Table 2.
Included studies characteristics and key findings.
| Quantitative studies | ||||||
|---|---|---|---|---|---|---|
| Author (s)/year of publication | Aims | Study design | Study population | Setting | Key findings | |
| 1 | Duthey et al.20 | To analyse the adequacy of consumption of opioid analgesics for countries and World Health Organization regions in 2010 as compared with 2006 | Adequacy of Consumption Measure using data for 2010 based on a method established by Seya et al. This method calculates the morbidity-corrected needs per capita for relevant strong opioid analgesics and the actual use for the top 20 Human Development Index countries. It determines the adequacy of the consumption for each country, World Health Organization region, and the world by comparing the actual consumption with the calculated need | Global macro datasets | Global (Asian data extracted) | • Study shows a global trend towards an increase in opioid adequacy in countries and world regions between 2006 and 2010 • Most of the increase in global consumption of opioids resulted from increases in high-income countries not in Asia • For World Health Organization Region Southeast Asia, three countries showed an increase in adequacy of consumption and four a decrease between 2006 and 2010 |
| 2 | Majeed et al.21 | (1) To identify and describe data for adequacy of the pain management in patients with advanced cancer; (2) to establish a relationship between analgesics prescribed and pain control; and (3) to examine the implementation of the WHO analgesic guidelines in these patients | Cross-sectional (survey) | Sample size: 136 patients with cancer-related pain ⩾5 on an 11 point Numerical Rating Scale for pain | Pakistan | • Study highlights the serious practice gaps in effective pain management in patients with advanced stage cancer in Pakistan • Identified evidence about failure to implement the WHO guidelines for cancer pain management in an overwhelming majority of the patients in this study leading to under-prescribing of opioids |
| 3 | Onishi et al.22 | To compare opioid prescribing patterns in the United States and Japan: primary care physicians’ attitudes and perceptions | Cross-sectional (survey) | Sample size: 461 Japanese clinicians and 198 from the United States | Japan (and United States) | • Overall, 24.1% of Japanese respondents reported that they would “never” or “seldom” use opioids for acute or chronic pain, compared with 1.0% of US physicians (p < .001) • US respondents were twice as likely as Japanese physicians to indicate that opioid treatment was a legal expectation (17.6% US vs 8.6% Japan; aOR, 2.03; p = .026) |
| 4 | De Lima et al.23 | To provide information on access to pain treatment, as measured by the availability and dispensed price of five opioids in 13 formulations, and the affordability of oral immediate-release (IR) Morphine | Cross-sectional (survey) | 30 pharmacists from 26 countries | Global (Asian data extracted) | • Identified affordability of opioids as a barrier, based upon the mean number of days’ wages required by the lowest-paid worker to purchase a 30 day treatment of morphine oral solid IR – 29.48 (Philippines) and 20.75 (India) • Found a significant positive correlation between a country’s gross national income and the availability of opioids |
| 5 | Cleary et al.24 | To describe opioid availability and accessibility for cancer patients in Asia | Cross-sectional (survey) | Representatives from 20 countries submitted reports on formulary availability and regulators barriers | Asia and the Middle East (Asian data extracted) | • Most included countries reported that opioids were only available in hospital pharmacies • Only in Afghanistan were pharmacists allowed to prescribe in emergency situations • In approximately half of included countries (11 of 20), medicines were provided to patients at no cost or <25% of the cost. Patients paid full cost of all medications in Bangladesh, Cambodia, Indonesia, Laos, Nepal and the Philippines |
| 6 | Srisawang et al.25 | To assess the knowledge and attitudes physicians and policy makers/regulators have regarding use of opioids for cancer pain management. Barriers to opioid availability also studied | Cross-sectional (survey) | Sample size: 266 (219 physicians + 47 policy makers/regulators) | Thailand | • Policymakers/regulators, perceived shortages or interruptions in opioid manufacture or distribution as the greatest barriers to opioid availability • Lack of education and training opportunities were the greatest barriers to prescribing amongst physicians • Lack of education/understanding about pain management identified amongst health policy makers and drug regulators |
| 7 | Gilson et al.26 | To examine government and health-care system influences on opioid availability for cancer pain and palliative care, as a means to identify implications for improving appropriate access to prescription opioids | A multivariate regression of 177 countries’ consumption of opioids (in milligrams/death from cancer and AIDS) contained country-level predictor variables related to public health, including Human Development Index, palliative care infrastructure, and health system resources and expenditures | NA | Global (Asian data extracted) | • Countries had greater opioid consumption when palliative care was more fully integrated into the country’s health-care infrastructure (p = 0.001), and when both consumption statistics and estimates were submitted to INCB consistently over the last 5 years (p = 0.004) • Extent of government spending positively predicted the aggregate consumption of opioids indicated for treating severe pain • The higher a country’s human development ranking, the greater its Total Morphine Equivalent consumption value (p < 0.0001) |
