CND Intersessional, 27 September 2017: Chapter 2 on access to controlled substances for medical and scientific purposes

Gilberto Gerra, UNODC. Only a few words from me to introduce my colleague. The rooms in the UN can be impermeable to sound, including the screaming of millions of people in unnecessary pain – people undergoing surgery, people suffering from pain. Thanks to cooperation with Belgium and others, we are working to overcome this – this operation is larger than just providing more medicines, it is about opening our eyes to the control system and what it is intended to achieve. The controlled drugs ate highly effective in managing moderate to severe pain, and the regulatory system needs to be discussed. When member states are providing their controlled medicine needs to INCB, I have some doubts about the sources and data they use. We do need to be careful, as we do not want a bank of medicines and pills, and to avoid abuse and diversion. The most important part is the individual relationship between the patient and doctor. We are working in pilot countries, but cannot scale-up due to resources. We are also working to overcome the barriers and ignorance of the problem, particularly among professionals.

Elizabeth Mattfeld, UNODC Drug Prevention and Health Branch. We urge you to start consulting some of the foundational documents on this topic – the 2010 INCB report, the 2010 WHO “Ensuring Balance” report, and the 2011 UNODC reports. Both the 2009 and 2016 UN documents speak specifically about the use of controlled drugs for medicinal purposes and provide actions for this. We can provide technical support to member states on the various recommendations of the UNGASS outcome document – and also in line with the SDGs. People suffering from pain cannot contribute to the SDGs unless we address that pain. It is important to first diagnose the problem – we need to increase access, availability and affordability. The question is how? The UNODC-WHO-IUCC joint programme has been in existence since 2013, and includes global advocacy and partnerships – including with civil society, national strategic planning in pilot countries (Ghana, Timor Leste, DR Congo), support for the development of national policy and guidelines (with EU funding in Nigeria, for example), and building data and research capacity in countries. We came up three of the most urgent areas: systems integration, education and awareness, and supply chain management – in line with the priorities identified in the previous documents and projects as well. We will do our best to identify foundational actions (such as basic instructions for health care workers), and then enhancing actions (such as full units on pain management integrated into curricula for health care workers) – as every member state is in a different stage in this area. The timeline is to have a draft document in the coming months, with a final document ready for CND in March 2018. I want to end with a quote from Hippocrates: “Cure sometimes, treat often, comfort always”.

H.E. Michael Adipo Okoth Oyugu, Kenyan Ambassador to Austria. This topic is of great importance for my country, for Africa, and for the international community at large. My remarks this morning are a broad review of the terrain. The availability of controlled drugs for medical and scientific purposes remains quite low, and non-existent in many countries around the world – as highlighted in the UNGASS outcome document which dedicated a stand-alone chapter to this issue for the first time ever. Removing unduly restrictive regulation, providing adequate capacity building and training, raising awareness, ensuring well-informed and coordinated scheduling decisions – these are all contained in the UNGASS outcome document. We must also ensure the availability and affordability of these substances – while also preventing their abuse, diversion and trafficking. The 1961 and 1971 Conventions underline the commitment to protecting the health and welfare of mankind. Yes this essential element of the Conventions is far from being universally achieved, leading to our commitment to enhance national and international cooperation on this issue. Striking the right balance to achieve the optimal outcome is therefore key. The 2017 World Drug Report focuses on the availability of pain medication, to improve the quality of life of people suffering from various ailments. Challenges include the lack of training and awareness, lack of resources, fear of diversion and an increasing concern of the misuse of opiates. Making prescription opiates available does not cause their misuse and addiction, and is an obligation established by the international drug control conventions. All member states need to scale-up our efforts to ensure that we make controlled medicines accessible, affordable and available. In implementing the recommendations of Chapter 2 of the UNGASS outcome document, we will also be contributing to the SDG agenda and especially Goal 3 to ensure healthy lives and wellbeing for all. Target 3.8b focuses on the provision of access to affordable medicines and vaccines. Target 3.8c aims for an increase in health financing and workforce. Our efforts at the national level cannot be fully productive without cooperation at the regional and international levels. We look forward to hearing good national practices and policies from member states today.

