Adapting Global Pain Guidelines to Local Contexts: Strategies for Low- and Middle-Income Countries

Adapting Global Pain Guidelines to Local Contexts: Strategies for Low- and Middle-Income Countries

Authors: 

• Robyna Irshad Khan MBBS, FCPS, MHSc, Associate Professor Anesthesiology, Associate Dean Allied Health, Aga Khan University, Karachi, Pakistan.
• Usman Bashir, MBBS, FRCA, FFPMRCA, King Faisal Specialist Hospital & Research Centre, Kingdom of Saudi Arabia
• Gauhar Afshan, MBBS, FCPS, Endowed Professor Anesthesiology & Pain Medicine, Aga Khan University, Karachi, Pakistan

Background

Opioids are indispensable for the treatment of severe short-lived pain during acute painful events and at the end of life ^[1]. Despite being recognized as an essential medication for pain management and palliative care by the World Health Organization (WHO), significant global disparities in opioid distribution persist ^[2-4]. Notably, 92% of the available opioids are consumed in high-income countries, while only 8% are distributed among low- and middle-income countries (LMICs) ^[5]. Several factors contribute to this inequity, including overly restrictive opioid regulations, market barriers, limited prescriber knowledge, and historical-social determinants that hinder accessibility in LMICs ^[6,7].

The Need for Opioids

Pain management has been recognized as a basic human right worldwide. While pain is prevalent all over the globe, the burden of untreated pain falls heavily on LMICs ^[8]. This is partly due to the lack of essential pain medication including opioids, which are crucial for severe pain management. The WHO’s Pain Relief Ladder highlights opioids as a crucial component in pain management, ensuring quality of life and reducing unnecessary suffering ^[9]. Lack of access to opioids has been identified as a barrier to effective pain management and palliative care in LMICs ^[10,11]. Additionally, inadequate legitimate access to opioids may drive individuals to seek illicit sources to manage their pain, increasing the risk of unsafe use and associated harms ^[12].

Current Status 

While opioids are widely used in high-income countries, their availability remains critically low in many LMICs ^[5]. The shortage is not only in the amount of opioids but also in the formulation of the medication. There is a significant lack of strong opioids such as morphine and oxycodone; instead, tramadol, tapentadol, and codeine accounted for 87.7% of total MME (milligram morphine equivalent) consumption in LMICs ^[3]. Notably, while tramadol has not been subject to national control in many LMICs, its widespread use has raised significant concerns regarding the associated risks ^[13]. Limited production, regulatory hurdles, and high costs are among the factors that contribute to opioid scarcity in LMICs. Furthermore, cultural perceptions and fear of addiction often lead to resistance in prescribing and dispensing opioid medications ^[7,11,14]. Despite the lack of access to essential pain medicine in LMICs, there are alarming reports of illicit use of opioids and overdoses in LMICs such as Ethiopia ^[15]. The overuse of opioids is particularly concerning to physicians and students. Additionally, the general public including young adults, drivers, and manual laborers face challenges due to the limited awareness of the dangers of opioid misuse.

Barriers to Opioid Use in LMICs

1. Regulatory and Legal Barriers: Strict opioid control policies aimed at preventing misuse often result in excessive restrictions that limit legitimate access for medical use. This also further exacerbates the fear of prescribing opioids among prescribers ^[7].
2. Limited Healthcare Provider Knowledge: Inadequate training on pain management and opioid prescribing among healthcare professionals contributes to underutilization ^{[4, 16]}.
3. Supply Chain and Market Barriers: Poor pharmaceutical supply chains, lack of local production, and economic constraints make opioid medications inaccessible for many patients ^[4,17,18]. Additionally, the scarcity is further exacerbated by the limited number of pharmacies authorized to dispense these medications, even when they are available ^[19,20].
4. Cultural and Social Stigma: Fear of opioid addiction and misconceptions about their use hinder both prescribing and patient acceptance ^[4,17,18].