| 8 | Javier and Calimag27 | To find out if opioid usage has improved in the Philippines 20 years after the introduction of the WHO analgesic ladder | Cross-sectional (survey) | Sample size: 211 physicians | Philippines | • Identified very good awareness amongst clinicians of the WHO analgesic ladder (72%) • Majority of the respondents were aware of opioids being available in their hospitals (89.57%), 4.27% commented that opioids are not available, whilst 6.16% are not sure about opioid availability in their hospitals • Two-thirds of the respondents (60.19%) had a Dangerous Drug (S2 licence) • Amongst those who do not have the licence, many respondents (60.66%) attribute this to the fact that their hospitals do not provide them with the necessary S2 licence and yellow prescription form even when they are in government practice |
| 9 | Khan et al.28 | The objective of the study was to gather pertinent Bangladeshi information to assist health professionals, policy makers and the community in the development of programs to improve the care of patients with moderate to severe pain | Cross-sectional (survey) | Sample size: 1000 physicians with pain management responsibilities in 47 districts in Bangladesh. Response rate 58.3% | Bangladesh | • Sixty-seven percent of included physicians reported no regulatory investigation about their opioid prescribing practices, 10% knew someone who had been investigated and 23% did not know regarding the matter • Distribution of the total knowledge, attitude and perceived barrier of the study physicians in relation to the practice setting • The majority of the physicians showed inadequate knowledge regarding opioid analgesic prescription • Amongst responding physicians only 31% believe that legitimate prescription of narcotic pain-relieving drugs in cancer patients do not cause addiction |
| 10 | De Lima et al.29 | This study addressed retail prices and availability of potent opioids in the developing countries of Argentina, Colombia, India, Mexico, and Saudi Arabia, and compared this to similar data for the developed countries of Australia, Canada, Denmark, Italy, Japan, Spain, and the United States | Cross-sectional (survey) | Pain and Palliative Care specialists collected data on the retail cost of a 30 day supply of 15 different opioid preparations | 5 developing and 7 developed countries.– see “aims” (Asian data extracted) | • In US dollars, the median cost of opioids differed between developed and developing countries ($53 and $112, respectively) • The median costs of all opioid preparations as a percentage of GNP per capita per month were 36% for developing and 3% for developed nations • In developing countries, 23 of 45 (51%) of opioid dosage forms cost more than 30% of the monthly GNP per capita, versus only three of 76 (4%) in developed countries |
| 11 | Thongkhamcharoen et al.30 | To provide an up-to-date overview of the role of multidisciplinary teams in the regulation of opioids in Thai government hospitals | Cross-sectional (survey) | Questionnaire distributed to government hospitals in Thailand and all private hospitals in Bangkok. There were 975 hospitals, including 93 private hospitals in Bangkok and 882 government hospitals. (NB: it is not reported who completed the questionnaires) | Thailand | • Respondents mentioned that community hospitals did not have enough doctors for opioid prescribing • Need for doctors to sign a special form for every single patient visit • Majority of hospitals have no specific regulation of opioid amount per prescription |
| 12 | Yu et al.31 | To assess the current status of cancer pain management, and physicians’ attitudes in China towards cancer pain management | Cross-sectional (survey) | A survey of 427 physicians and 387 cancer pain patients from one Chinese general hospital | China | • 62.8% of clinicians had concerns about regulatory investigation for prescribing narcotics • 72.8% of clinicians felt medical school training with regard to cancer pain management was inadequate leading to a reluctance to prescribe opioids |
| 13 | Berterame et al.32 | To provide up-to-date worldwide, regional, and national data for changes in opioid analgesic use, and to analyse the relation of impediments to use of these medicines | Cross-sectional (survey) | 214 countries | Worldwide, regional, and national study (Asian data extracted) | • Study reports impediments to the availability of opioid analgesics in East and Southeast Asia as: “Absence of awareness or training in use of opioid drugs in members of the medical profession” 3 (33%), “Restricted financial resources” 5 (56%), “Issues in sourcing from industry or imports” 3 (33%), “Fear of diversion to illicit channels” 6 (67%), “Control measures applicable to international trade such as need for import or export authorisation” 1 (11%), “Fear of criminal prosecution or sanction” 3 (33%), and “Onerous regulatory framework for prescription of narcotic drugs for medical use” 1 (11%) |
| 14 | Vijayan et al.33 | To obtain a clearer picture of the current role and clinical use of Tramadol in Southeast Asia | Cross-sectional (survey) | Pain specialists from seven countries in the region were invited to participate in a survey of their individual use and experience of Tramadol | Southeast Asia | • Respondents from India, Indonesia and Pakistan also stated that there is limited or no availability of controlled opioid analgesics in their countries • Every one of the respondents considered tramadol to be either significant or highly significant in the treatment of moderate to severe non-cancer pain in their home country, specifically mentioning acute indications such as labour pain, postoperative and post-traumatic pain, and chronic indications such as low back pain and osteoarthritis • Respondents strongly agreed that tighter regulation would lead to a significant reduction in the medical availability of tramadol, especially in the outpatient setting • In total, 72% of responders (33 of 46 countries) expressed concern that the introduction of control measures would limit accessibility to tramadol and make doctors more reluctant to prescribe it |