World Health Organisation (by video from Geneva). The international drug conventions realise the importance of health and wellbeing, and recognise the medical use for the relief of pain and suffering (1961) and the medical and scientific purposes of these drugs (1971). Our work on this is also guided by resolutions from the World Health Assembly. 70 percent of the world population – most often in low income settings – have no access to these medicines, which from an ethical perspective is unacceptable. Over ten years (2001-2003 to 2011-2013), the situation has improved in terms of access to opioids for pain relief – albeit with serious challenges remaining in Africa and other regions. There is still a huge disparity between regions, with Africa and South-East Asia the lowest. The trends in consumption are improving overall, but seems to be falling in Africa which is a major concern.

There are many barriers: insufficient knowledge and training among medical staff; behaviours linked to fear of diversion, abuse and sanctions; inaccurate quantification of needs by national bodies and weak supply chain systems; and regulatory practices that are too strong – resulting in too few prescriptions. Monitoring the trends of these problems since 1995, lots of improvements have been noted – but problems of sourcing, training and resources remain precarious. INCB’s 2015 report also outlined the prevalence of different barriers, and member states can contact me for more information on this. Other barriers include: ineffective implementation of national policies; lack of domestic resources; insufficient leadership and coordination; insufficient capacity and national regulatory authorities; and non-evidence based guidelines. The process for procuring and importing these medicines is a complex one and takes a lot of time.

The WHO Essential Medicines List is revised every two years, and already includes a large number of controlled medicines – including methadone. The first List was developed 40 years ago, and already included several controlled medicines – yet few steps have been achieved to make these available. The 20th List was adopted in 2017, and we have also revised the technical guidelines for managing pain in children, the pharmacological treatment of opiate dependence, for cancer in adults, etc. Our collaborative projects in this area include the Access to Opiate Medication in Europe (ATOME), the UNODC-WHO-IUCC Joint Program, the WHO-INCB Guide on estimating requirements, work to develop the access to medicines components of the UNODC Model Drug Law (still pending), and collaboration with the Africa Union (for access to morphine and ketamine, for example, this is the priority region for our actions). Ketamine is an important analgesic, and the ECDD has recommended again that it should not be internationally controlled as it is effective. Our ongoing work with international partners is well aligned with the UNGASS recommendations. Based on the existing political commitments and the fact that access to medicines is high on the international agenda, we really now need to transcribe the political commitments endorsed by member states into real concrete actions – which starts with the mobilisation of resources, including domestic resources.

Stefano Berterame, Chief of the Narcotics Control and Estimates Section, INCB. I want to focus mainly on three things – two related to the UNGASS outcome document (supporting national estimates, and building capacity), and a third related to preventing diversion as there has been over-consumption in some countries which has led to an increase in death rates. INCB has developed the I2ES platform with member states to help support national estimates and requests – to help overcome a number of challenges identified in this process. The platform is free to use, user-friendly, and compliant with the Convention requirements. It helps moves the process from a paper one to an electronic one, and some countries have enabled automatic uploads from their national systems (such as Switzerland). There is a meeting next week to discuss and improve the platform. 40 countries have registered into I2ES, and 26 have active accounts. We urge countries to engage and use the platform – to ensure a faster process. Regarding capacity and building, INCB has developed several training and learning tools and projects, including e-learning materials, regional trainings and other resources on the INCB website.

We have found an improvement in reporting capacities, greater commitments to improve availability. Additional trainings are now scheduled, with contributions from USA, France, Australia and Belgium. Finally, the third aspect is preventing diversion. The global consumption of fentanyl, for example, has grown continuously from 1995 to 2015 – yet this does not seem to reflect a rational increase in need for the medicine, but more a reflection of aggressive marketing by pharmaceutical companies, and use of limited evidence that showed lower risks of dependence. The number of overdose deaths linked to fentanyl and heroin have increased sharply – more so than other opioids. The increased risks of abuse and death has been limited to a few countries – but all governments should be aware of these risks. We also need to address the availability of less dangerous opioids in Africa, for example. Prescribing must follow a rational approach based on the evidence and guidelines, and must also consider alternatives to opioid analgesics for chronic non-cancer pain.

