauritius Ireland Kiribati Panama Luxembourg Malaysia Cameroon New Caledonia China Kyrgyzstan Slovakia Portugal Turkey Bulgaria Wallis and Futuna Islands Turkmenistan Poland Haiti India Mexico Bosnia and Herzegovina Azerbaijan Gibraltar Guyana Guatemala French Polynesia Ukraine Bolivia Brazil Dem. Peop. Rep. of Korea Ghana Finland Belarus Dem. Rep. of the Congo Seychelles Saudi Arabia Indonesia Czech Republic Tonga Zimbabwe Israel Oman Bangladesh Bhutan Anguilla Grenada Chile St Vincent & Grenadines Iraq Italy El Salvador Mali Costa Rica Russian Federation Chad Uruguay Viet Nam Afghanistan Estonia Nicaragua Yemen Hong Kong SAR Peru Honduras Argentina Zambia Tajikistan Namibia Serbia Togo Croatia Uganda Botswana Japan Tuvalu Benin Lithuania Armenia Eritrea Tunisia Qatar Lao Peop. Dem. Rep Mongolia Sri Lanka Myanmar Cyprus Dominican Republic Côte d'ivoire Bahrain Greece Angola Latvia Morocco Malawi Jordan United Rep of Tanzania Source: International Narcotics Control Board; World Health Organization population data Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 12

16 mg/capita Graph 4. Global Consumption of Fentanyl, 2010 Sri Lanka Albania Ukraine Kyrgyzstan India countries Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012 Bangladesh

17 TABLE 4: Global Fentanyl Consumption, 2010: (mg/capita) Note: Countries not listed either did not report, or reported an amount of zero (0) for fentanyl consumption, to the INCB for Germany Saudi Arabia Armenia Gibraltar Mauritius Kazakhstan Austria Belarus Syrian Arab Republic Canada Cyprus Trinidad and Tobago Belgium Macao Mongolia Spain Panama Kyrgyzstan Switzerland Lebanon St Vincent & Grenadines United States of America Bhutan Philippines Denmark Jordan Yemen Luxembourg Bulgaria Azerbaijan Finland Colombia India France Bahrain Indonesia Norway Venezuela Iceland Sweden Uruguay Mozambique Ireland United Arab Emirates Uzbekistan Greece Malta Tonga Netherlands Bahamas Sri Lanka United Kingdom Malaysia Grenada Australia Qatar Angola Slovenia Brunei Darussalam Botswana Hungary Tunisia Turkmenistan Czech Republic Hong Kong SAR Anguilla Cayman Islands El Salvador Zimbabwe Israel Costa Rica Côte d'ivoire Slovakia Namibia Cook Islands Italy Russian Federation Tajikistan New Caledonia Oman Mali Croatia Thailand Nepal Andorra Ecuador Togo Republic of Korea China Madagascar New Zealand Egypt Dominica Portugal Cuba Kiribati French Polynesia Mexico Iraq South Africa Peru Lao Peop. Dem. Rep Poland Albania Kenya Montenegro Georgia Saint Lucia Serbia Jamaica Guyana Lithuania Macedonia (TfYR) Bangladesh Japan Nicaragua Zambia Latvia Morocco Benin Wallis and Futuna Islands Ukraine Myanmar Republic of Palau Seychelles Chad Turkey Algeria Ghana Argentina Republic of Moldova Afghanistan Bosnia and Herzegovina Cape Verde Cameroon Estonia Honduras Haiti Chile Dominican Republic Bolivia Singapore Iran (Islamic Republic of) Dem. Rep. of the Congo Brazil Guatemala Eritrea Kuwait Viet Nam Source: International Narcotics Control Board; World Health Organization population data Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 14

18 Graph 5. Global Consumption of Hydromorphone, 2010 mg/capita No consumption data available for attending Fellows countries 47 countries Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

19 TABLE 5 Global Hydromorphone Consumption, 2010: (mg/capita) Note: Countries not listed either did not report, or reported an amount of zero (0) for hydromorphone consumption, to the INCB for Canada Austria United States of America Germany Denmark Switzerland Luxembourg Sweden Australia Czech Republic Belgium Slovenia Slovakia France Hungary Spain Ireland Cayman Islands Italy Serbia Kuwait New Caledonia Republic of Korea United Kingdom Iceland Finland Portugal Netherlands Norway Colombia Singapore Croatia United Arab Emirates Belarus Saudi Arabia Brazil Mexico Turkey Argentina Israel Jordan Poland Egypt China Venezuela Japan Philippines Sources: International Narcotics Control Board; World Health Organization population data Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 16

