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

Introduction: The Adequacy of Opioid Consumption (AOC) Index uses the human development index (HDI) to benchmark pain management. This does not account for health system factors such as the anesthesia workforce and can misrepresent high consumption as better. We improved the AOC index by adjusting it for physician anesthesia provider (PAP) density to provide a better indicator for pain management and perioperative care. Methods: Country-level mean opioid consumption in milligrams per capita (mg/capita) for 2017-2021 (five-year arithmetic mean) was obtained from the International Narcotics Control Board Annual Report 2022. For parsimonious analysis, we included 11 opioids and analogs present in the WHO Model List of Essential Medicines 2023. Projections for PAP density per 100,000 people for 2019 were based on the World Federation of Society of Anaesthesiologists Survey (2015-16) and physician density estimates (2015-2019) derived from the Institute for Health Metrics and Evaluation. A generalized linear regression model for 137 countries was run with mean essential opioid analgesic consumption as the dependent variable and PAP density and HDI (2019) were independent variables to get PAP-adjusted consumption values. The arithmetic mean of PAP-adjusted consumption values of the top 20 countries was used as the adequacy threshold. PAP-adjusted AOC index was calculated as the ratio of the country's adjusted essential opioid analgesic consumption to the threshold multiplied by 100. Results: PAP-adjusted AOC index values ranged from 129.14 for Switzerland to 0.23 for Mali. Merely 7.3% of countries had a high AOC. About 5.97 billion people are estimated to be living in regions of low to extremely low PAP-adjusted AOC which are mainly situated in low and middle-income countries in the global south. Conclusion: In this comprehensive up-to-date global analysis, we find that most low- and lower-middle-income countries lack access to essential opioid analgesics. These point to the need for investing in the anesthesia workforce and ensuring access to opioid analgesics in tandem.