Actions taken by countries include: take-back prescription initiatives; independent and unbiased training of staff of the risks; awareness raising campaigns for the public; the availability of methadone and buprenorphine for people who use drugs; and access to overdose reversing medicines such as naloxone – and availability to first responders.

Mexico. I want to highlight the importance of information and awareness – INCB recently published a notice for countries in emergency situations, such as Mexico, to remind them that there are emergency steps available to simplify and speed up the import process in such situations. The forthcoming Latin America workshop will focus on this.

Post-UNGASS Facilitator. I want to take this opportunity to extend to Mexico and other countries in the Caribbean our solidarity.

Kurt Doms, Coordinator Drug Unit, Belgian Federal Service of Public Health. Belgium is pleased that the UNGASS outcome document brought us a legacy of joint commitments and recommendations for this issue. The under-treatment of pain has been reported in more than 150 countries, leading to the unnecessary suffering of men, women and children. The outcome document sets the framework for work in this area in the coming years and over the coming decade. The implementation of these recommendations is key. The UNGASS document refers to reviewing national policies and guidelines and the WHO guidelines is a useful tool in this respect.

The Access to Opiate Medication in Europe (ATOME) project delivered this review in 12 countries, using a quick scan tool which can be simply used to identify hurdles, locate unbalanced legislation, and identify quick wins for progress to be made. Secondly, for many years, Belgium has also provided capacity building and e-learning tools for healthcare professionals. Patients also have their roles and responsibilities – so awareness raising for them is also important. In Belgium we have invested in campaigns to improve knowledge and change behaviours. Thirdly, the INCB and WHO have provided all technical guide needed for countries to improve their estimates. The technical expertise and guidance is available. This will gain greater impact when INCB, UNODC and WHO work together more closely, and we welcome their work in this area and the recent Memorandum of Understanding between UNODC and WHO.

Belgium, through the Ministry of Health, started to fund this programme in 2015 – with a focus on DR Congo, a long-term development partner of our government. This work uses existing structures and a top-down and bottom-up approach – with multilateral commitments matched by bilateral ones, including through NGOs in the sector. We cannot ignore the rise in abuse of certain controlled substances in some parts of the world, and efforts to tackle this deserve our support. However, we hope that this does not dissuade other countries to take the necessary steps to address access to medicines. All stakeholders need to be engaged – including patients and their families, who can help to identify barriers and stigma from a community perspective to raise awareness amongst health care professionals. We hope that this will help to fulfil the goals that we have all agreed to.

Video Message from Alberto Miguel Guzman, COFEPRIS (Mexico). A year since the UNGASS, it is possible to observe important progress that has been made by member states. I want to explain how Mexico ensures access for medical and scientific uses, and our national law lists which substances are considered as narcotics. The supply etc of these substances must have the approval of the Ministry of Health, to avoid their improper use. We have adopted various laws and guidelines for this purpose, including guidance for the electronic platform for prescription of the aforementioned medicines. This innovation provides doctors with secure access, and stores data using information technologies to improve the situation by reducing the time required to just a few days. Prescriptions can also be issued 365 days a year, 24 hours a day – with barcodes on the prescriptions that contain details of the doctor for traceability purposes. Prescriptions can be repeated three times before requiring further approval. In this way, the Government of Mexico is making important measures to ensure that these medicines are only available for medical and scientific purposes.

Professor David Oliver, European Association for Palliative Care. I speak as a retired palliative medicine physician. I have worked in a hospice in the UK providing palliative care and pain relief to over 20,000 people. My role has been in the care of people who require palliative care, often facing pain and distress at the end of their lives, working as part of a wider multidisciplinary team caring for people with advancing illness and their families.