Overcoming Challenges

• Regulatory Reforms: Governments should balance opioid control policies with access needs by implementing WHO-recommended opioid availability frameworks ^[21].
• Education and Training: Enhancing pain management education for healthcare providers is crucial to optimizing opioid prescribing practices ^[4,22]. Educational efforts should aim to (1) support the appropriate use of opioids in clinically indicated cases, and (2) mitigate the risks associated with opioid misuse, abuse, and overdose-related mortality.
• Improving Supply Chains: Strengthening pharmaceutical distribution networks and encouraging local opioid production can help bridge the accessibility gap ^[23].
• Public Awareness Campaigns: Addressing opioid-related stigma through targeted community education programs can promote their appropriate use in pain management ^[4,18].
• International support: Enhancing safe opioid accessibility requires collaborative efforts and policy changes that often cannot be achieved by individual countries alone. Partnering with influential international organizations in the field and fostering cooperative initiatives can significantly improve the likelihood of success ^[18].

References

1. International Association for the Study of Pain. Opioids for pain management. 2018. https://www.iasp-pain.org/advocacy/iasp-statements/opioids-for-pain-management. Assessed 18 July 2025
2. Hadjiat Y, Toufiq J, Ntizimira C, Arendt-Nielsen L, Burucoa B, Treillet E, Authier N, Perrot S. Analysis of opioid analgesics consumption in Africa: a longitudinal study from a 20-year continental perspective. Lancet Glob Health. 2024 Jul;12(7):e1120-e1128. https://doi.org/10.1016/S2214-109X(24)00146-3 
3. Jayawardana S, Forman R, Johnston-Webber C, Campbell A, Berterame S, de Joncheere C, Aitken M, Mossialos E. Global consumption of prescription opioid analgesics between 2009-2019: a country-level observational study. EClinicalMedicine. 2021 Nov 13;42:101198. https://doi.org/10.1016/j.eclinm.2021.101198 
4. Berterame S, Erthal J, Thomas J, Fellner S, Vosse B, Clare P, Hao W, Johnson DT, Mohar A, Pavadia J, Samak AK, Sipp W, Sumyai V, Suryawati S, Toufiq J, Yans R, Mattick RP. Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. Lancet. 2016 Apr 16;387(10028):1644-56. https://doi.org/10.1016/S0140-6736(16)00161-6 
5. International Narcotics Control Board. No patient left behind: progress in ensuring adequate access to internationally controlled substances for medical and scientific purposes. Vienna: United Nations, 2023. https://www.incb.org/documents/Publications/AnnualReports/AR2022/Supplement/E_INCB_2022_1_Supp_1_eng.pdf. Assessed 18 July 2025
6. Berterame S, Erthal J, Thomas J, Fellner S, Vosse B, Clare P, Hao W, Johnson DT, Mohar A, Pavadia J, Samak AK, Sipp W, Sumyai V, Suryawati S, Toufiq J, Yans R, Mattick RP. Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. Lancet. 2016 Apr 16;387(10028):1644-56. https://doi.org/10.1016/S0140-6736(16)00161-6 
7. Clark J, Gnanapragasam S, Greenley S, Pearce J, Johnson M. Perceptions and experiences of laws and regulations governing access to opioids in South, Southeast, East and Central Asia: A systematic review, critical interpretative synthesis and development of a conceptual framework. Palliat Med. 2021 Jan;35(1):59-75. https://doi.org/10.1177/0269216320966505
8. Vos T., Allen C., Arora M. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1211–1259. https://doi.org/10.1016/S0140-6736(17)32154-2 
