Access to therapeutic opioid medications in Europe by 2011? Fifty years on from the single convention on narcotic drugs.

Nearly 50 years after the Single Convention on Narcotic Drugs, the importance of this statement continues to hold true and is reinforced by recent UN policy declarations (ECOSOC, 2006). However there continues to be ongoing problems with access to opioid analgesics for relief of pain globally. Cherny and his colleagues from the European Association for Palliative Care (EAPC) and the European Society of Medical Oncology (ESMO) Drug Policy Initiative have documented the current status in Europe of access to opioids for pain relief in an article published in the current issue of Annals of Oncology. The authors reference the extensive work of the University of Wisconsin–Madison Pain and Policy Studies Group (PPSG), aWHOCollaborating Center for Policy and Communication in Cancer Care. PPSG has described the opioid consumption trends around the world, using consumption data reported by governments to the International Narcotics Control Board (INCB).Most of the countries of the world, including those in Eastern Europe, fall well below the European and global means for opioid consumption. While there has been a significant increase in opioid consumption in Western Europe, there has been little change in the last 20 years in Eastern Europe. There is evidence that in many European countries, particularly those in Eastern Europe, patient access to the opioid medicines recommended by the WHO to relieve cancer pain is profoundly restricted by inadequate formularies, excessive regulation and the attitudes and misconceptions of both clinicians and patients. While there are clear disparities between Eastern and Western Europe, there is also variation within the two regions. Morphine (sustained or immediate release [IR]) is available to the patient for less than 25% of the total cost in every Western European country except Iceland where patients pay 100% of the cost, perhaps a norm of their health care system. Turkey is the only Western European country without IR morphine, but does have available controlled release (CR) morphine and transdermal fentanyl, two preparations that are included in the International Association of Hospice and Palliative Care (IAHPC) list of essential drugs for palliative care. However, in that list, the IAHPC panel of experts recommended to the WHO that governments should not approve controlled release formulations of morphine, fentanyl or oxycodone, without first guaranteeing the wide availability of IR oral morphine. The lack of IR morphine in Turkey is evident in many countries in Eastern Europe. No IR morphine is available in Albania although CR morphine is available. Belarus has no IR morphine but has CR morphine and TD fentanyl, as do Lithuania, Georgia, and the Ukraine (patients bear 100% of the cost of fentanyl in Georgia). While these are available in many Eastern European countries because of the marketing practice of pharmaceutical companies, the PPSG opioid consumption data for morphine (as shown in the paper) demonstrates a low level of consumption of CR morphine in these countries and the low level of fentanyl consumption is shown on the PPSG web site (http:// www.painpolicy.wisc.edu). These data suggest that the national approval of a controlled-release opioid pharmaceutical does not necessarily lead to the appropriate use for analgesia, and may inadvertently minimize the importance of IR formulations. Cherny and colleagues warn us that some aspects of their data, provided by practicing clinicians in 41 countries, may have deficits due to the selective nature of the survey process. On the other hand, the results are valuable perceptions of practice by these clinicians in their respective countries. The ESMO and EAPC survey is an important step; it is a window that can be used to continue the study, discussion and reform of regulatory barriers in Europe. It should be recalled that these laws were not enacted to prevent pain relief but rather to address drug abuse and diversion, an understandable concern about public health and safety of many governments.