| 15 | Singh et al.34 | To assess current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals towards the use of opioid analgesics | Cross-sectional (survey) | Sample size: 308 medical practitioners at three tertiary hospitals in New Delhi | India | • Two-thirds of the participants (61.7%) reported that they had never received any formal training in pain management, whilst 38.5% of the participants had • Seventy-eight percent (78.6%) of the participants reported that they had never faced any unwanted attention from the authorities as a result of prescribing opioids • Those who felt that addiction potential was a barrier to prescribing opioid analgesics were not more likely to report that they have not received adequate training in pain management |
| Qualitative studies | ||||||
| Author (s)/year of publication | Aims | Study design | Study population | Setting | ||
| 16 | LeBaron et al.35 | To examine barriers to opioid availability and cancer pain management in India, with an emphasis on the experiences of nurses, who are often the front-line providers of palliative care | Ethnography | 59 oncology nurses affiliated with 37 South Indian Cancer Hospitals and 22 others who interacted closely with nurses | Cancer hospitals in South India | • Morphine is more available at study site than in most of India, but access is limited to patients seen by the palliative care service, and significant gaps in supply still occur • Systems to measure and improve pain outcomes are largely absent • Key barriers related to pain management include the role of nursing, opioid misperceptions, bureaucratic hurdles, and sociocultural/infrastructure challenges |
| 17 | Husain et al.36 | To determine whether national drug control laws ensure that opioid drugs are available for medical and scientific purposes, as intended by the 1972 Protocol amendment to the 1961 Single Convention on Narcotic Drugs | Policy analysis of a sample of national drug laws | Laws from 15 countries | India, Nepal, Philippines, Vietnam (Asia data extracted) | • No country in Asia had a drug control law that recognised that the medical use of opioid drugs continues to be indispensable for the relief of pain and suffering • Only in India and Vietnam, did laws in Asian countries specifically declare an intention to implement the Single Convention on Narcotics • No Asian country declared adequate provision of opioids |
| 18 | Dehghan et al.37 | To investigate the use of Morphine in advanced cancer in palliative care setting in Bangladesh, in order to inform clinical practice and fledgling service development | Single semi-structured qualitative interview study | 20 cancer patients, family members and palliative care specialists in two medical settings | Bangladesh | • Lack of availability of morphine was identified as the main barrier to pain control • Low awareness amongst clinicians of therapeutic benefits of opioids and concerns about addition/side-effects limit prescribing • Families encounter irregularity of supply, meaning that prescriptions are not fulfilled • High cost of opioids (fentanyl) limit access • Patients face logistical challenges in accessing centralised prescribing centres |
| Mixed methods studies | ||||||
| Author (s)/year of publication | Aims | Study design | Study population | Setting | ||
| 19 | McDermott et al.38 | To assess the current state of palliative care in India, mapping the existence of services state by state, and documenting the perspectives and experiences of those involved | A multimethod review and synthesis of published and grey literature findings, ethnographic field visits, interviews, with existing public health data | 87 interviews with key in-country experts and palliative care activist from 12 states | India | • Opioid accessibility is a constant problem for the providers of hospice and palliative care in India • Identified a range of barriers to morphine availability, including: stringent central government legislation, state government reluctance to implement/ignorance regarding simplified narcotics regulations, difficulties with some state bureaucracy, fears about morphine addiction amongst state officials, health professionals, patients and their families, pharmaceutical companies unwilling to produce morphine, products prohibitively expensive, few dispensing services, health professionals’ lack of experience of prescribing morphine, fear of side effects in patients, and little training/education about morphine provided to health professionals and the general public |
| 20 | Joranson et al.39 | To develop an initiative to improve availability and patient access to opioids for palliative care | Implementation research methods including developing cooperation with government and non-government organisations, identifying regulatory barriers to Morphine availability through analysis of national narcotics control policies according to the principle of “balance,” proposing changes in policy, developing workshops to support and implement policy change, and monitoring the effects on availability and patient access to Morphine | NA | India | • State narcotic rules, which varied from state to state, were complex, requiring that medical institutions obtain a number of licences to possess opioids such as morphine • Bureaucratic procedures can delay for months and even years the approval of all the necessary licences for obtaining morphine, because the excise officers in charge may not be familiar with the medical subject of pain relief, and are likely to have a view of narcotic drugs that is limited to concern about addiction. When the last of the licenses is finally issued, it is likely that one or more of the other licences have expired • Simplified narcotic regulations in Kerala improve opioid availability |
| 21 | Kitreerawutiwong et al.40 | To develop a community-based palliative care model in a district health system based on the form of action and evaluation | Three-step action research | Stakeholders were patients and families undergoing palliative care health professionals, and social workers in the district | Thailand | • District Health Service does not prescribe morphine to be used in the community/at home due to a lack of regulatory guidelines • Lack of trained morphine prescribers, in context of concerns regarding abuse |