Background The INCB oversees international drug law with a remit of restricting illicit access to opioids whilst enabling access for medical use. Two opioid crises are present under its jurisdiction. One relates to dependence and abuse the other to inadequate supply for clinical purposes globally.

Methods Systematic analysis to investigate the discourse of the INCB through language used regarding opioids in a sample of Annual Reports, 1968–2018. Key terms (narcotic, opiate, opioid, analgesia) were retrieved. Two coding phases developed themes. Frequencies per1000 words of themes and terms, overall and by decade.

Results 5 themes from 3 domains: Abuse and Dependency, Illegal Trade (illicit), Policy and Enforcement (illicit and therapeutic), and Access for Therapeutic Use, Estimates of Need (therapeutic). For 50 years focus has been on Illegal Drugs and Abuse and Dependency; less attention to Access to Opioids for Therapeutic use and Estimates of Requirements.

Discussion The INCB must focus on improving availability of therapeutic opioids to reduce suffering safely and effectively. Evidence based approaches to measuring population level need for opioids are urgently required.