Poppy-based medicines such as morphine play a fundamental role in the treatment of
pain, and the overall worldwide need for adequate and sustained pain relief is
increasing. Research shows that in more than 150 countries, containing about 80% of
the world’s population, only a tiny minority of the patients in need of morphine
treatment actually receives this morphine. Millions of people, particularly cancer
and HIV/AIDS sufferers in emerging countries, live and die in unnecessary pain
because their needs for essential morphine medicines are not being met.
| Principles of the current system |
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The production, international trade and use of poppy-based medicines such as
morphine are strictly controlled under international law through an elaborate system
of estimates and statistical returns.
The 1961 Single Convention on Narcotic Drugs governs the annual international trade
of opiates raw materials used for scientific and medical purposes. Adherence to the
rules and regulations of this Convention is overseen by the International Narcotics
Control Board (INCB). National governments must submit to the INCB quarterly and
annual statistical reports on the manufacture, use, import and export of poppy-based
medicines to ensure that the worldwide supply of these medicines does not greatly
exceed demand, nor fall significantly below the prescribed targets. As such, the
international supply of raw materials used to make morphine depends almost entirely
on the estimated global demand for these raw materials, as measured through the
INCB-administered system.
Providing for the strict control of the raw poppy materials used in the production of
medicines, this system can be described as an almost perfect closed, planned
economy. Importantly, under article 21 of the 1961 Single Convention on Narcotic
Drugs, the quantity of essential opium-based medicines manufactured in, or imported
into, a country must never exceed the official estimate which that country had
submitted to the INCB. These statistical reports constitute a country’s official
requirements of narcotic drugs for the following year; once validated by the INCB,
the estimates become binding for governments. Supply countries are only legally
allowed to produce as much as is necessary to meet the total estimated global
requirements. Thus the availability of morphine around the world in any one year is in
effect dependent on the total use of primary materials from two years previous.
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Afghan Red Crescent volunteers, unaided by the international community, are endeavouring to help the hungry in Helmand province
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Although significant stocks of raw poppy materials currently exist in several
countries, these stocks do not represent a global over-supply. Stocks appear within
the current poppy-based medicine supply system for two main reasons:
1. Because INCB-administered commodities constitute the raw materials for a range
of essential medicines, consumer countries often build up strategic reserves to be
able to cope with future shortage;
2. Producing countries build stocks to both smooth price trends over time, and to
compete effectively with other producing countries.
Typically, stocks of agricultural commodities are at levels sufficient to cover several
years of consumption. In comparison, current stocks of raw poppy materials are
relatively low. Moreover, because these stocks are created and managed within the
current supply system, they can not be used to supply needs un-accounted for by the
INCB-administered system.
| Current system provides for “market” demand, not actual need |
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The INCB administered system is designed to identify market demand for raw poppy
materials and to manage the related supply. The INCB has proven efficient
administrating this highly regulated market. It does not, however, state the actual need
for poppy-based medicines.
In less economically developped and emerging countries, patients’ demands for morphine and other
poppy-based medicines are currently significantly underestimated because of a selfperpetuating
cycle of medical under-prescription and restrictive regulations which
inhibit countries’ ability to import morphine. Given that demand is measured - under
the current supply system - by actual consumption the previous year, demand from
less economically developed nations remains structurally low and systematically understates the actual need. As such, many countries, most of the less economically
developed and emerging countries, but also even highly industrialised countries, are
caught in a cycle that deprives patients of the essential medicines necessary to ease
the global pain crisis. Furthermore, in a number of countries the system to assess and
submit estimates to INCB does not function well.
Un-met need for painkillers in Latin America
The consumption of poppy-based medicines in Latin America is extremely low,
despite its large population and increasing cancer and HIV/AIDS burdens. Latin
America accounts for less than 1% of the global consumption of morphine, due to
under-prescription by medical staff untrained in poppy-based medicines, overly
restricted laws and the high cost. In most countries consumption is below the global mean of 6.2 mg
of poppy-based medicines per capita, although some countries have increased. In
2005 the entire population of Argentina (39.9 million) used just 96 kg of morphine,
what represent 2.4 mg per capita. This only represents one tenth of the morphine
consumption per capita rate in Germany, which in 2005 was 24.5 mg.
Only 5–10% of patients in Latin America in need of palliative care receive it, and
97% of palliative care provision is available in large cities. In 2005, to meet the pain
needs of the end-stage HIV/AIDS and cancer patients in Latin America, 7.1 metric
tons of morphine would have been needed, but just 600 kg of morphine was actually
used, leaving 91% of these patients’ pain needs un-met.
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Low estimates of a country’s demand for morphine are a result of a number of factors,
including doctors’ reluctance to prescribe medicines their patients will not be able to
actually purchase; the relatively high cost of these medicines; dysfunctional
bureaucracies that impose overly restrictive regulations which limit the number of
pharmacies that stock the medicines, thereby further limiting patients’ access to these
medicines and constraining doctors’ prescribing practices; and cultural
misunderstandings related to the effects of poppy-based medicines. This in turn results in an inadequate supply of poppy-based medications, leaving countries such as
those in Latin America with a great disparity between need and supply (see box).
For those countries whose bureaucracies and health system are able to identify and
supply a demand corresponding to the essential need of their population, the current
international system of supply functions adequately. Nevertheless, the INCB has
admitted that “Most developing countries lack the resources and expertise required for
determining medical needs and adjusting drug supply to meet those needs.” The
existence and perpetuation of an un-met need outside the market demand is an
alarming fact that calls for watchful analysis and swift action.
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