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 pain-free 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.