1. Overviews of the Drug Distribution System & Barriers to Opioid Availability Dr. Bishnu Dutta Paudel International Pain Policy Fellowship Training Program Madison, Wisconsin, USA 6 August 2012

2. GLOBAL DISPARITIES In 2010, eight countries together accounted for 85% of global consumption of morphine.

3. Why is opioid use so low? INCB Survey of government drug control authorities 1995(65 countries) & 2007( 144 countries) By: University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center, 2008 International Narcotics Control Board. (1996). Report of the International Narcotics Control Board for 1995: Availability of Opiates for Medical Needs. New York, NY: United Nations.

4. Why is opioid use so low?  Barriers to opioid availability: 1)Fear of addiction 2) Lack of training health care providers 3) Excessively restrictive laws and regulations 4) Fear of legal consequences

5. Why is opioid use so low? 5) Insufficient supply of opioids 6) Cost of opioids 7)Inadequate health care resources 8) Lack of national policy, guidelines

6. Why is opioid use so low?  2006 Survey of Health care workers, and hospice/PC staff in Asia, Africa and Latin America By: University of Wisconsin Pain & Policy Studies Group/WHO Collaborating Center, 2008 Adams, V. (2007). Access to Pain Relief – an essential human right. Help the Hospices, Worldwide Palliative Care Alliance.

7. Why is opioid use so low?  Barriers to accessing oral morphine: 1)Excessively strict national drug laws and regulations; 2)Fear of addiction; 3)Poorly developed health care systems; 4)Lack of knowledge

8. Barriers to opioid availability 1) Opioid Regulatory Policy 2) Drug Distribution System 3) Cost of Opioid Analgesics 4) Knowledge & Attitudes

9. DRUG DISTRIBUTION SYSTEM The entire system of medication procurement and distribution for health care.

10. Opioid Analgesics Information Level 1: International Narcotics Control Board Level 4: Hospitals / Pharmacies / Hospice/ PC facilities Level 6: PATIENTS Level 2: National Competent Authority Level 3: Importers / Manufacturers / Distributors Level 5: Physicians / Pharmacists / Nurses

13. DRUG DISTRIBUTION SYSTEM BARRIERS Government has not made procurement arrangements for importation or domestic manufacture of opioids Delays in government decision-making Inadequate methods for assessing medical needs

14. DRUG DISTRIBUTION SYSTEM BARRIERS Pharmacies that stock opioid medications are inadequate in number, in geographical location (rural areas), and/or hours of operation No system to ensure the safe transport of medications from wholesale level to retail level LACK OF DEMAND / Not ordered within country

15. COST OF OPIOID ANALGESICS -More expensive opioid analgesics available - No reimbursement for pain management or palliative care in national policies

16. COST OF OPIOID ANALGESICS Lack of low-cost / generic oral opioid analgesics (powder to make into tablets or solution)

17. CONCLUSIONS Barriers to opioid availability and patient access can be found at different levels: 1) Opioid Regulatory Policy 2) Drug Distribution System 3) Cost of Opioid Analgesics 4) Knowledge & Attitudes -

18. CONCLUSIONS Barriers must be identified and addressed in order to improve opioid availability to achieve pain relief. The International Pain Policy Fellowship is designed to assist with this process. Consider the barriers in your country before working on your Action Plans.

19. THANK YOU !