Adequacy of essential opioid analgesic consumption for anesthesia across 137 countries and territories from 2017 to 2021

Abstract

Inadequate access to pain management has consequences for perioperative care. Access to perioperative care globally is critical for equitable surgical, obstetric, trauma, and anesthesia (SOTA) care. Adequacy of prescription opioid consumption (AOC) can fill this gap. This study aimed to use the AOC index to assess global adequacy using recent data across 214 countries and territories, World Health Organization (WHO) regions, and World Bank Income Groups (WBIGs). We conducted a cross-sectional retrospective analysis using data on prescription opioid consumption for 214 countries and territories using previously published data for 2017. Country-wise data on the mean annual consumption of all prescription opioids were obtained in milligrams per capita. For adequacy, AOC normative threshold was calculated as the arithmetic mean of prescription opioid consumption of twenty countries with the topmost HDI values as of 2017. Country-wise AOC index was calculated as the mean annual prescription opioid consumption of a country divided by the threshold and the fraction multiplied by a hundred. The adequacy levels were classified as adequate (AOC >100), moderate (<100 and >30), low (<30 and >10), very low (<10 and >3), and extremely (<3). AOC was also calculated for WBIGs (as of 2017) and WHO regions. AOC values across WBIGs and WHO regions were compared using Welch Analysis of Variance (ANOVA) tests. Post-hoc pairwise comparisons were conducted using the Games-Howell test with Holm Bonferroni correction for multiple comparisons. A conventional significance level of 5% was used for all tests. Analysis was conducted in Google Sheets, JAMOVI, and RStudio. The average prescription opioid consumption of the top twenty HDI countries was found to be 172.8 mg/capita annually. Across countries, AOC index values ranged from 279.23 for Germany to 0.0012 for Angola. Merely 4.21% of the 214 countries and territories had an adequate level of consumption of prescription opioids. 6.54% of countries had moderate, 10.75% had low, 18.69% had very low, and a staggering 59.81% of countries had extremely low AOC index depicting massive differences in adequacy. 190 countries could be assigned to WHO regions and WBIGs. AOC values differed significantly across WHO regions (p<0.001). AOC values differed significantly across country income groups (p=0.001). In this systematic global analysis, we find that most low- and middle-income countries (LMICs) situated in the Global South lack access to prescription opioids. A majority of LMICs fall severely short, with their AOC index <1%. Low AOC can be seen as an indicator of poor access to pain management and thereby anesthesia care. This calls for the integration of AOC in the broader SOTA care indicators.

Achieving Surgical, Obstetric, Trauma, and Anesthesia (SOTA) care for all in South Asia

“…Another important indicator is an adequate supply of analgesics for perioperative pain management which can be captured using the scaled index called adequacy of opioid consumption (AOC) (50). Estimation of the AOC index reveals that the values for all South Asian countries are below one compared to the target of 100 (43).…”