Global Analysis of Adequacy of Prescription Opioid Consumption across 214 Countries and Territories

IntroductionThe Adequacy of Opioid Consumption (AOC) Index uses the human development index (HDI) to benchmark pain management. This does not account for health system factors such as the anesthesia workforce and can misrepresent high consumption as better. We improved the AOC index by adjusting it for physician anesthesia provider (PAP) density to provide a better indicator for pain management and perioperative care. MethodsCountry-level mean opioid consumption in milligrams per capita (mg/capita) for 2017-2021 (five-year arithmetic mean) was obtained from the International Narcotics Control Board Annual Report 2022. For parsimonious analysis, we included 11 opioids and analogs present in the WHO Model List of Essential Medicines 2023. Projections for PAP density per 100,000 people for 2019 were based on the World Federation of Society of Anaesthesiologists Survey (2015-16) and physician density estimates (2015-2019) derived from the Institute for Health Metrics and Evaluation. A generalized linear regression model for 137 countries was run with mean essential opioid analgesic consumption as the dependent variable and PAP density and HDI (2019) were independent variables to get PAP-adjusted consumption values. The arithmetic mean of PAP-adjusted consumption values of the top 20 countries was used as the adequacy threshold. PAP-adjusted AOC index was calculated as the ratio of the countrys adjusted essential opioid analgesic consumption to the threshold multiplied by 100. ResultsPAP-adjusted AOC index values ranged from 129.14 for Switzerland to 0.23 for Mali. Merely 7.3% of countries had a high AOC. About 5.97 billion people are estimated to be living in regions of low to extremely low PAP-adjusted AOC which are mainly situated in low and middle-income countries in the global south. ConclusionIn this comprehensive up-to-date global analysis, we find that most low- and lower-middle-income countries lack access to essential opioid analgesics. These point to the need for investing in the anesthesia workforce and ensuring access to opioid analgesics in tandem. O_TEXTBOXO_TEXTBOXNOResearch in contextC_TEXTBOXNO Evidence before this studyBefore undertaking the analysis, a rapid review of the literature was conducted to assess existing evidence on global opioid analgesic consumption and adequacy. Relevant publications included comparing opioid consumption for varying numbers of countries using data from the International Narcotics Control Board (INCB), IQVIA MIDAS database, the Organisation for Economic Cooperation and Development, and the European Monitoring Centre for Drugs and Drug Addiction. Three studies quantified the adequacy of opioid consumption between 2006-2015 using ACM and AOC indices. The added value of this studyOur study provides the latest available data for essential opioid analgesic consumption (190 countries) and adequacy (137 countries) between 2017-2021. We only include opioids and their analogs enlisted in the WHO list of Essential Drugs and use a modified AOC index which is adjusted for Physician Anesthesia Provider (PAP) density. This makes our index specific for anesthesia and perioperative pain management. Adjusting for PAP density normalizes the distribution of AOC by bringing higher and lower extremes closer to the mean adjusted consumption and thus accounts for opioid overconsumption values in developed countries. Implications of all the available evidencePAP-adjusted AOC can be used as an indicator to assess regional disparities in access to anesthesia and pain management. AOC has already been used as one of the indicators to measure access to anesthesia and pain management in the South Asian Region. Its national and sub-national mapping can help identify unmet needs and aid in drafting tailored healthcare policies and plans. Further research should be focused on adjusting the AOC based on other health system indicators like surgical rate and burden of disease, and also explore more global indicators for anesthesia care which would aid in tracking its process in global healthcare development. C_TEXTBOX