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. 2025 Feb;69(2):204-215.
doi: 10.1016/j.jpainsymman.2024.10.026. Epub 2024 Oct 28.

Distributed Opioids in Morphine Equivalent: A Global Measure of Availability for Palliative Care

Felicia Marie Knaul  1 , Héctor Arreola-Ornelas  2 , Xiaoxiao J Kwete  3 , Afsan Bhadelia  4 , Stefano Berterame  5 , Stephen R Connor  6 , Liliana De Lima  7 , Julia Downing  8 , Eric L Krakauer  9 , Oscar Méndez-Carniado  10 , Tania Pastrana  11 , Pedro E Pérez-Cruz  12 , Russell K Portenoy  13 , William E Rosa  14 , Michael Touchton  15 , Valentina Vargas Enciso  16 , Lukas Radbruch  17
Affiliations

Distributed Opioids in Morphine Equivalent: A Global Measure of Availability for Palliative Care

Felicia Marie Knaul et al. J Pain Symptom Manage. 2025 Feb.

Abstract

Context: Estimates of serious health-related suffering (SHS) demonstrate immense unmet need for palliative care, predominately in low- and middle-income countries (LMICs). Because opioids are essential medicines in palliative care (PC), measuring their availability can be used to evaluate the capacity of health systems to meet need.

Objectives: Present the methodology for calculating Distributed Opioids in Morphine Equivalents (DOME)- introduced in the Lancet Commission on Global Access to Palliative Care and Pain Relief report - and how it can be used as a simple indicator to quantify unmet pain relief and PC need.

Methods: Using International Narcotics Control Board (INCB) data, DOME applies relative potency estimates to convert the annualized quantities of clinically appropriate opioids procured by a country to oral morphine equivalent milligrams. To quantify unmet need, an expert group proposed health condition-specific estimates for opioid need and used available data on the burden of SHS to posit the annual opioid quantity required by country for symptomatic treatment of pain or breathlessness. Comparing this to DOME generates DOME%SHSNEED, the proportion of opioids needed for palliative care that can be fulfilled by the opioid procured by a country during a year.

Results: DOME and DOME%SHSNEED can be used to measure, over time, the capacity of countries to meet PC need, as a key component of universal health coverage. Identifying access gaps disproportionately impacting LMICs can promote better health system performance and guide countries and institutions in policy making.

Conclusion: DOME and DOME%SHSNEED can be used to monitor health system progress to redress disparities and promote access to medically indicated opioid therapy in palliative care.

Keywords: Opioids; global health; health systems; pain; pain management; palliative care; serious illness.

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Conflict of interest statement

Disclosure and Acknowledgments FMK reports research grant funding to the University of Miami from the U.S. Cancer Pain Relief outside the submitted work; ABC Global Alliance outside the submitted work; research grant funding from the Medical Research Council to FUNSALUD (Mexican Health Foundation) for work related to palliative care outside the submitted work; research grant funding from the University of Edinburgh to the University of Miami for work related to palliative care outside the submitted work; research grant funding to the University of Miami outside submitted work from Merck KGaA/EMD Serono; and personal fees from Merck KGaA/EMD Serono and Tecnológico de Monterrey. FMK is on the board of the IAHPC, Founding President of Tómatelo a Pecho, A.C, and Senior Economist for FUNSALUD. HAO reports research grants from MerckKGaA/EMD Serono via the University of Miami. XK and AB report consulting fees from the University of Miami Institute for the Advanced Study of the Americas for part of the submitted work and consulting fees through a research grant from the Medical Research Council to the University of Edinburgh for work related to palliative care outside the submitted work. AB also reports Honoraria from Memorial Sloan Kettering for presentation and Recipient of Fulbright U.S. Scholar Teaching and Research Award from the Bureau of Educational and Cultural Affairs, U.S. Department of State related to palliative care and outside of submitted work. SRC reports paid employment as executive director from Worldwide Hospice Palliative Care Alliance; Royalties from Routledge Publishing for book “Hospice and Palliative Care: The essential guide, 3rd ed” (2017 - present); Honoraria for Plenary at annual meeting 2023 from Hong Kong Jockey Club; Travel reimbursement for speaking 2023 from Hong Kong Jockey Club; International children's Palliative Care Network Board member (non-paid); Elisabeth Kubler-Ross Foundation Board member (non-paid); International Work Group on Death, Dying, & Bereavement Board member (non-paid); Mt Sinai Hospital, National Palliative Care Research Center Scientific Advisory Board member (non-paid); Journal of Pain & Symptom Management Editorial Board (non-paid); Public Health & Palliative Care International Member Ex-officio Board Member (non-paid). LDL reports Executive Director, International Association for Hospice and Palliative Care. WER partially supported by NCI/NIH Comprehensive Cancer Center Award P30CA008748; receives book royalties from Springer Publishing, Jones & Bartlett Learning, and Oxford University Press. LR reports Chair of the Board of Directors of the International Association for Hospice and Palliative Care. All other authors declare no competing interests. We would like to thank the participants in the expert panels who contributed to the estimates of opioid needs for adults and children. We are also grateful to Abigail Schcolnik and Paul Vila for their research support. We also thank The Tecnológico de Monterrey (Challenge-Based Research Funding Program, I036- IOR005-C5-T3-T) and the The Ibero-American General Secretariat (SEGIB) and the European Union (Memorandum of Cooperation: DJ-TM-GSL/ITESM-INV/2024-030) and the University of Miami Institute for Advanced Study of the Americas for financial support.

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