China con­sid­ers up­ping its painkiller dosage

The painkillers work, but the Chi­nese worry about ad­dic­tion Af­ter a drug bot­tle broke, “we ... each had to write a self-crit­i­cism”

Bloomberg Businessweek (Asia) - - CONTENT - −Bruce Ein­horn and Hui Li

More than most coun­tries, China has good rea­son to be wary of opi­oids, syn­thetic drugs like Oxy­Con­tin that share opium’s power to sup­press pain. In the 19th cen­tury the na­tion lost two wars to the Bri­tish in a fu­tile at­tempt to keep opium out of the coun­try. Af­ter the de­feats, part of what the Chi­nese call their cen­tury of hu­mil­i­a­tion, millions of peo­ple be­came addicted to the drug: In the early 1900s more than 25 per­cent of Chi­nese men used opium reg­u­larly. One of the gov­ern­ment’s proud­est achieve­ments af­ter the com­mu­nists took power in 1949 was wip­ing out “the scourge of opium,” as China’s State Coun­cil put it. Partly out of that his­toric sen­si­tiv­ity, China today re­stricts the use of opi­oids far more tightly than the U.S. and other West­ern coun­tries.

China’s aver­sion to opi­oids is part of a global puz­zle: How do hos­pi­tals, health min­istries, and pharma com­pa­nies use these pow­er­ful painkillers ef­fec­tively with­out lay­ing the ground­work for se­ri­ous abuse and ad­dic­tion? No­body has the an­swer. In­stead the world’s use of opi­oids is se­ri­ously lop­sided, as the

UN-linked In­ter­na­tional Nar­cotics Con­trol Board re­ported in Fe­bru­ary. Al­most all of the world’s opi­oids are con­sumed in North Amer­ica, Europe, Aus­tralia, and New Zealand. The U.S., fac­ing an epi­demic of pre­scrip­tion painkiller abuse, con­sumed 43,879 de­fined daily doses (a stan­dard unit for mea­sur­ing drug con­sump­tion) of opi­ates per mil­lion peo­ple in 2011-13, while China con­sumed just 91.

The Chi­nese to­tal was more than triple that of a decade ear­lier, a sign that at­ti­tudes are chang­ing. For com­pa­nies that make painkillers, China is a po­ten­tial prize. The global opi­oids mar­ket was $34.9 bil­lion in 2015, ac­cord­ing to a re­port by Per­sis­tence Mar­ket Re­search, a con­sul­tant and re­searcher, and de­mand will grow 3.2 per­cent an­nu­ally from 2015 to 2021. Chi­nese will use 76.86 mil­lion grams of nar­cotic drugs this year, ac­cord­ing to the INCB, a frac­tion of the 1.36 bil­lion grams Amer­i­cans will take. When it comes to treat­ing pain, “China has made progress, but it’s still sig­nif­i­cantly be­hind,” says Dr. James Cleary, a pro­fes­sor at the Univer­sity of Wis­con­sin School of Medicine and Pub­lic Health, where he is di­rec­tor of the Pain & Pol­icy Stud­ies Group.

The gov­ern­ment in China knows it needs to al­low doc­tors to pre­scribe more painkilling drugs to pa­tients, es­pe­cially those with cancer. China ac­counts for 22 per­cent of new cancer cases world­wide, and to­tal cancer deaths in the coun­try in­creased 74 per­cent from 2006 to 2015. “As peo­ple’s qual­ity of life im­proves, they won’t just suf­fer through the pain,” says Dr. Huang Bing, a pain spe­cial­ist at Ji­ax­ing City First Hospital in Zhe­jiang prov­ince. “They nat­u­rally want to buy bet­ter ser­vice and painfree health care.”

The strict con­trols stem in part from a se­ri­ous so­cial prob­lem. “I think it has to do with the fact that there are many drug abusers in China, and some of these peo­ple may try to ob­tain these in­jectable nar­cotic painkillers,” says Dr. Ni Ji­ax­i­ang, di­rec­tor of the pain cen­ter at Bei­jing’s Xuanwu Hospital. China had more than 3.2 mil­lion reg­is­tered drug ad­dicts in 2015, ac­cord­ing to the of­fi­cial Xin­hua news agency, and more than 14 mil­lion Chi­nese have abused nar­cotics at some point. The state-run me­dia fre­quently pub­lish sto­ries about the abuse of heroin, crystal meth, and ke­tamine, a vet­eri­nary medicine that’s used recre­ation­ally.

So, while the gov­ern­ment is en­cour­ag­ing lo­cal drug com­pa­nies to do more re­search and devel­op­ment on opi­oids, says Zhen­jiang Yue, chief ex­ec­u­tive of­fi­cer of Aox­ing Phar­ma­ceu­ti­cal, the of­fi­cial ap­proach to pre­scrip­tion painkillers “is still very re­stric­tive.” Aox­ing last year re­ceived a li­cense to make ti­li­dine opi­oid tablets, a painkiller widely used in Ger­many.

In China, out­pa­tients are al­lowed pre­scrip­tions for no more than seven days’ worth of reg­u­lar nar­cotics. Cancer pa­tients can get pre­scrip­tions for up to 15 days but must first re­ceive a doc­u­ment from a qual­i­fy­ing hospital cer­ti­fy­ing that they need treat­ment us­ing nar­cotics. To keep track of the drugs, doc­tors who ad­min­is­ter in­jectable opi­oids must re­turn the empty drug vials. “Once, we ac­ci­den­tally broke a used bot­tle, and the doc­tor, the hospital man­ager, and I each had to write a self-crit­i­cism,” says Ni.

Ex­perts in the state-con­trolled me­dia have been writ­ing ed­u­ca­tional ar­ti­cles about the need for opium-de­rived drugs in pain treat­ment. In Septem­ber, China’s Na­tional Health and Fam­ily Plan­ning Com­mis­sion called for an in­creased fo­cus on pain man­age­ment. Chi­nese doc­tors are get­ting the mes­sage “loud and clear that cancer pain has to be ad­e­quately con­trolled,” says Dr. Frieda Law, a con­sul­tant at Shan­tou Univer­sity Med­i­cal Col­lege.

The Chi­nese may be do­ing the right thing in pro­ceed­ing cau­tiously. Pain is a se­ri­ous is­sue, but so is ad­dic­tion to these po­ten­tially life-de­stroy­ing drugs. More Amer­i­cans die from opi­oid over­doses than traf­fic ac­ci­dents, Pres­i­dent Obama said in a March 29 sum­mit on pre­scrip­tion drug abuse. “You see an enor­mous on­go­ing spike in the num­ber of peo­ple who are us­ing opi­oids in ways that are un­healthy,” he said, “and you’re see­ing a sig­nif­i­cant rise in the num­ber of peo­ple who are be­ing killed.”

Fac­ing grow­ing op­po­si­tion from Amer­i­can politi­cians to the over­pre­scrip­tion of opi­oids in the U.S., drug­mak­ers hope chang­ing at­ti­tudes else­where about pain will fuel growth in un­der­served coun­tries such as China. That wish may be com­ing true. Oxy­Con­tin maker Mundipharma had about $100 mil­lion in China sales last year, a 45 per­cent in­crease over 2014. At a growth rate like that, China will soon have a lot more opi­oids—and per­haps more prob­lems, too.

The bot­tom line Global opi­oid sales are $34.9 bil­lion a year, but if China loosens its re­stric­tions, the mar­ket will grow much more.

The U.S. used opi­oids at more than 14 times theglobal av­er­age

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