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Low- and middle-income countries

In this article, Dr Morell-Ducos discusses the variations in opioid prescription patterns observed in low- and middle-income countries.
Pills arranged in shape of world map

In this step, Dr Fausto Morell-Ducos, Consultant in Anaesthesia and Pain Medicine at University College London Hospitals, discusses opioid prescription patterns in low- and middle-income countries (LMICs).

The WHO estimates that 5.5 billion people do not have access to treatments for moderate-to-severe pain, while more than 90% of the world’s opioids are consumed by less than 20% of the world’s population [1]. This disparity in availability of opioids goes hand in hand with the inequality of access to safe surgery, whereby out of the nearly 232 million major surgeries which take place worldwide every year, only 3.5% occur in LMICs, in spite of the fact they contain more than 85% of the world’s population.
Although studies specifically looking at the use of opioids in the management of post-surgical pain in LMICs are lacking, the following infographic regarding the availability of opioids for palliative care purposes gives an idea of what has been termed the “access abyss” of opioids [2].
As a result much pain from surgery often goes untreated. For example, one survey in Nigeria found that 68.7% of patients had moderate to unbearable pain at 24 hours after surgery, and 51.7% at 48 hours [1].
The lack of access to analgesic treatments, in particular morphine, has been attributed to a number of factors including low prioritisation of pain relief, patient and staff expectations and attitudes, lack of staff training and lack of access [1].
Although morphine is cheap to manufacture and off-patent, national regulations and complex import/export systems can mean that opioids are more expensive in certain LMICs than in many high-income countries (HICs). Other LMICs impose significant restrictions, such as opioids being dispensed from police stations, or limiting supplies to a maximum of two days at a time [3].
Concerns regarding the dangers of opioid use which lead to excessive restrictive practices by healthcare workers have been termed opiophobia [1], and represent the other extreme of how societal attitudes towards pain management can influence the prescription of analgesic medications.

Your turn now

Use the comments section below to share your thoughts and experiences. Watch the short BBC News video clip below. Consider what the consequences of limited opioid use may be in surgical patients. Where do you think the righ balance lies between restricting opioid use and allowing patients to benefit from analgesia?

Please do not share any details that could be patient-identifiable. You can ‘like’ and comment on other learners’ comments, as well as ‘follow’ other learners so you don’t miss their comments.

This is an additional video, hosted on YouTube.


1. Morriss WW, Roques CJ. Pain management in low- and middle-income countries. BJA Ed 2018;18:265-70.

2. Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Kwete XJ, et al. Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report. 391(10128):1391-1454.

3. The negative impact of drug control on public health: the global crisis of avoidable pain. The Global Commission on Drug Policy, Geneva (2015).

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Opioids and Surgery

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