The United Nations Office on Drugs and Crime (UNODC) warned in its annual World Drug Report released this week as much as 86 percent of the world’s population has “too little access” to pharmaceutical opioids – despite identifying opioids as “the leading cause of deaths in fatal overdoses.”

The World Drug Report is a thorough analysis of drug trafficking, drug use, and the criminal ramifications of the drug trade around the world. In addition to opioids, the report covers cocaine, cannabis, amphetamines, psychoactive substantives, MDMA and related drugs, and unspecified “sedatives” and other less common drugs. This year’s edition covers the year 2021.

While the majority of the report identified availability of drugs as detrimental to public health and society, the report identified “pharmaceutical opioids” as necessary for “pain relief” and patients in palliative care, and urged governments to work to increase access to them.

“Controlled drugs needed for palliative care and pain relief, namely pharmaceutical opioids, are denied to those who desperately need them, with too little access in many countries – mainly low- and middle-income countries, where some 86 percent of the world’s population lives,” the UNODC executive director, Ghada Waly, wrote in the introduction to the report.

“World drug problems may be global, but they do not affect all the world equally,” the report continued. “It is the vulnerable, the poor and the excluded who pay the highest price … They suffer from the violence and insecurity fuelled by drug trafficking, as well as from insufficient access to and availability of controlled medicines.”

In the report’s subsection on opioids, the UNODC observed “large inequalities” in which countries have readily available access to “internationally controlled opioids.”

“Overall, there is a 40-fold difference in the availability of opioids per capita for pain management and palliative care between high-income and low- and middle-income countries,” the report noted. “Although a number of countries in North America, Oceania and Western Europe continue to have high levels of availability, most other countries have extremely low levels of availability of opioids for medical purposes, notably countries in Africa and Asia.”

The UNODC documented “progress” in access to opioids, particularly methadone and buprenorphine, “two opioids which are used not only as analgesics but also as opioid agonist medication in the treatment of opioid use disorders.” The two drugs are the only ones in the report named in the segments on expanding access to pharmaceutical opioids.

Two other pharmaceutical opioids approved for medical use by the American Food and Drug Administration (FDA) appear elsewhere in the report in a much more negative light: tramadol and fentanyl. Fentanyl, the largest driver of drug use deaths in America currently, is “approved by the Food and Drug Administration for use as an analgesic (pain relief) and anesthetic,” the Drug Enforcement Agency (DEA) notes on its website. Tramadol, more popular for abuse in Africa, is “approved to treat moderate to moderately severe pain in adults,” according to the FDA.

The UNODC identified opioids generally as responsible for 69 percent of drug use deaths in 2019 and the vast majority of deaths in North America.

“Opioids accounted for nearly 70 per cent of the 128,000 deaths attributed to drug use disorders in 2019. Opioid use disorders also accounted for the majority (71 per cent of the 18 million healthy years of life lost owing to premature death and disability in 2019,” the report observed.

In North America, fentanyl is the main driver of drug deaths, according to the report.

“In the United States in 2021, following a year-on-year trend of increase, there were more than 80,000 opioid overdose deaths,” the World Drug Report observed. “Most of those deaths, 70,000 [87.5 percent], were attributed to any pharmaceutical opioid with synthetic opioids (primarily fentanyls).”

The UNODC also documented “significant misuse” of tramadol, particularly throughout Africa.

“The problematic non-medical use of tramadol is visible in the high proportion of people entering drug treatment for tramadol use disorders in Egypt, Iraq, Nigeria and the United Arab Emirates,” the report documented. “Significant numbers have also been reported in other countries, including Liberia, the Niger and Sierra Leone, indicating in some cases recent sharp increases in the demand for treatment for tramadol use disorders.”

The World Drug Report did not explicitly exclude fentanyl or tramadol from its call for expanded access to pharmaceutical opioids.

In its booklet identifying “special points of interest,” the 2023 World Drug Report again lamented that “86 per cent of the global population lived in countries where availability of pharmaceutical opioids for medical use was below the global average” and called for expanded access to the drugs.

“Prioritizing public health concerns remains a challenge in the face of growing commercial interest in developing and profiting from new, legal drug markets,” the report noted. “If frameworks for medical use are not well designed and adequately resourced, ensuring access and availability of the drugs for medical purposes, approaches could contribute to the creation of illicit markets through limited supply or diversion of therapies for non-medical use.”

“Regulatory approaches can be designed to ensure sufficient availability of products with proven safety and efficacy, while at the same time restricting access to legitimate medical needs,” the report concluded. “Such approaches may also limit potential spill-over into a non-medical or recreational use market.”

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