20 Graph 6. Global Consumption of Oxycodone, 2010 mg/capita No consumption data available for attending Fellows countries 69 countries Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

21 TABLE 6: Global Oxycodone Consumption, 2010: (mg/capita) Note: Countries not listed either did not report, or reported an amount of zero (0) for morphine consumption, to the INCB for United States of America New Caledonia Canada Bulgaria Australia Colombia Denmark Hungary Norway Singapore Sweden El Salvador Finland Argentina Germany Kuwait New Zealand Venezuela Switzerland Peru Cayman Islands Malaysia Ireland Guatemala Israel Poland United Kingdom Chile Netherlands Ecuador Iceland Costa Rica France Dominican Republic Belgium Brazil Italy Honduras Slovenia Philippines Czech Republic Jordan Austria Mexico Republic of Korea Panama Andorra China Spain Bolivia Slovakia Latvia Estonia Saudi Arabia Japan Nicaragua Cyprus French Polynesia Hong Kong SAR Qatar Gibraltar United Arab Emirates Bahamas Serbia Syrian Arab Republic Lithuania Luxembourg South Africa Croatia Source: International Narcotics Control Board; World Health Organization population data Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 18

22 Graph 7. Global Consumption of Pethidine, mg/capita Global mean, mg Sri Lanka Bangladesh countries Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012 India

23 TABLE 7: Global Pethidine Consumption, 2010 (mg/capita) Note: Countries not listed either did not report, or reported an amount of zero (0) for pethidine consumption, to the INCB for Cayman Islands Portugal Nepal Canada Brunei Darussalam Hungary Bahamas Oman Bangladesh St Vincent & Grenadines Macao Colombia Bhutan Iran (Islamic Republic of) Cuba United States of America Singapore Peru Dominica Turkey Slovenia Saint Lucia Malawi Japan Trinidad and Tobago Brazil Viet Nam Denmark Greece Tunisia Switzerland Tonga Finland New Zealand Belgium Cape Verde Jamaica El Salvador Uganda Mauritius Kiribati Togo Kuwait South Africa Latvia Bahrain Ireland Iraq Cook Islands Saudi Arabia Botswana Republic of Palau Zimbabwe Lao Peop. Dem. Rep Cyprus Kenya Indonesia Norway Qatar Philippines Czech Republic Slovakia Zambia Malta Chile France Jordan Germany French Polynesia Republic of Korea Sweden Yemen Guyana Guatemala United Republic of Tanzania Malaysia Netherlands Eritrea United Kingdom Thailand Gibraltar Israel United Arab Emirates Bosnia and Herzegovina Lebanon Tuvalu Mozambique Lithuania Iceland Costa Rica Namibia Croatia Algeria Syrian Arab Republic Andorra Bolivia Australia China India Spain Austria Ghana Grenada Argentina Honduras Poland Luxembourg Myanmar Anguilla Egypt Dem. Rep. of the Congo Montserrat Italy Chad Bulgaria Panama Angola Estonia Montenegro Cameroon Seychelles Sri Lanka Source: International Narcotics Control Board; World Health Organization population data Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 20

24 Graph 8. Global Consumption of Methadone, mg/capita Global mean, mg/capita Kyrgyzstan Ukraine Albania countries Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012 Sri Lanka

25 TABLE 8: Global Methadone Consumption, 2010: (mg/capita) Note: Countries not listed either did not report, or reported an amount of zero (0) for methadone consumption, to the INCB for Switzerland Republic of Moldova New Zealand Albania United States of America Hungary United Kingdom China Denmark Costa Rica Ireland Slovakia Canada Poland Australia Armenia Mauritius Mexico Malta Indonesia Portugal Myanmar Belgium Azerbaijan Spain Republic of Palau Netherlands Chile Luxembourg Thailand Norway Namibia Italy New Caledonia Croatia Colombia TfYR of Macedonia Brazil Israel Cayman Islands Hong Kong SAR El Salvador Malaysia Viet Nam Slovenia Saudi Arabia France French Polynesia Iran (Islamic Republic of) United Rep of Tanzania Bulgaria Saint Lucia Estonia Uruguay Germany Nepal Sweden Uzbekistan Austria Cyprus Finland Qatar Bosnia and Herzegovina Singapore Macao South Africa Montenegro Afghanistan Kyrgyzstan Venezuela Greece Guatemala Lithuania Jordan Georgia Kuwait Andorra Bahrain Serbia Japan Belarus Peru Latvia United Arab Emirates Iceland Sri Lanka Ukraine Kenya Czech Republic Morocco Sources: International Narcotics Control Board; World Health Organization population data Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 22

