In 1996, the following barriers to adequate pain management in Mexico were reported:¹³

• poor availability of frequently used opioids
• poor communication among health care professionals, health policy makers, drug regulators and drug manufacturers on the needs for opioids for cancer pain control
• severe legal restrictions imposed on pharmacies by the government concerning the storage and dispensing of opioids
• bureaucracy and delays in policies making
• the need for importing most recommended strong opioids
• lack of interest in the government and pharmaceutical industry concerning the manufacture of opioids in order to make them more readily available in the country
• lack of medical knowledge and experience on the prescription of strong opioids

In 2004, Dr. Argelia Lara describes:

“… we are lucky enough to have morphine and other strong opiates; a few years ago we did not have this facility. Currently in Mexico, morphine can be obtained in two formulations, oral and parenteral. [The oral route is the most frequently used]. [There are several different presentations] but we have not got a great variety in terms of dose formulations and this is a limitation. For instance, we do not have syrup or solution of morphine. [There is a parenteral solution of morphine that allows its subcutaneous or intravenous administration; we also have a special presentation of morphine for its spinal use] Morphine remains our basic medicine and this is very much because of costs. And also the patient can use it in a more flexible way than other type of opiates. We have got other opiates that are worth mentioning. Recently, [about] six months ago, hydromorphone and methadone were introduced into Mexico, both available in oral formulations only. From several years now, we have had other medicines, such as fentanyl patches and fentanyl for injections. We have had sub-lingual tablets of buprenorphine and buprenorphine for injections for at least ten years. We have also had nalbuphine and of course weak opioids such as tramadol, codeine, dextropropoxyphene [either alone or in combination with paracetamol or NSAIDs in normal- and slow-release tablets]”.¹⁴
NB: interview transcription edited by Dr. Argelia Lara (29-09-04).

Ms. Beatriz Montes de Oca, nurse in palliative care and founder of Hospice Cristina in Guadalajara in Jalisco in the Mexican western coast, speaks as follows about barriers to adequate opioid availability and attitudes towards the use of opioids:

“… in the city of Guadalajara there are only three pharmacies in the whole city where opioid medicines can be obtained. These pharmacies are opened only in the morning, not over night neither during week ends. Three or four days beforehand, we have to anticipate the morphine we will need for our patients before we have used all of it. But pharmacies do not want to assume this responsibility [of storing and selling opioids] because they believe that it is going to be a big problem, because it [morphine] can be stolen, because patients will become addicts and it is much terror what it is felt in Mexico, more than anything else. I had the need for letting physicians working in the private sector know about using opioids because they are the most concerned about [using opioids]. In public hospital, they can administer them [opioids] very well, but they [opioids] do not exist in private hospitals. It was one thing that caught my attention: to see so many patients in intensive care units, that they [physicians] do not want to use morphine, that they [patients] are dying “of pain”, that we can diminish that pain and that the doctor keep a closed mind towards using these opioids”. ¹⁵

Graph 2 shows the average daily consumption of Defined Daily Doses (DDD)¹⁶ of morphine per million inhabitants during the years 1994-1998 for Central American and Caribbean countries according to the world requirement estimates for 2000 of the International Narcotics Control Board (INCB) (Statistics for 1998).¹⁷

Graph 2. Average daily consumption of DDD of morphine per million inhabitants in countries of Central America and the Caribbean for the 1994/1998 period. Global consumption of principal narcotic drugs International Narcotics Control Board (2000) Narcotic Drugs: Estimated World Requirements for 2000. New York: United Nations.

According to these figures, Mexico is seventh in the region. The highest numbers correspond to Costa Rica and Cuba. The average daily consumption of DDD of morphine per year has been suggested as an indicator of adequate pain relief and palliative care developments in the country.¹⁸

Although, from a legal viewpoint, improvements in opioid availability have been made in Mexico during the last decade, these achievements have not been translated into medical practice yet. In this sense, Dr Mayer points out:

"The reality is that, if we look at trends on this [opioid] consumption in defined daily doses, they have remained stable; they haven’t increased as they should. And, in fact, in relation to the volume of population in our country compared against the population of other Latin American countries, we are using morphine very much below the amount we should be using, which is the standard measure. And there are many reasons for this situation”¹⁹