Article Text

Relation between opioid consumption and inclusion of opioids in 137 national essential medicines lists
  1. Georgia C Richards1,
  2. Jeffrey K Aronson1,
  3. Carl Heneghan1,
  4. Kamal R Mahtani1,
  5. Constantinos Koshiaris2,
  6. Nav Persaud3,4
  1. 1Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
  2. 2Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
  3. 3Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Centre for Urban Health Solutions, Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
  1. Correspondence to Georgia C Richards; georgia.richards{at}


Introduction Opioids are deemed essential medicines by the World Health Organization (WHO). However, many countries have inadequate access to them. Whether including opioids in national essential medicines lists (EMLs) influences national opioid consumption has not been evaluated.

Methods We conducted a cross-sectional study to determine whether the listing of opioids in national EMLs was associated with consumption. We quantified the numbers and types of all opioids included in 137 national EMLs, for comparison with opioids in the WHO’s Model List of Essential Medicines. Using the International Narcotics Control Board (INCB) consumption statistics for 2015–2017, we assessed the relation between annual mean opioid consumption (mg/person) and the numbers of opioids included in EMLs, controlling for region, population, healthcare expenditure, life expectancy, gross domestic product, human development and corruption.

Results Five opioids were included in the 20th edition of the WHO’s Model List of Essential Medicines: codeine, fentanyl, loperamide, methadone and morphine. On average, countries’ lists included significantly (p<0.05) more opioids than the WHO’s Model List. However, there were wide variations in the numbers (median 6 opioids; IQR: 5–9) and types (n=33) of opioids included in national EMLs. Morphine (95%), fentanyl (83%) and codeine (69%) were the most commonly included opioids. Most national EMLs were out of date (median publication date: 2011, IQR: 2009–2013). After adjusting for country characteristics, there was no relation between mean opioid consumption and the number of opioids in EMLs.

Conclusions Including opioids in national EMLs was not associated with consumption. National EMLs should be regularly updated to reflect the availability of opioids and the populations’ needs for managing pain.

  • epidemiology
  • health policy
  • pharmacology
  • public health
  • treatment

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  • Handling editor Eduardo Gómez

  • Twitter @Richards_G_C

  • Contributors GCR devised the research question, designed the methods, wrote the protocol, conducted data screening, data cleaning and management, analysed the data, conducted the literature review and wrote the original manuscript. JKA conducted secondary data screening for the master list of opioids, reviewed preliminary findings, critically revised the manuscript and provided supervisory support. CH, KRM and NP reviewed the protocol and preliminary findings, critically revised the manuscript and provided supervisory support. NP provided access to the Global Essential Medicines Database and was the catalyst for conducting this study. CK provided statistical advice, reviewed the statistical model and preliminary findings and critically revised the manuscript. All authors read, reviewed and approved the final manuscript.

  • Funding The lead author is financially supported by the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation and the Rotary Foundation.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health and Social Care.

  • Patient and public involvement statement We involved three patients who have chronic pain and experience of taking opioids and other medicines for pain at the analysis phase of our research. Lead author (GCR) presented the preliminary findings to the patients during a formal face-to-face PPIpatient and public involvement meeting in December 2019. Patients provided suggestions forn final analyses, the presentation of results, and the dissemination plans for our research. Preliminary findings were also presented to stakeholders at the inaugural Global Essential MedicinesGlobal Essential Medicines Meeting in November 2019 in Toronto, Canada, which included members of the WHO’s Expert Committee on the Selection and Use of Essential Medicines. All stakeholders will be involved in the dissemination of our research.

  • Patient consent for publication Not required.

  • Ethics approval Not required

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. Our protocol, study materials, data and statistical code are all openly available on the Open Science Framework ( and GitHub (

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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