Gilberto Gerra, UNODC: At the 60th session of the CND we will organise a special event on access to essential medicines, alongside a large number of UN agencies. Palliative care is not only an issue about drugs, it’s an issue focusing on improving the quality of life of the patients. It is a complex problem that needs a holistic approach. We need the medication. Morphine is very cheap but 80% of the planet doesn’t have access for the treatment of pain which is unacceptable. Let me give you a conclusion here – we must better interpret the convention, we must invest on training of authorities and health practitioners and we must change public opinion. We must also address the abuse of these medications. Practitioners should be trained to recognise this population at risk to appropriately prescribe that medication and avoid misuse and diversion. Now you can genotype people to know which people are most at risk of drug abuse.
UNODC: We have been looking into operationalising the UNGASS outcome recommendations which detail 3 vulnerable populations: women, children & the elderly. There exist considerable barriers to treatment and strategies, identified by regional & national reviews. These findings can then be applied to a wider level. Access to essential medicines often viewed as a health or regulatory issue – should be seen as both. Work should look to map healthcare systems, in Panama, for example, excellent provision in oncology, poor provision in emergency care. Broaden focus to increase the number of access points. Provide guidelines about core competency and training. Outcome document recommendations may seem trivial but are complex at a national level:
- Affordability – each country should have the ability to source essential medicines.
- Distribution, availability of generics and penetrance of rural areas.
- National capacity – UNODC relies on partnership with WHO to increase capacity for health authorities and develop clinical guidelines.
- Regarding palliative care – issues exist surrounding supply chain. How do countries select medicines? Procure them? Store them?
To address the confusion over essential vs controlled medicines. Essential is a list of medicines which all countries should have access to. A subset of essential medicines are controlled medicines. Our work is to look at the differences between the two, and increasing access to all medicines – not just controlled! Would like to mention ongoing partnering with civil society organisations. None of the interventions would be possible without working with CSO. To close: “The greatest evil is physical pain” – this should be viewed from a humanitarian angle and efforts should be stepped up!
INCB: There is a need to review domestic legislation, streamline existing workflows, remove restrictive regulations, and make issuing of prescription and represcriptions easier. All this needs to be done while maintaining proper control. Many countries before and after UNGASS have started this process. Mexico introduced a new morphine regulatory system with an online component in June 2015, which reduced the time of access from 30 to 3 days and allows the country better to monitor prescription. UAE & NZ have also gone electronic. It is crucial to ensure while there is control of these substances, there is also access to these medicines. In Uganda, the base of prescription has been broadened – nurses in rural areas are permitted to prescribe morphine in the absence of doctors. Extensive paperwork required by conventions is cumbersome and prevents procurement. INCB with UNODC have developed a platform which facilitates this process by eliminating paperwork between importers and exporters. For this to work, more member states must sign up (i.e. both sides of the selling chain). To address affordability, members states must cooperation with the private sector and look towards the manufacture of generics. Regarding distribution – controlled medicines needs to reach rural areas. In Rwanda, morphine powder is imported and the syrup made locally. This is then free of charge to patients. Capacity building : April 2016, training with 9 countries in Kenya, Bangkok with 19 countries, and a plan is in place for West Africa. E-learning modules are being made available for those not capable of attending in person. Importance of supply and management systems at a national level. Guidance provided by INCB & WHO.
Malta, on behalf of the European Union & Turkey, Macedonia, Montenegro, Serbia, Albania, Bosnia + Herzogovina, Ukraine, Moldova, Andorra and Armenia:
I will start by reiterating the fact that, in regard to items 44 to 46 of the remarks of H.E. Ambassador Pedro Moitinho de Almeida, which in effect are a proposal for a way forward, the EU and its Member States fully support the three recommendations pertaining to, action that could be taken by the CND to support Member States in the implementation of the UNGASS operational recommendations, reviewing the work of the UN subsidiary bodies in order that they are able to better support the implementation of operational recommendations of the outcome document at regional level, and finally, to strengthen the use of the CND post UNGASS website.
The EU and its Member States are fully cognisant of the importance of the access and availability of essential medicines such as opiates medications in the treatment of pain and opioid dependence whilst also acknowledging the potential for the diversion of these medications for use other than that legally stipulated. The underlying framework of the International Drug Control Treaties provides for adequate availability of narcotic and psychotropic substances for medical and scientific purposes.
The EU and its Member States are committed to facilitating access and availability of controlled substances whilst also acknowledging the need to have in place measures to prevent diversion, and fully support the principle of provision of the necessary up to date information, be it technical and /or scientific, to better enable the CND to take informed and co-ordinated scheduling decisions. All such information, namely, that related to prior to a scheduling decision and that related to following a scheduling decision, will need to be uploaded on the CND portal to better inform countries on the rationale for such, and thus assist them in implementing the operational recommendations of the UNGASS outcome document in relation to chapter 2 of the said document.
The EU and its Member States consider that the CND should examine how its subsidiary bodies can better contribute to the implementation of the UNGASS outcome document, including through the regular exchange of information, good practices and lessons learned among national practitioners from different fields. We should also consider additional measures to further facilitate meaningful discussion among those practitioners. We welcome the fact that a working group on this topic has already been created following the UNGASS outcome document.
