Morphine is considered the essential medicine for managing moderate to severe pain

The global distribution of morphine, as a vital pain medicine, is unequal with over 80 percent of morphine being distributed for consumption in countries within America and Europe, the World Health Organization (WHO) has said in its new report.

“There is a 5- to 63-fold difference in the estimated median consumption of morphine between high-income countries and lower income countries,” the report said.

Morphine is an essential medicine for relieving moderate to severe pain. It is also essential for treating severe breathlessness that is refractory to treatment of the underlying cause, especially at the end of life. Its medical uses span multiple clinical settings in today’s medical practice, including surgical care, cancer care, palliative care, emergency care, paediatric care, and long-term care.

“(Morphine) must be available both as an oral, immediate-release preparation and as an injectable preparation for any patient with moderate or severe pain or with terminal dyspnoea,” the WHO said in the report.

The supply of morphine and other strong opioids for medical use is regulated internationally by the United Nations Single Convention on Narcotic Drugs, and Convention on Psychotropic Substances, and is subject to the laws of individual countries.

“As a result, the supply process can be lengthy as it requires strong coordination among multiple parties involved in decision-making and authorizations,” the report said. “Poor process coordination can disrupt supply of morphine and other strong opioids, thereby delaying or obstructing access for people in need.”

Dr Yukiko Nakatani, WHO Assistant Director-General for Medicines and Health Products said that “leaving people in pain when effective medicines are available for pain management, especially in the context of end-of-life care, should be a cause of serious concern for policy-makers.”

“We must urgently advocate for safe and timely access to morphine for those in medical need through balanced policy, everywhere,” he added.

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History

The effect of opium for pain relief has been known for millennia. Morphine was first extracted from opium poppy plants in the early 1800s and its medical uses have since been well recognized. Morphine has been listed in the WHO Model List of Essential Medicines (EML) since 1977, and in the WHO EML for children since 2007.

The 2019 WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents provide a strong recommendation that “regularly dosed immediate-release oral morphine, or regularly dosed slow-release morphine”, should be used to maintain effective and safe pain relief whenever oral dosing is possible.

However, like other medicines and other opioids, morphine use is associated with side effects, including constipation, drowsiness, and less often confusion, dry mouth, nausea and vomiting. Clinical guidance in managing these common side-effects is well established. People receiving morphine and other strong opioids in doses high enough to cause sedation may also experience respiratory depression. If severe and left untreated, respiratory depression can be fatal.

“Nevertheless, when internationally accepted dosing guidelines are followed, evidence suggests that significant respiratory depression is uncommon or rare, and clinically manageable,” the report said.

Research result

Morphine is considered the essential medicine for managing moderate to severe pain, particularly in palliative care. It is also less expensive than other derivative and synthetic opioids, such as oxycodone and fentanyl, which have been associated with the “opioid overdose epidemic” in a few high-income countries. For these reasons, the WHO report presents the status regarding access to morphine and other strong opioids for patients in need globally.

According to the report, Turkey, Australia, France and China were the main cultivators of opium poppy (Papaver somniferum) for pharmaceutical production. A total of 235,000 kg of morphine was available for pharmaceutical manufacturing in 2021, comprising extractions from these raw materials combined with the existing stocks from the previous year’s production.

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