Understanding and Using INCB Opioid Consumption Statistics: Including Morphine Equivalence 8 August 2012 Martha Maurer, MSW, MPH, PhD Pain & Policy Studies Group World Health Organization Collaborating Center for Policy and Communications in Cancer Care for Policy and Communications in Cancer Care University of Wisconsin Carbone Comprehensive Cancer Center

The Single Convention establishes two mechanisms: (1) statistical returns system for narcotic drugs, and (2) estimates system for narcotic drug requirements.

UN Single Convention Article 1, paragraph 2 For the purposes of this Convention a drug shall be regarded as “consumed” when it has been supplied to any person or enterprise for retail distribution, medical use or scientific research; and “consumption” shall be construed accordingly.

UN Single Convention Article 20, paragraph 1 The parties shall furnish to the Board…statistical returns on forms supplied by it in respect of the following matters: …(c) consumption of drugs.

Who is responsible?

PPSG Collaboration with INCB - INCB publishes consumption statistics annually - Public INCB reports do not include reported amounts that are less than 500 g - PPSG has a long-term relationship with INCB - PPSG receives complete annual raw data, including amounts less than 500 g, for the most recent year

Uses of Consumption Statistics -Identification of the opioids that are available (i.e., manufacture or import authorization) in a country -An indicator of a country’s current and historical ability to treat moderate to severe pain -A tool to evaluate the efforts to improve opioid availability (i.e., following removal of a barrier.)

Limitations of Consumption Statistics - Some countries may not annually report or may report incorrect statistics - Not able to distinguish between different clinical uses, e.g., methadone to treat pain vs. addiction (dependence syndrome) - Not able to distinguish between types of pain being treated, e.g., acute vs. chronic - Consumption for single drugs offers only a partial view of a country’s ability to manage pain

Global Consumption of Morphine, 2010 **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, 2012 mg/capita 152 countries Global Mean

Disparity in Consumption: High vs. Low- and Middle-income countries (LMIC) 2010 Morphine Consumption (kg) High Income (90%) LMIC (10%)

**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, 2012 mg/capita WHO Regional Office for Europe (EURO) 2010 Morphine Consumption

Sources: International Narcotics Control Board; World Health Organization population data By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2012 mg/capita WHO Regional Office for Southeast Asia (SEARO) 2010 Morphine Consumption

Morphine Equivalence (ME) statistic – a more complete picture PPSG developed a morphine equivalence (ME) statistic for each principal opioid used to treat severe pain: Fentanyl Hydromorphone Methadone Morphine Oxycodone Pethidine Allows for a comparison of the consumption of morphine to the equianalgesic consumption of other medications Total ME statistic represents in one metric the aggregate consumption of these principal opioid analgesics used for severe pain

Pain & Policy Studies Group University of Wisconsin Carbone Cancer Center WHO Collaborating Center 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 Global Consumption in Morphine Equivalence (ME) , mg/person

2009 Opioid Consumption in Morphine Equivalence

Opioid Consumption Motion Chart

PPSG’s Country Profiles

PPSG’s Country Profiles

Conclusions INCB data are an important source of data about opioid availability around the world Prior to 1986 morphine consumption alone was a reasonable indicator of total opioid consumption Subsequently morphine consumption alone less valid indicator Morphine Equivalence statistics allow for equianalgesic comparison across drugs Total morphine equivalence statistic represents aggregate consumption of all principle opioids used for severe pain