9. World Health Organization (WHO). WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. 2018. https://www.who.int/publications/i/item/9789241550390. Assessed 18 July 2025
10. Abu-Odah, H., Molassiotis, A. & Liu, J. Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews. BMC Palliat Care 19, 55 (2020). https://doi.org/10.1186/s12904-020-00558-5
11. Goucke R, Morriss W. Pain management in Low and Middle Income Countries (LMIC) just put up with it? Egyptian Journal of Anaesthesia. Volume 28, Issue 1, 2012, Pages 1-2, ISSN 1110-1849, https://doi.org/10.1016/j.egja.2011.11.005.
12. Manchikanti L, Cash KA, Damron KS, Manchukonda R, Pampati V, McManus CD. Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables. Pain Physician. 2006 Jul;9(3):215-25
13. Boun SS, Omonaiye O, Yaya S. Prevalence and health consequences of nonmedical use of tramadol in Africa: A systematic scoping review. PLOS Glob Public Health. 2024 Jan 18;4(1):e0002784. https://doi.org/10.1371/journal.pgph.0002784 
14. Nchako E, Bussell S, Nesbeth C, Odoh C, Barriers to the availability and accessibility of controlled medicines for chronic pain in Africa, International Health, Volume 10, Issue 2, March 2018, Pages 71–77, https://doi.org/10.1093/inthealth/ihy002
15. Onohuean H, Oosthuizen F. The burden of unlawful use of opioid and associated epidemiological characteristics in Africa: A scoping review. PLoS One. 2025 Mar 7;20(3):e0317036. https://doi.org/10.1371/journal.pone.0317036 
16. Tafere C, Tefera BB, Yehualaw A, Demsie DG, Kefale B, Feyisa K, Yismaw MB, Aschale E, Debasu Z, Yilma Z, Agmassie Z, Siraj IA, Yayehrad AT, Mulatu S, Endeshaw D. Community Pharmacists’ Knowledge and Attitude Towards Opioid Pain Medication Use in Bahir Dar City, North-West Ethiopia. J Multidiscip Healthc. 2024 Feb 27;17:833-841. https://doi.org/10.2147/JMDH.S452350 
17. Aregay A, O’Connor M, Stow J, Ayers N, Lee S. Perceptions of Barriers to Using Opioid Analgesics: A Mixed Methods Study. Palliat Med Rep. 2023 Aug 30;4(1):249-256. https://doi.org/10.1089/pmr.2023.0021 
18. Krakauer EL, Thinh DHQ, Khanh QT, Huyen HTM, Tuan TD, The THN, Cuong DD, Thuan TV, Yen NP, Van Anh P, Cham NTP, Doyle KP, Yen NTH, Khue LN. Palliative Care in Vietnam: Long-Term Partnerships Yield Increasing Access. J Pain Symptom Manage. 2018 Feb;55(2S):S92-S95. https://doi.org/10.1016/j.jpainsymman.2017.03.038 
19. Yenet A, Nibret G, Tegegne BA. Challenges to the Availability and Affordability of Essential Medicines in African Countries: A Scoping Review. Clinicoecon Outcomes Res. 2023 Jun 13;15:443-458. https://doi.org/10.2147/CEOR.S413546 
20. Hadjiat Y, El Azhari A, Burucoa B, Treillet E, Ntizimira C, Perrot S. Douleurs du cancer en Afrique francophone : recherche et analyse des freins à la prise en charge et à l’accès aux analgésiques opioïdes. Douleur et analgésie. 2024;37(2):87-103. https://doi.org/10.1684/dea.2024.0288 
21. World Health Organization. (‎2011)‎. Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization. https://iris.who.int/handle/10665/44519 . Assessed 18 July 2025
22. Peri K, Honeycutt L, Wennberg E, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E, Moiz A, Martel MO, Eisenberg MJ. Efficacy of interventions targeted at physician prescribers of opioids for chronic non-cancer pain: an overview of systematic reviews. BMC Med. 2024 Feb 20;22(1):76. https://doi.org/10.1186/s12916-024-03287-1
23. World Health Organization. (2011). Local production for access to medical products: developing a framework to improve public health. World Health Organization. https://www.who.int/publications/i/item/9789241502894  Assessed 18 July 2025