Access to controlled medication

[Guest guest]

Hi Bashaar,

Pleasure to hear from you in Afghanistan. I remember you taking keen

interest in this topic during 2007 TBS at WHO HQ Geneva. We look

forward to hearing from you.

Joining me for WHO funded RUM course at IIHMR Jaipur, India from 23

March 2008 to 3 April?

Vijay

> Dear Dr Mangesh,

>

> Thank you for the elaborative post documenting important issues

regarding unavailability or difficult access to controlled drugs,

and existing situation in India, Here are some reasons why the

access to controlled medicines is big problem.

>

> For many people, pain is part of their daily life. Every minute

they are reminded of it; there is no means of escape. It is thing to

wonder why so many people do not have access to analgesia and have

to suffer so much pain. Although unavailability of drugs may deprive

patients of their fundamental rights and the opportunity for relief

from pain, excessive availability of drugs may result in the

diversion of such drugs to illicit trafficking and in drug abuse,

leading to drug dependence, and may thus cause unnecessary

suffering.

> The extent of the medical use of drugs, including controlled

substances, depends on many factors and variables. The economic and

social conditions in a country, together with the importance

accorded to health care, determine to a large extent the national

capacity and ultimately the availability of medicines in general.

The effective functioning of regulatory controls is also an

important factor.

> Figures for global consumption of drugs show that the bulk of

the medicine continues to be consumed in a handful of countries, and

the proportion is even higher for narcotic drugs and psychotropic

substances. Economically weak countries and the poorer segments of

society continue to have little or no access to medicines.

> Important factsà

> Based on INCB(international narcotics control board) reports,

the WHO estimated in 2006

> Ø 80% of cancer patients have no access to pain relief

medication.

> Ø ~ 10.9 million new cancer cases worldwide,

> Ø ~ 24.6 million people alive with cancer (within three

years of diagnosis) .

>

> Why are opioids and other analgesics not accessible to

palliative care patients.

> Reasons for the lack of availability could be categorised as:

> 1. Excessively strict national laws and regulations.

> 2. Fear of addiction, tolerance and side effects.

> 3. Poorly developed healthcare systems and supply.

> 4. Lack of knowledge – HCWs(health care workers), public

and policy markers.

>

> Excessively strict national laws and regulations.

>

> 1. Process requires several forms, special licenses and/or

authorization stamps which are time consuming and/or difficult to

acquire and thus deter HCWs from prescribing opioids. Palliative

care doctors have a right to prescribe morphine but cannot obtain it

if they work in a hospital which is not registered in the MoH

(ministry of health) as a medical organization.

> 2. Length of supply allowed is short requiring repeated

procurement – which are potentially expensive, a long way and

difficult. For example, In Malawi (African country)only three days

supply of analgesics are dispensed.

>

> 3. Lack of HCWs qualified to prescribe controlled drugs. In

India (Tamil Nadu),Mongolia, Peru only specialist palliative care

or oncology doctors are allowed to prescribe morphine. In the

Philippines only doctors with two special licenses are able to

prescribe morphine.

>

> Fear of addiction, tolerance and side effects

> In Africa over 50% professional feel that patient will become

addicted to morphine and other opioids. High percentage all fear of

acquisition of misusing it if they prescribe or dispense it.

>

> Poorly developed healthcare systems and supply

>

>

> - Poor access to health centers/doctors owing to distance,

expense,

> - Poor access to health centers/owing to preference for

traditional/local medicines, treatments.

> Morphine is not available continuously.

Small amount imported and next order placed after finishing and

reporting previous supply. Drug importer does not inform the health

centres about the arrival of the next supply. Thus there is a long

period of drug absence because waiting for importing and informing.

> Other factor is the cost. In some

countries, morphine (and all the other opioid analgesics, eg

oxycodone, hydromorphine, fentanyl) is available readily to private

patients but, owing to expense, only rarely available to non-private

patients.

>

> Lack of knowledge – HCWs(health care workers), public and policy

markers

> Lack of knowledge on pain assessment, how to control pain and/or

use and titration of oral morphine, lack of training/interest in

palliative care. It is very strange that oral morphine is not

available sometimes whereas expensive fentanyl patches can be made

available for the rich patients. Lack of doctors training, awareness

and cure orientated approach of the society as well as of the

medical community makes palliative medicine away from the reach of

people needing it more.

> Also lack of undergraduate training in pain treatment,

palliative care and use of opioids.

> As an undergraduate: 82% of HCWs in Latin America and 71% of

HCWs in Asia had no training on pain or opioids.

> Opinions from the members are awaited..

>

> Regards,

> Dr Deepali

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