INCB recommends increased morphine production for palliative care

In its 2024 Annual Report, the International Narcotics Control Board (INCB) once again draws attention to a longstanding failure of the UN drug control regime: the persistent lack of, and stark disparities in access to affordable morphine. In doing so, the Report underscores the importance of opioids for severe pain management in palliative care and harm reduction, and of psychotropics to treat mental health conditions, including in situations of conflict.

According to the INCB, opioid consumption remains higher in Western and Central Europe, North America and Oceania – while consumption continues to be inadequate in East and South-East Asia, Central America and the Caribbean, South Asia and Africa. North America continues to have the highest per capita consumption of opioids (United States 27,709 S-DDDpmpd) and Africa has the lowest (Namibia, 92 S-DDDpmpd).

The largest producers of the world’s morphine include France, Iran, India, Norway, the UK, Japan, and Australia. Most of the morphine manufactured in the world is utilised to produce codeine (211,202 kg) and other substances. As a result, only 33,547 kg are used directly for palliative care, mostly in high-income countries, with only a fraction (4,750 kg) being consumed for that purpose in low- and middle-income countries. This falls drastically short of the INCB’s estimate that at least 43,000 kg of morphine would be needed annually to reach minimally adequate consumption levels in all regions. This is the amount required to raise the availability to 200 S-DDDpmpd in all regions with low consumption¹. The INCB Report urges opioid-producing countries to increase the manufacture of morphine preparations for pain management and palliative care, and to make morphine more broadly available and more affordable, in particular in low- and medium-income countries.

The Report also highlights the chronic under-provision of opioid agonist therapy (OAT) for people dependent on opioids – pointing out that only 10% of people in need have access to OAT with methadone and buprenorphine, mostly in the Americas and Europe. The largest consumer country (24,6 tons) remains the United States, accounting for half of the global consumption. In a notable shift from previous years, the Board’s Report for 2024 explicitly encourages countries to develop and expand services, including the use of controlled medicines such as methadone and buprenorphine for OAT – a reflection of the INCB’s evolving stance on harm reduction.

Various psychotropic substances controlled under the 1971 Convention – such as alprazolam (the most consumed psychotropic in the world), diazepam, lorazepam, midazolam and phenobarbital, which are all included on the WHO Model List of Essential Medicines – are used for the treatment of ADHD, anxiety, narcolepsy, epilepsy and sleeping disorders. It is estimated by WHO that 301 million people were suffering from anxiety globally in 2019, a number that has increased by 25% since the pandemic. And yet, once again, access is highly unequal. In 2023, the consumption of alprazolam in the United States stood at 9.89 S-DDDpmpd, while it didn’t exceed 1 S-DDDpmpd in Africa and East and South-East Asia. In this context, the Board recommends better training of healthcare providers to ensure more rational prescribing, particularly in low- and middle-income countries.

With the increased instability and exacerbation of conflicts in various parts of the world over the past few years, it is unsurprising that the Board devotes a special section of its Annual Report to humanitarian emergencies caused by armed conflict. In doing so, the Board reaffirms that the safe passage of medical supplies is a critical aspect of the Geneva Conventions, and that the international drug control conventions allow for the expedited movement of controlled medicines during emergencies, even in the absence of import authorisations or estimates.

This Report reflects a notable shift by the INCB over the past decade towards a recognition of the importance of ensuring better access to controlled medicines for palliative care, pain relief and harm reduction. These changes have been gradually made thanks to the evolving composition of the Board and increased engagement with civil society, which have encouraged more progressive views about the complexity of the drug situation. Nonetheless, the recent US funding cuts on foreign aid and health cooperation are now adding an extra challenge for low- and middle-income countries to implement the INCB’s recommendations.

The persistent challenge in ensuring access to controlled medicines for an overwhelming majority of the world’s population also raises serious concerns over the ability of the current UN drug control regime to fulfil its core mandate – the protection of the ‘health and welfare of humankind’. As the UN system is undergoing a severe financial and liquidity crisis and the Secretary-General is embarking on an overall reform of the UN, the global drug control regime is also facing criticism. In March, a resolution tabled by Colombia and supported by a cross-regional coalition of Member States was adopted at CND to create a panel of 19 independent experts appointed by the CND, the UN Secretary-General, the INCB and the WHO, to rethink the implementation of the drug control conventions. The panel is an opportunity to propose concrete changes prioritising health and human rights and thus close the gap in access to and availability of controlled medicines for palliative care and harm reduction.

Notes:

¹ The INCB considers consumption under 200 S-DDDpmpd to be inadequate. S-DDDpmpd: defined daily doses for statistical purposes per million inhabitants per day.