Barriers and Solutions to the Opioid Gap

The Lancet study identified several impediments to opioid use. These include a lack of physician training, concerns about diversion and dependence, financial restrictions, sourcing problems, cultural attitudes, international trade controls, and restrictive regulations.3

On the positive side, opioids are not expensive, and most are not under patent protection. They can be manufactured in sufficient quantity to meet the global need.

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“The most important barriers to be addressed are lack of capacity of health care professionals to prescribe and administer pain medications, onerous regulations and complicated administrative processes, and cultural and social resistance to the use of opioids analgesics,” Dr Berterame said.

The causes of the opioid gap are significant, but are they insurmountable? For developed countries where the problem is overuse, Dr Kaye sees reason for optimism. In the 2014 review, the authors called for comprehensive, goal-directed guidelines to improve future pain management.2

“Drug formulation strategies for abuse deterrence [are] still evolving, but it appears that this is the direction we are heading in the future. We need standards of education and training. We need regular testing of competencies and required urine testing for those taking these medications. We need to agree on best practice strategies and standards,” Dr Kaye emphasized.

In the rest of the world, barriers to opioid pain management are starting to be addressed. “At the international level, there is indeed a movement. As stated in the report, there is need for countries to review their national legislation, to ensure availability to those in need, and not impede access, while ensuring that there is no diversion,” said Dr Berterame.

“In this area, discussions in the International Narcotics Control Board and the work of United Nations Office on Drugs and Crime are important. However, there is also an issue of local capacity in terms of health systems to deliver appropriate palliative care. The WHO is in the driving seat on this. Finally, at the local level, patient and professional associations have an important role to play to overcome stigma and lack of information,” Dr Berterame added.

Important Information for Primary Care Providers

Dr Kaye suggests a key takeaway for primary care providers: “Organizations around the country have educational meetings on topics such as substance abuse and opioid prescribing. These courses should be attended, and education on these topics should be a regular activity. Primary care physicians are the primary prescribers of opioids and have an obligation to be experts in prescribing or not prescribing these powerful agents.”

As for physicians working on the negative side of the opioid gap, Dr Berterame says that, “primary care providers may need to ask their national authorities to consider the recommendations in the report, and evaluate how these can be implemented to enable them to better perform their roles.”

The study was funded by the International Narcotics Control Board and the United Nations. The authors report no conflicts of interest.


1. Sarah Goltz; European Society for Medical Oncology. Global access to pain relief: Evidence for action. Undated. Accessed February 18, 2016.

2. Manjiani D, Paul DB, Kunnumpurath S, Kaye AD, Vadivelu N. Availability and utilization of opioids for pain management: Global issues. The Ochsner Journal. 2014;14(2): 208-215. Accessed February 18, 2016.

3. Berterame S, Erthal J, Thomas J, et al. Use of and barriers to access to opioid analgesics: a worldwide, regional, and national study. The Lancet. 2016; (16):1-13.