Perhaps to start with the story of Mrs B who was admitted to the hospice where I worked with severe pain in her back, from breast cancer which had spread to her bones. She was unable to cope with her everyday activities due to the pain, and her children and husband were distressed. Regular morphine was able to control her pain so that she was able to get out of bed, care for herself and be interested and talk with her husband and children for the remaining weeks before she died, without pain.

I am a Board Member of the European Association of Palliative Care, which is taking an active role to help our membership in improving access to controlled medicines as per the recommendations of Chapter Two of the Outcome Document. The EAPC was closely involved in the Access to Opioid Medication in Europe (ATOME) project, looking at the issues of accessibility to opioid medication. For example, in Turkey, up until 2014 there was limited access to opioid medication. In 2014 the ATOME project sought to overcome the barriers to opioid use. In 2010 the adequacy of opioid use was assessed at 7% and there were administrative requirements in the prescription, dispensing, distribution of morphine and there was a lack of clarity in the language used about “Toxic substances” causing “intoxication”. The ATOME Project made many recommendations and oral morphine was produced and palliative care was partially reimbursed in state hospitals. Opioids are now more widely available and palliative care is expanding.

Evidence for the use and efficacy of strong opioids, such as morphine for the management of moderate to severe pain is well-documented and evaluated. Many people develop pain, particularly towards the end of life. Over 70% of patients with advanced cancer will experience severe pain at some time in the progression of the disease, but pain is also very common in other diseases, such as heart disease, respiratory disease and neurological disease.

The need for palliative care and pain management is increasing globally, as more people are living longer, and are diagnosed with non-communicable diseases, such as cancer, heart disease, and diabetes among others. The need for pain management will increase as at present there are 14.1 million new cases of cancer worldwide annually in 2012, with 8.2 million deaths, and this is expected to increase to 20 million new cancer cases by 2015. Other people who require access to adequate pain management include older persons, children, those suffering from traumatic injuries and violence, post-surgical pain, and obstetrical complications.

There is unequivocal evidence to support the use of opioids for the management of chronic pain and this includes not only cancer, but chronic pain syndromes. In these situations, opioids are often used in conjunction with other non-pharmacological management techniques.

In clinical practice, the efficacy of opioid medication for the management of pain can be seen daily as patients with moderate to severe pain receive the relief they need and are able to live their lives again, thus dramatically improving their quality of life. For instance, a man with amyotrophic lateral sclerosis (also known as motor neuron disease) was in continuous discomfort, although he would not admit that he had actual pain. Within 24 hours of starting morphine he was more comfortable, needed less adjustment of his position and stated “the pain that I did not have, has gone away”. He was able to talk more easily with his family who were able to visit and enjoy their time together, without the need for continual adjustment of position and his evident discomfort.

A doctor who had becoming paralysed from the waist down from the collapse of his vertebrae due to prostate cancer. He was in continuous pain and talked of wanting “to end it all”. Within two days on regular morphine he was more active in his wheelchair and looking forward to going out and seeing his family, and no longer talked of hastening his death.

Access to opioids for the management of pain can make a real difference to patients, particularly at the end of life. How people die lives in the memory of their loved ones forever, often affecting their own view and perception of death and dying. It is important to ensure that people at end of life die in comfort and with dignity. The use of strong opioids enables this to be a reality.

The availability of opioid medication varies greatly across the World. 90.5% of the morphine consumption in 2013 was from Europe, USA, Canada, Australia, New Zealand and Japan, although these countries account for only 18.9% of the population. WHO estimate that 5 billion people live in countries with low or no access to controlled medication and there is insufficient access to treatment for severe or moderate pain in over 150 countries. Even in Europe the ATOME study, in which the EAPC were involved, found that opioid consumption is low or very low in 12 countries with many restricting the use by legislation.