26 mg/capita VIII. Regional Consumption, 2010 Graph 9. AFRO Regional 2010 Morphine Consumption Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

27 Graph 10. AFRO Regional 2010 Fentanyl Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

28 Graph 11. AFRO Regional 2010 Hydromorphone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

29 Graph 12. AFRO Regional 2010 Oxycodone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

30 Graph 13. AFRO Regional 2010 Pethidine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

31 Graph 14. AFRO Regional 2010 Methadone Consumption mg/capita Mauritius Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

32 Graph 15. AMRO Regional 2010 Morphine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

33 Graph 16. AMRO Regional 2010 Fentanyl Consumption mg/capita Canada USA Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

34 Graph 17. AMRO Regional 2010 Hydromorphone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

35 Graph 18. AMRO Regional 2010 Oxycodone Consumption mg/capita Canada Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

36 Graph 19. AMRO Regional 2010 Pethidine Consumption mg/capita Canada Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

37 Graph 20. AMRO Regional 2010 Methadone Consumption mg/capita Canada Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

38 Graph 21. EMRO Regional 2010 Morphine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

39 Graph 22. EMRO Regional 2010 Fentanyl Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

40 Graph 23. EMRO Regional 2010 Hydromorphone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

41 Graph 24. EMRO Regional 2010 Oxycodone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

42 Graph 25. EMRO Regional 2010 Pethidine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

43 Graph 26. EMRO Regional 2010 Methadone Consumption mg/capita Iran Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

44 Graph 27. EURO Regional 2010 Morphine Consumption mg/capita **Austria includes data for substitution therapy Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

45 Graph 28. EURO Regional 2010 Fentanyl Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

46 Graph 29. EURO Regional 2010 Hydromorphone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

47 Graph 30. EURO Regional 2010 Oxycodone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

48 Graph 31. EURO Regional 2010 Pethidine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

49 Graph 32. EURO Regional 2010 Methadone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

50 Graph 33. SEARO Regional 2010 Morphine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

51 Graph 34. SEARO Regional 2010 Fentanyl Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

52 Graph 35. SEARO Regional 2010 Hydromorphone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

53 Graph 36. SEARO Regional 2010 Oxycodone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

54 Graph 37. SEARO Regional 2010 Pethidine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

55 Graph 38. SEARO Regional 2010 Methadone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

56 Graph 39. WPRO Regional 2010 Morphine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

57 Graph 40. WPRO Regional 2010 Fentanyl Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

58 Graph 41. WPRO Regional 2010 Hydromorphone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

59 Graph 42. WPRO Regional 2010 Oxycodone Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

60 Graph 43. WPRO Regional 2010 Pethidine Consumption mg/capita Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

61 Graph 44. WPRO Regional 2010 Methadone Consumption mg/capita New Zealand Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center,

62 IX. NATIONAL CONSUMPTION TRENDS,

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80 X. MORPHINE EQUIVALENCE: GLOBAL AND NATIONAL TRENDS, Graph 81. Morphine Equivalence Global Consumption, (ME), Mg/person 70 Fentanyl ME 60 Hydromorphone ME Methadone ME Morphine ME 50 Oxycodone ME Pethidine ME Total ME Data sources: Consumption data - International Narcotics Control Board; Population United Nations World Population Prospects, 2010 Revision; ME conversion factors WHOCC Centre for Drug Statistics Methodology Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 77

81 TABLE 9: GLOBAL Opioid Consumption in Morphine Equivalence (ME), Mg per person Fentanyl ME Hydromorphone ME Methadone ME Morphine ME Oxycodone ME Pethidine ME Total ME Data sources: Consumption data International Narcotics Control Board Population United Nations World Population Prospects, 2010 Revision ME conversion factors WHOCC Centre for Drug Statistics Methodology Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 78