China India RussianFederation

Nigeria Indonesia Pakistan Bangladesh Philippines Mozambique Egypt0

100k

200k

300k

400k

500k

600k

700k

canceratlas.cancer.org

0 1 - 1 , 5 9 8 1 , 5 9 9 - 5 , 2 7 05 , 2 7 1 - 1 3 , 6 0 41 3 , 6 0 5 o r m o r eN o d a t a

High Income

Middle Income

Low Income

High Income

Middle Income

Low Income

High Income

Middle Income

Low Income

canceratlas.cancer.org canceratlas.cancer.org

32 TAKING ACTION

FIGURE 32.3

Untreated deaths in pain by region, 2016

Essential medicine lists of the World Health Organization and many countries include opioid analgesics, such as morphine. The moderate or severe pain experienced by approximately 80% of people with advanced cancer cannot be relieved without them.

But access to opioid analgesics is limited in low- and middle-income countries, where 85% of the world’s population consumes just 7% of the medicinal opioids. FIGURE 32.2 Legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of healthcare providers, poorly functioning markets, weak health systems, and concern about addiction and non-medical use all contribute to limited access, even though morphine, the most effective treatment for severe pain, is safe, effective, inexpensive, and easy to use.

Meanwhile, some high-income countries are dealing with a very different challenge related to pain relief, as rates of addiction continue to rise due to harmful and non-medical use of opioids.

Worldwide, the number of cancer patients in need of pain relief is projected to increase 48% from 2018 to 2035, but the increase is likely to be considerably higher in the regions with more rapidly increasing cancer rates and with the lowest access to pain relief, including South-Eastern Asia (projected 54% increase in cancer cases) and Africa (72% increase), where consumption of pain relief is sufficient to cover less than 25% of deaths in pain.FIGURE 32.3 A balanced approach to access to opioids with sufficient measures to prevent harmful and non-medical use has been achieved by many Western European countries and in some low- and low-middle income countries.

PAIN CONTROLMillions of cancer patients, almost entirely in low- and middle-income countries, lack access to essential pain medicines.

FIGURE 32.1

Untreated deaths in pain due to HIV and cancer, 2016

FIGURE 32.2

Total cancer and HIV deaths in pain and those treated for pain, by income level, 2016

Almost all untreated deaths in pain due to cancer and HIV are in

low- and middle-income countries.

Three quarters of untreated deaths in

pain occur in just ten countries

The greatest numbers of untreated deaths in pain are in East

Asia and the Pacific; South Asia; and sub-Saharan Africa.

East Asia & Pacific

South Asia

Sub-Saharan Africa

Europe & Central Asia

Latin America & Caribbean

Middle East & North Africa

North America*

Treated deaths in pain, based on opioid consumption

Total deaths in pain due to cancer or HIV, treated and untreated 651,867

*Zero untreated deaths in pain in North America, 2016.

2

41K 1

09K 95K 921K

578K

714K

The Pain-Free Hospital Initiative, a one-year hospital-based

health worker training initiative designed to improve the

quality of pain assessment and treatment, resulted in a tripling

of the use of essential pain medications and a

25% decrease in average pain scores in the oncology unit after

being implemented at Kenyatta National Hospital

in Nairobi, Kenya.

ACCESS CREATES PROGRESS

HIGH INCOME

99.9%

57%

17%

MIDDLE INCOME

LOW INCOME

2,094,499 Total deaths

5,306,664 Total deaths

3,022,701 Treated deaths

76,163 Treated deaths

2,091,578 Treated deaths

447,538 Total deaths

Improved access to oral morphine is mandatory for the treatment of moderate to

severe cancer pain, suffered by over 80% of cancer patients in terminal phase.

— World Health Organization

“86% of untreated deaths in pain are in middle-income

countries.

copyright © 2019 the american cancer society, inc.

13,605 or more No data5,271–13,6041,599–5,270Zero 1–1,598

MAP 32.1

Untreated deaths in pain, 2016

JordanMorocco

MauritaniaMali

Niger

Nigeria

Chad Sudan

South Sudan

Ethiopia

Eritrea

Somalia

Sri Lanka

Senegal

Guinea

Cameroon

Central African Rep.

Ghana

GabonCongo

Rwanda—

AngolaZambia

Malawi

Zimbabwe

Botswana

Namibia

S. Africa

UgandaKenya

Tanzania

—Burundi

Burkina Faso

Benin

|Togo

Côte d’Ivoire

Gambia—

Guinea-Bissau

Sierra Leone

Liberia

AlgeriaEgypt

Kazakhstan Mongolia

China

Australia

IndiaSaudi Arabia

Libya

Armenia—

Lebanon—

Maldives—

—IsraelKuwait—

Syria

GeorgiaAzerbaijan

Turkmenistan

Afghanistan

Pakistan

Uzbekistan

Tajikistan

Japan

Philippines

Kyrgyzstan

—Lesotho

—Comoros

— Mauritius

—Djibouti

—QatarBahrain—

UAE

Oman

Nepal

Bangladesh

Bhutan

DPR Korea

Rep. Korea

Myanmar

Thailand

Cambodia

Viet Nam

Lao PDR

Yemen

Iraq

Kuwait—

New Zealand

Indonesia

Singapore—Malaysia

—Eswatini

Turkey

Cabo Verde |

Equatorial Guinea—Sao Tome & Principe—

Madagascar

— Seychelles

Brunei Dar.—

—Timor-Leste

Fiji—

Samoa—Vanuatu—

Solomon Is.|

United Kingdom

Ireland

Iceland

Portugal

Tunisia

Spain

France

Belgium

Netherlands |

Denmark

Norway

Sweden

Finland

Germany

Croatia

Poland

Bulgaria

Romania

Ukraine

Belarus

Lithuania Latvia

Estonia

GreeceItaly

Slovenia—

Slovakia

—Malta

Swit.

Andorra— | Monaco

Lux.— Czechia

Serbia

MoldovaAustria Hungary

Albania

Montenegro—N. Macedonia

Bos. & Herz.

Russia—

Papua New Guinea

Tuvalu—

—Palau | Micronesia

|Marshall Is.

|Kiribati

Nauru|

Tonga— Cook Is.—Niue—

Russia

Palestine—

DR Congo

IranCyprus—

Canada

Mexico

—Belize

GuatemalaHonduras

| El Salvador Nicaragua

Costa Rica

Panama

Colombia

Ecuador

Peru

Bolivia

Brazil

Paraguay

Uruguay

Argentina

Chile

Venezuela

Haiti

Guyana

Suriname

United States of America

Jamaica—

—Barbados—St. Lucia

|

Dominica

—Antigua & Barbuda

| St. Kitts & Nevis

—Grenada—Trin. & Tob.

St. Vin. & Gren.—

| Dominican

Rep.

Cuba

—Bahamas

Mozambique