Disparities and crisis: access to opioid medicines in Mexico
Authors: Felicia Marie Knaul
Journal: The Lancet Public Health (2021)

The Lancet Commission on Palliative Care and Pain Relief report1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar identified an extensive, global gap between need and access that has been ignored in global health and overlooked in the quest for universal health coverage. Our Commission found that, while high-income countries tend to stock much more opioid medication than needed, most low-income and middle-income countries (LMICs) have access to only a small proportion of the medication required for palliative care to relieve serious health-related suffering (SHS).1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar Only 1% of opioid medicines—measured in distributed opioid morphine equivalent—are found in the countries in which the poorest 50% of the global population reside. By contrast, 90% of these medicines are kept in the wealthiest 10% of countries. Mexico, an upper-middle-income country that is widely recognised as a pioneer in universal health coverage, served as an anchor country for the Lancet Commission analysis because of the availability of robust data and the depth and breadth of policy initiatives.1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar, 2The EconomistUniversal health care, worldwide, is within reach.https://www.economist.com/leaders/2018/04/26/universal-health-care-worldwide-is-within-reachDate: Apr 26, 2018Date accessed: December 19, 2020Google Scholar, 3Knaul FM Gonzàlez-Pier E Gómez-Dantés O et al.The quest for universal health coverage: achieving social protection for all in Mexico.Lancet. 2012; 380: 1259-1279Summary Full Text Full Text PDF PubMed Scopus (320) Google Scholar Although Mexico is in a far better position than many other countries worldwide, the Lancet Commission measured distributed opioid morphine equivalent using data from the International Narcotics Control Board, and found that Mexico stocked only a third of the opioids needed for palliative care and less than 5% of the opioids required to meet overall need between 2010 and 2013.1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar In The Lancet Public Health, David Goodman-Meza and coauthors4Goodman-Meza D Friedman J Kalmin MM et al.Geographical and socioeconomic disparities in opioid access in Mexico, 2015–19.Lancet Public Health. 2020; 6: e88-e96Summary Full Text Full Text PDF Scopus (7) Google Scholar provide an update on opioid access in Mexico in 2019, using novel prescription surveillance data from the Federal Commission for the Protection against Sanitary Risk (COFEPRIS). The authors demonstrated that access to opioid medications increases significantly with the socioeconomic status of the state (rate ratio [RR] 1·88, 95% CI 1·33–2·58, p=0·00016)—when comparing states with very high socioeconomic status with those with very low socioeconomic status, they observed a ten-times higher level of access (RR 10·45, 2·56–44·15). The innovative analysis by Goodman-Meza and colleagues demonstrates that the abyss in access across countries is compounded by gross inequities within them. Such analyses should be replicated wherever data are available. Linking access to opioid medication to policy change is important because palliative care and pain relief are too often ignored when assessing universal health coverage. Mexico declared universal health coverage in 2012, based largely on the effective extension of social protection in health through the national health-care programme, Seguro Popular.3Knaul FM Gonzàlez-Pier E Gómez-Dantés O et al.The quest for universal health coverage: achieving social protection for all in Mexico.Lancet. 2012; 380: 1259-1279Summary Full Text Full Text PDF PubMed Scopus (320) Google Scholar However, universal health coverage is unattainable without addressing one of the most basic and essential elements of care—the relief of pain and suffering—and evidence indicates that this element is sorely lacking in Mexico, similar to most other LMICs. The gap between universal health coverage and access to palliative care and pain relief in Mexico rapidly became obvious due to the work of an interinstitutional group, which included representation from the executive and judicial branches of the Mexican Government, civil society and academia, the work of Human Rights Watch,5Lohman D García AH Care when there is no cure. Human Rights Watch, New York, NYOct 28, 2014https://www.hrw.org/report/2014/10/28/care-when-there-no-cure/ensuring-right-palliative-care-mexicoDate accessed: December 19, 2020Google Scholar and the launch of the Lancet Commission.1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar In response, considerable progress was made on the legislative, policy, and programmatic fronts between 2014 and 2019.1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar, 4Goodman-Meza D Friedman J Kalmin MM et al.Geographical and socioeconomic disparities in opioid access in Mexico, 2015–19.Lancet Public Health. 2020; 6: e88-e96Summary Full Text Full Text PDF Scopus (7) Google Scholar For example, the Mexican Ministry of Health issued the detailed technical regulations required to make existing laws operational in 2014,6Diario Oficial de la FederaciónNORMA Oficial Mexicana NOM-011-SSA3-2014, Criterios para la atención de enfermos en situación terminal a través de cuidados paliativos.https://www.dof.gob.mx/nota_detalle.php?codigo=5375019&fecha=09/12/2014Date: Dec 9, 2014Date accessed: December 7, 2020Google Scholar and subsequently devoted increased administrative resources, promoted physician training, and increased data collection. In 2015, COFEPRIS changed policy from allowing only complex, paper prescribing for controlled medicines, to electronic prescribing. As of 2016, the Seguro Popular programme, which provided public health insurance for more than 50 million Mexicans and focused on the poorest populations, explicitly included pain relief and palliative care in the basic package to be provided at primary and secondary levels of care.7Comisión Nacional de Protección Social en SaludSeguro PopularSecretaria de SaludCatálogo Universal de Servicios de Salud, Causes 2018. Comisión Nacional de Protección Social en Salud, Mexico City2018http://www.documentos.seguro-popular.gob.mx/dgss/CAUSES_2018c.pdfDate accessed: January 13, 2021Google Scholar However, on the basis of the data from COFEPRIS, Goodman-Meza and colleagues4Goodman-Meza D Friedman J Kalmin MM et al.Geographical and socioeconomic disparities in opioid access in Mexico, 2015–19.Lancet Public Health. 