It is also important for CND to work with the other UN entities in this area, such as INCB and WHO, given their relevant expertise in this field. A concrete example would be the WHO/UNODC/UICC Joint Program on increasing access to controlled medicines for medical purposes. Joint CND events with the World Health Assembly and coordination meetings with the WHO could also address the issue of access and availability of these controlled substances.
The EU and its Member States are only too ready to support the CND in its efforts to make accessible and available such controlled substances together with the need to equally support the control systems in place to deter the diversion of such.
Thank you, Chair.
Belgium: Belgium aligns with the EU statement. Speaking in a national capacity: in 2016, Belgium joined the Joint Global Programme to increase access to essential medicines – a programme which coordinates the work of UNODC, WHO, UICC. In 2017, we convened a policy dialogue on essential medicines – Government public health officials met the UNODC & WHO in Brussels which allowed for exchange of views on UNGASS chapters. In addition, there was a technical meeting (health and development experts with palliative care NGOs) which discussed the state of play and current challenges.
Russia: CND should concentrate on issues solving access to controlled substances all the while ensuring quality, safety & effectiveness. It is of particular importance to take into account financial issues. Disaster and emergency areas & armed conflict areas should have access. In this digital age, states should make use of e-systems for prescriptions and further help expanding distribution networks.
Colombia: CND should support a regular publication of a list of essential medicines. CND should have more regular information sessions to make better informed decisions. It is Columbia’s opinion that the work of this expert group should be further built up and the WHO guides for essential medicines brought up to date.
Kseniia Shapoval-Deinega, International Renaissance Foundation: On behalf of the NGO coalition for balanced drug policy in Ukraine “With respect to human dignity” and on behalf of the International Renaissance Foundation, let me thank The Commission on Narcotic Drugs (CND) and United Nations Office on Drugs and Crime (UNODC) for the Outcome Document recommendations and also for the involvement of civil society in the process of its preparation and implementation. I was honored to be a member of the Ukraine delegation to CND last year, and to the UNGASS in April. Speaking as a member of the official delegation, I have to note that the involvement of public health specialists and NGO representatives in the work of the delegation and in parallel sessions within the special session, made it possible to implement a balanced approach to access to controlled medicines in Ukraine. In particular, to look at the problem not only in terms of the fight against drugs, but also in terms of human rights.
The Ukrainian National Preventive Mechanism is an ‘Ombudsman Plus’ model, composed of staff from the NPM Department under the Office of the Ukrainian Parliament Commissioner for Human Rights and civil society representatives. There are more than 200 civil monitors regularly visiting places of detention as part of the NPM. The involvement of civil society in the NPM work has been crucial to be able to monitor the large number of places of detention in the country and to conduct research on specific thematic areas.
What does this have to do with controlled medicines, you might wonder? In 2015, the NPM also started to monitor hospices and palliative care departments within hospitals, which are considered to be places of deprivation of liberty as the majority of patients do not give their consent for hospitalisation and treatment. More than 50% of patients of these establishments do not have access to pain relief; patients are being kept in terrible material conditions, in agony without appropriate medication. Their report stated that such deprivation without appropriate treatment with controlled medicines is equivalent to torture and that palliative care and pain medicine restore liberty to persons whose pain has previously been uncontrolled. Patients needing adequate pain relief at home also suffer, although Ukraine has one of the most liberal regulation of controlled medicines use in Eastern Europe. Testimonies, collected in 2016 in Ukraine, within our joint research with Human Rights Watch, are evidence of systemic problems with the prescription and use of controlled medicines in Ukraine.
We urge policymakers, patients, their relatives and lawyers, to speak out about the problem of access to pain relief. We would like to ask decisionmakers who maintain that the problem of lack of access to pain medicine is overstated – to get out of their offices and take off their rose-colored glasses. We turn to CND and colleagues from NGOs, asking to distribute WHO guidelines on treatment of cancer pain, to base their work on the principles of evidence-based medicine, and to heed the voices of seriously ill patients who need our support, access to pain relief and preservation of human dignity. Palliative care is not about someone else, it is about all of us and our families. We also recommend that you include public health experts on your delegations to CND so that they can help your countries develop a balanced approach to drug policy.
Peru: Access to controlled medicines is an important issue. We recommend analysis based on knowledge exchange of existing mechanisms. We must investigate precursors or psychoactive substances which constitute a threat and prevent their diversion to non-medical purposes.
USA: The USA sees work being done as a strong example of international collaboration in drug policy. INCB has an important role in raw material provision. Tripartite collaboration (WHO/UNODC/UICC) – help healthcare providers to give patients the treatment they need. Keep this issue on CND’s agenda.
China: Conducting survey on access to essential medicines with the focus of reducing suffering of patients. International community should pay attention to insufficient supply in some countries but also to drug abuse and illicit diversion. CND and UNODC should support balance between these two aspects. China supports CND in its goal to enforce the 3 UN drug conventions.
- UNODC should strengthen the study of access to control substances. Level of availability is not only influenced by regulatory factors – also affordability, training of healthcare programmes, and social norms. UNODC should provide targeted technical assistance to those countries in need.
- Affordability for legal supply should be ensured. Training more professionals capable of prescribing essential med and investigate low cost generics.
- Efforts should be made to prevent abuse/diversion of controlled subs. Some countries are too lenient in use of controlled medicines, leading to death and overdose.