A major barrier to availability is fear of addiction or overdose stopping patients taking medication that could help them and this is often related to restrictive policies for their prescription. Patients and families, healthcare professionals and government and public bodies fear that greater availability may lead to increased misuse and diversion. At the same time in certain countries, in particular the USA, there has been a large increase in opioid use together with an increased fear of misuse, leading to restrictive policies. These fears may have been overestimated and it has been argued that there is confusion about the misuse of “prescribed opioids” and “prescription opioids” – the former being the correctly prescribed medication whereas the latter is the use of opioids which are available on prescription but that may have been stolen or illicitly trafficked or manufactured.

It is important to differentiate those people who: received medication for a legitimate medical purpose and use it as intended; received medication for a legitimate medical purpose and used it in a different way, such as not complying with instructions (there are papers suggesting that up to 21-29% of patients receiving opioids misuse them, but this also includes non-compliance, such as not taking medication regularly as instructed. In the general population, non-compliance with other medication is found in 25% and it is likely that this is also the case with prescribed opioids); and used medication for non-medical use.

Many people with substance use disorder start on prescription opioids and may then take heroin. However, importantly, although 60-100% of people with substance abuse disorder have taken prescription opioids, only a very small number (0.01% to 4%) of people treated with opioids for pain go on to develop dependency. There have been many alarming stories of the use of opioids in the USA, where there is an increased number of overdose deaths and claims that “enough prescriptions were written to give every American a bottle of pills” (when the reality is the bottle would contain only 7-10 pills). There has been the misapprehension of the causation of the problems – the drugs are considered to be the cause of the abuse problem, whereas the problem may be in the better use and prescription of medication for those who are in need of pain relief. As a result of these fears, restrictive drug policies may lead to patients with pain not receiving the medication they require and becoming distressed, and leading to distress of their families and carers.

The use of opioid medication for medical use is complex, as part of the wider assessment and management of pain and other symptoms. In many countries there is little education of health care professionals in the assessment and management of pain, and other symptoms. In 2014 a survey by the International Narcotics Control Board found that only 70 countries reported an educational curriculum for medical practitioners which included the prescription and use of opioids. Of these countries, 51 (73%) showed an increase in the per capita consumption of opioids over a 4 year period to 2013. Good education and training of healthcare professionals will ensure the safe and timely administration of opioid medication. The fears and myths surrounding the use of opioids may result in practitioners underestimating patients’ pain and subsequently result in the underuse of pain medication. This may be from the fear of misuse, the concerns of side-effects of opioids or legal investigation. Legislation that restricts the use of opioids may further discourage their use in pain control.

The development of palliative care was been endorsed by the World Health Assembly Resolution on Palliative Care in 2014 which urged the global development of an integrated approach to palliative care. The resolution encourages palliative care education and training to include basic, intermediate and advanced training. Importantly the resolution also suggests that in order to improve access to controlled drugs, such as opioids, and other medication that they should be included on the WHO Model list of Essential Medicines.

In summary, there is strong evidence to support the efficacy and use of strong opioids in the management of pain. Globally, there are many countries where opioids are not available. This is due to a number of reasons including a lack of training and support in the use of opioids and fear and/or legislation. There is the need for opioids to be accessible and available for the millions of people who have unnecessary pain or other symptoms where access to opioids could make a real difference. There is the need for education of all healthcare professionals in the correct and responsible use of opioids, including the minimization of misuse. Access to opioids is essential for medical and scientific use; for the relief of pain and distress for millions of patients and their families. Legislation should not interfere with the use of opioids in these circumstances. Click here to read the full statement.

Canada (response to Professor David Oliver)My country is one facing these issues at the moment. One of the things I see is the fear that patients have of being cut-off from their medicines as a result, so how would you recommend we protect those who really need this medicine and what messages can we provide to doctors to ensure that people who need these medications can continue to get them.

Professor David Oliver. The biggest issue is the training of doctors and other healthcare professionals in the management of pain – it is often not taught in medical school or in further education. So long-standing doctors may have got into habits and behaviours that are not evidence-based or based on the knowledge 20 or 30 years ago. A team should assess each person individually and their specific issues – which may need medication and other tools to manage their pain. It is a challenge for us all to do that.

