By Pat Anson, PNN Editor

A new report by the World Health Organization (WHO) warns that limited access to morphine and other opioids is leaving millions of people in many parts of the world suffering in preventable pain.

The report, “Left Behind in Pain,” calls morphine a low cost, essential medicine for relieving moderate to severe pain. But access to morphine and other opioids is inadequate in many low and middle-income countries, with consumption patterns in wealthier nations that don’t correspond to medical need. Over 95% of the world’s supply of opioids is distributed in wealthy countries, with only 0.03% distributed in low-income ones.

“Leaving people in pain when effective medicines are available for pain management, especially in the context of end-of-life care, should be a cause of serious concern for policy-makers,” says Yukiko Nakatani, MD, WHO Assistant Director-General for Medicines and Health Products. “We must urgently advocate for safe and timely access to morphine for those in medical need through balanced policy, everywhere.”

The report calls for expanded access to morphine through local and regional distribution centers, changes in restrictive laws and guidelines, and reduced stigma surrounding opioid use.

“Some historical events, cultural beliefs, misinformation and disinformation about pain, and social stigma related to opioid use are known to have caused mistrust of opioids and contributed to fear of using them,” the report found.

Lawsuits and regulatory controls on the pharmaceutical industry are so strong in some countries that drug makers have stopped manufacturing morphine because the profit is low and risk of liability is high.

That may have played a role in Mundipharma’s recent decision to discontinue supplying Ordine, a liquid formulation of morphine, to Australia. Mundipharma is owned by the Sackler family, which has been enmeshed in opioid litigation over its role in the opioid crisis in the U.S. through its operation of Purdue Pharma.

A Mundipharma spokesperson told the Australia Broadcasting Corporation that the company’s third-party manufacturer decided to stop producing Ordine and that "sourcing another manufacturer would not be commercially viable."

Evolving Stance on Opioids

WHO’s position on opioids has evolved over the years. WHO’s guidelines for treating chronic pain, for example, used to say that opioids “are known to be safe and there is no need to fear accidental death or dependence.”

That changed in 2019, after two U.S. congressmen – without any real evidence -- accused WHO of being “corruptly influenced” by opioid manufactures. WHO withdrew the guidelines a month later, citing “new scientific evidence” – although critics said caved in to political pressure and threats to withdraw U.S. funding of WHO.

In 2021, WHO backpedaled further, recommending that morphine only be given to sick children when they are dying. Physical therapy and “biopsychosocial” treatments such as cognitive behavioral therapy were suggested as alternatives for children who are in pain, but expected to live.

WHO’s latest report recognizes the potential harms of opioids, couched in language about the world facing two opioid crises.

“The world is facing two crises related to the use of opioids. In the first, inappropriate use and over-prescription combined with the wide availability of illicit unregulated opioids, such as fentanyl, in some countries is causing significant harm and loss of life. In the second, a lack of access to opioids such as morphine in many parts of the world means that millions of people continue to suffer preventable pain,” said Nakatani.

About 80% of the world’s morphine supply was consumed in North America in 2021, primarily in the United States, although the rest of the developed world is catching up. Opioid consumption in the U.S. has fallen so sharply in recent years that Canada, Australia and several European countries have become the highest consumers of opioid analgesics, according to a 2022 study that ranked the U.S. as being 8th in per capita opioid sales.