title: Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study.
abstract: BACKGROUND
  Despite opioid analgesics being essential for pain relief, use has been inadequate in many countries. We aim to provide up-to-date worldwide, regional, and national data for changes in opioid analgesic use, and to analyse the relation of impediments to use of these medicines.
  
  
  METHODS
  We calculated defined daily doses for statistical purposes (S-DDD) per million inhabitants per day of opioid analgesics worldwide and for regions and countries from 2001 to 2013, and we used generalised estimating equation analysis to assess longitudinal change in use. We compared use data against the prevalence of some health disorders needing opioid use. We surveyed 214 countries or territories about impediments to availability of these medicines, and used regression analyses to establish the strength of associations between impediments and use.
  
  
  RESULTS
  The S-DDD of opioid analgesic use more than doubled worldwide between 2001-03 and 2011-13, from 1417 S-DDD (95% CI -732 to 3565; totalling about 3.01 billion defined daily doses per annum) to 3027 S-DDD (-1162 to 7215; totalling about 7.35 billion defined daily doses per annum). Substantial increases occurred in North America (16,046 S-DDD [95% CI 4032-28,061] to 31,453 S-DDD [8121-54,785]), western and central Europe (3079 S-DDD [1274-4883] to 9320 S-DDD [3969-14,672]), and Oceania (2275 S-DDD [763-3787] to 9136 S-DDD [2508-15,765]). Countries in other regions have shown no substantial increase in use. Impediments to use included an absence of training and awareness in medical professionals, fear of dependence, restricted financial resources, issues in sourcing, cultural attitudes, fear of diversion, international trade controls, and onerous regulation. Higher number of impediments reported was significantly associated with lower use (unadjusted incidence rate ratio 0.39 [95% CI 0.29-0.52]; p<0.0001), but not when adjusted for gross domestic product and human development index (0.91 [0.73-1.14]; p=0.4271).
  
  
  CONCLUSIONS
  Use of opioid analgesics has increased, but remains low in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe. Identified impediments to use urgently need to be addressed by governments and international agencies.
  
  
  BACKGROUND
  International Narcotics Control Board, UN.
authors: Secretariat of the International Narcotics Control Board, Vienna International Centre, Vienna, Austria. Electronic address: stefano.berterame@incb.org.
authors: Stefano
authors: S
authors: Berterame
authors: Secretariat of the International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Juliana
authors: J
authors: Erthal
authors: Secretariat of the International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Johny
authors: J
authors: Thomas
authors: Secretariat of the International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Sarah
authors: S
authors: Fellner
authors: Secretariat of the International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Benjamin
authors: B
authors: Vosse
authors: National Drug and Alcohol Research Centre, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
authors: Philip
authors: P
authors: Clare
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria; Psychiatry, Mental Health Institute, Central South University, Changsha, China.
authors: Wei
authors: W
authors: Hao
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: David T
authors: DT
authors: Johnson
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria; Unidad de Epidemiología, Instituto Nacional de Cancerología, Instituto de Biomédicas, Universidad Nacional Autónoma de México, Tlalpan, Distrito Federal, Mexico.
authors: Alejandro
authors: A
authors: Mohar
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Jagjit
authors: J
authors: Pavadia
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Ahmed Kamal Eldin
authors: AK
authors: Samak
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Werner
authors: W
authors: Sipp
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria; Association of Southeast Asian Nations Institute for Health Development, Mahidol University, Salaya, Nakhonphathom, Thailand.
authors: Viroj
authors: V
authors: Sumyai
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria; Division of Medicine Policy and Management, Department of Pharmacology and Therapeutics, Faculty of Medicine, GadjahMada University, Yogyakarta, Indonesia.
authors: Sri
authors: S
authors: Suryawati
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria; Faculty of Medicine, University Mohammed V, Rabat, Morocco; Hôpital Universitaire Psychiatrique Arrazi, Salé, Morocco.
authors: Jallal
authors: J
authors: Toufiq
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria.
authors: Raymond
authors: R
authors: Yans
authors: International Narcotics Control Board, Vienna International Centre, Vienna, Austria; National Drug and Alcohol Research Centre, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
authors: Richard P
authors: RP
authors: Mattick
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000600:supply & distribution; D001291:Attitude of Health Personnel; D004334:Drug Administration Schedule; D004363:Drug Utilization / Q000706:statistics & numerical data / Q000639:trends; D014943:Global Health / Q000706:statistics & numerical data* / Q000639:trends; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008137:Longitudinal Studies; D009369:Neoplasms / Q000188:drug therapy / Q000453:epidemiology; D059408:Pain Management / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data
chemical_list: D000701:Analgesics, Opioid