2020; 6: e88-e96Summary Full Text Full Text PDF Scopus (7) Google Scholar showed that these extensive policy efforts did not translate into a significant increase in access to pain medication. Although opioid dispensing increased steadily from 2015 to 2019, the increase was small and unequally distributed across the country, which was likely to have been compounded by extreme existing inequities in access to palliative care. 2020 was a landmark year for access to pain medication for several reasons—none of them positive. The Seguro Popular programme was dismantled in January, 2020, leaving most Mexicans, especially the poor and unsalaried workers who lack access to social security, without publicly funded insurance.8Frenk J Gómez-Dantés O Knaul FM Arreola-Ornelas H Salud: Focos Rojos: Retroceso en los tiempos de la pandemia. Debate, Mexico City, Mexico2020Google Scholar, 9Reich MR Restructuring health reform, Mexican style.Health Systems and Reform. 2020; (published online Jun 22.)https://doi.org/10.1080/23288604.2020.1763114Crossref Scopus (26) Google Scholar Furthermore, the closure of the Seguro Popular programme was done without establishing the replacement—the Instituto de Salud para el Bienestar (INSABI)—leaving the health system in a precarious state.8Frenk J Gómez-Dantés O Knaul FM Arreola-Ornelas H Salud: Focos Rojos: Retroceso en los tiempos de la pandemia. Debate, Mexico City, Mexico2020Google Scholar, 9Reich MR Restructuring health reform, Mexican style.Health Systems and Reform. 2020; (published online Jun 22.)https://doi.org/10.1080/23288604.2020.1763114Crossref Scopus (26) Google Scholar The absence of clarity regarding the coverage and operation of INSABI continues, and by extension, little is known about how palliative care and pain relief will be provided or financially covered in the future. 4Goodman-Meza D Friedman J Kalmin MM et al.Geographical and socioeconomic disparities in opioid access in Mexico, 2015–19.Lancet Public Health. 2020; 6: e88-e96Summary Full Text Full Text PDF Scopus (7) Google Scholar, 9Reich MR Restructuring health reform, Mexican style.Health Systems and Reform. 2020; (published online Jun 22.)https://doi.org/10.1080/23288604.2020.1763114Crossref Scopus (26) Google Scholar In addition to the demise of Seguro Popular and the disruption in health-care supply that was subsequently created, conditions in Mexico worsened considerably as of March, 2020, when the COVID-19 pandemic began. COVID-19 caused a sudden increase in SHS and resulting demand for opioid medicine to relieve dyspnoea and thoracic pain (Allende S, National Cancer Institute of Mexico [Mexico City, Mexico], personal communication).10Radbruch L Knaul FM Lima LD Joncheere CD Bhadelia A The key role of palliative care in response to the COVID-19 tsunami of suffering.Lancet. 2020; 395: 9-15Summary Full Text Full Text PDF Scopus (134) Google Scholar The experience of the palliative care unit of the National Cancer Institute of Mexico illustrates that as a result of the fixed and very limited supply in Mexico, the availability of various essential opioid medicines decreased for patients with cancer and other patients in need (Allende S, National Cancer Institute of Mexico, personal communication). These decreases in access coincided with challenges in local production as one of the major suppliers of opioid medicines was sanctioned. All of these factors contributed to a scarcity of opioid medicines that resulted in excess suffering for patients and their families in Mexico, a country where the COVID-19 syndemic continues unabated.11University of Miami Observatory for the Containment of COVID-19 in the Americas. Mexico. Public Policy Adoption Index.http://observcovid.miami.edu/mexico/Date accessed: December 19, 2020Google Scholar, 12Institute for Health Metrics and EvaluationCOVID-19 projections: Mexico.https://covid19.healthdata.org/mexico?view=total-deaths&tab=trendDate accessed: December 19, 2020Google Scholar While the resources required to tackle the pandemic could not have been foreseen, if government actors had made policy changes based on the evidence put forward by the Lancet Commission1Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief–an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (442) Google Scholar and Human Rights Watch,5Lohman D García AH Care when there is no cure. Human Rights Watch, New York, NYOct 28, 2014https://www.hrw.org/report/2014/10/28/care-when-there-no-cure/ensuring-right-palliative-care-mexicoDate accessed: December 19, 2020Google Scholar they could have been better prepared to facilitate guaranteed access to pain relief and palliative care. Going forward, coverage and access to pain relief should be a priority for policy makers to alleviate immediate and future SHS. Monitoring access to opioid medicines is essential to ensure that pain and suffering, especially among the poorest populations, is neither ignored nor neglected. I report personal fees from Merck KGaA; grants from Roche, Vitas Healthcare, and Chinoin; travel expenses from the Grunenthal Foundation; and grants to civil society organisations with whom I collaborate from Merck MSD, Pfizer, Novartis, and Grunenthal, outside the submitted work. I also served as the Chair of the Lancet Commission on Palliative Care and Pain Relief. I would like to thank Héctor Arreola-Ornelas, Silvia Allende, and Sonia Xochitl Ortega Alanis for providing important background ideas that were incorporated into this paper, Renu Sara Nargund for excellent research assistance, and Stephanie Sutherland for support in developing an outline. Geographical and socioeconomic disparities in opioid access in Mexico, 2015–19: a retrospective analysis of surveillance dataMeasures introduced by the Mexican federal Government to increase opioid access for patients with palliative care needs were only marginally successful in raising opioid prescription rates. Opioid access should be improved for patients with palliative care needs who live in geographical areas of lower socioeconomic status. Full-Text PDF Open Access