Post-UNGASS Facilitator. I now open the floor for interventions relating to Chapter 2.

Belgium. The need for technical assistance is clear. The Belgian Federal Agency on Medicines is about to make a voluntary contribution to INCB for this purpose, which should enable for a regional training in French-speaking countries in West and Central Africa. This will help ensure better recording of timely estimates for national need, to strengthen capacity to avoid diversion, and to improve access to statistics and data. We thank INCB and UNODC staff for their continued engagement in this area.

Australia. We are committed to promoting the adequate availability of pain medicines, and believe that the drug conventions were not designed to limit this availability for medical uses. Opiate analgesics provide cost-effective relief from pain for many conditions. Australia has taken an active role in addressing the underlying factors contributing to this disparity, and is pleased to support countries to get the basic frameworks right. It is possible to make positive steps to address complex barriers, as seen through the UNODC-WHO-IUCC Joint Program, and we have pledged further contributions to continue this work. We also thank INCB for their work in this regard, and we are encouraged by the partnership emerging within the multilateral community in Vienna, Geneva and beyond. We must continue working together to address the global disparity of access to controlled medicines for pain relief, and in the implementation of the UNGASS recommendations in this regard.

Estonia, on behalf of the European Union. The EU thanks you for organising this thematic discussion. The EU appreciates the importance of access to and availability of controlled substances such as opioids for pain alleviation and treatment for drug dependence. The lack of access to substances for pain treatment and mental health treatment is a concern and leads to unacceptable suffering. At the same time, misuse of these substances is highly problematic. We welcome the work of member states on these matters. However, the opioid epidemic in certain parts of the world should not lead to lack of access to medicines as affirmed in the UNGASS outcome Document. We note that the inadequate interpretation of the UN drug control conventions may limit availability of access to medicines. The EU advocates the need to remedy this situation as outlined in our new action plan 2017-2020 which tackles both aspects of access and avoiding diversion. This requires special training on use, and professional development. The EU project on this issue will increase understanding of customer sales, patters of use, misuse and dependence, with tracking systems. This may provide an example of best practice on how to improve availability and accessibility without aiding their diversion. The EU supports the efforts of WHO, UNODC and INCB in providing technical guidance in this regard. We also underline the importance of working with civil society and the scientific community.

Nigeria. We note that a lot of data was presented today, and Nigeria does not have a lot of data. We recently conducted a survey using consumption based data of narcotic medicines. We had two reviews done for the quantification of opioid medicines. This gives us a new baseline for reporting to the INCB. The MoH has upgraded two pharmaceutical facilities for the production of narcotic medicines. We will carry out inspections and monitoring of facilities.

Pakistan. The importance of ensuring access while avoiding diversion is a key aspect of the conventions, reiterated by the 2009 Political Declaration and the 2016 UNGASS outcome document. We attach great importance to access for medical purposes and we are taking appropriate measures. We appreciate the work of UNODC as well as INCB and WHO in providing technical guidance. We welcome the UNODC initiative of convening an informal meeting on the topic. Technical guidance should be adopted in close partnership with member states. We should continue to be guided by the UN drug conventions and other key documents. We should raise awareness and share good practices. Affordability should also be addressed, this was emphasized during UNGASS. We should ensure measures to counter diversion and misuse. Several recommendations in the UNGASS outcome document will guide us in this area.

Russia. Over the past 3 years, there has been a 50% increase in the number of pharmacies to issue prescription opioids. We are working with rural areas to prescribe and dispense opioids to citizens in need. The trend in opioid analgesics dispensing has been upward in 2016. Prescription of oral opioid analgesics has doubled as well. As recommended in the outcome document to improve doctors’ skills in handling opioids, Russia organised seminars and conferences for doctors, neurologists, oncologists on analgesic care and palliative care. We organised 617 courses in 55 regions for families on pain relief. We also have helplines and call centres to provide care for patients. We managed to increase effective pain relief by 15% in the first half of 2016 compared to the previous year. We are moving towards electronic prescription for opioid analgesics.

Dr. Sunita Panta, Nepal Military Hospital, Nepal. I have been working in a hospital for the past 15 years. Palliative care is very new. Before we had many patients who were suffering from acute and chronic pain. We had a clinic built to deal with these patients. We follow the WHO pain medication model to manage pain with opioids. For opioids the regulation was tight so there was limited access. We used codeine and tramadol but the results were not very good. There were advocacy groups in our hospital which dealt with the authorities. The government then made opioids more accessible. We now have opioids in the form of tablets and liquid form. But we still have very little supply of fentanyl. Patients can now stand, walk, do light exercises. They come to the clinics regularly. If they are not able to come regularly we can supply them with what they need. People can now lead a normal life. Opioids have managed to improve pain management in our country. Morphine is now also available in big hospitals and is particularly useful, so we hope it will be more available later on.

Colombia. Colombia has a specialised agency for issuing licences and implementing control measures from the 1961 and 1971 treaties. We have strategies to improve its work, working with the national association for hospice and palliative care. The centralised procurement will be an alternative for access, and continuous coordination and communication. The INCB special report of 2016 on access to substances remarks that the Colombian access is above what is recommended. Over the last year, we’ve worked to identify internal barriers to access to medicines through the MoH. We have issued guidelines for the supply of these substances in regions where there are deficiencies. We have made progress in production and distribution. We have done something similar with scientific research. There is a constant need for trainings for doctors and law enforcement. We also need to ensure that access is not a national average but make sure we work with provinces and localities to ensure availability through rationalised access.

Our congress approved law 1787 in 2016 to ensure safe access to cannabis and its derivatives for medical and scientific purposes in our territory, in line with the 1961 Convention. This promotes separation of markets vis a vis the non-medical use of cannabis. We developed training for small and medium size growers and a series of rules of a technical nature for the obtention of cannabis resin abstracts and processing for prescription medicines. We presented this t the INCB and gain the approval for the necessary amounts so that we can process this. We have received 20 requests from national and foreign companies and we hope to implement this very soon. The main challenges are: strengthen the system to issue licences so that people have safe access to cannabis without diversion, train and raise awareness, maintain constant monitoring for control and oversight.

Turkey. In line with the UNGASS outcome document and conventions, we are committed to improving access while avoiding diversion. In March, the MoH put together a new prescription service (electronic and paper), while providing strong controls against diversion. All pharmacies now use this system. This ensure effective demand and supply as well as data collection.

Philippines. We recognise the importance of the issue and have formulated policies and recommendations to avoid diversion and misuse. Policies and regulations included in the 3 UN drug conventions and those locally controlled depend on the Dangerous Drug Board. Various approaches have been taken, policies on regulatory control are continuously reviewed to ensure access to substances for legitimate purposes, with information systems to streamline information to producers, sellers, for export permits, etc. There is continuous dialogue with affected sectors to remove obstacles that impede access. Information is regularly submitted to UNODC. We collaborate with a variety of government departments, the industry involved in the effort. The MoH provides free morphine all over the country. Regular training and seminars are conducted for healthcare professionals for access to controlled medicines including for pain relief and on the rational use of controlled medicines. The MoH and National Centre for Access have worked to improve access to controlled medicines, and this is constantly updated. We are open to other worthwhile measures that could strengthen our commitments.

Samy Alsirafy, Cairo University Medicine Unit, Egypt. More than 2 years ago, one of our patients with terminal cancer was suffering from pain, and he looked in agony. When he approached me, he pushed himself to the ground, begging me to relieve morphine. He was not an addict. But oral morphine had become unavailable in Egypt. This is heart breaking. Morphine is only available in one form, one concentration in Egypt, provided by one company. Now it’s not available at all. We tried our best to provide oral morphine available, we asked the pharmaceutical company why that was. We tried to import tablets from a cheaper source, but we failed. We asked why morphine was available. We asked the CND, the INCB to find out who is benefiting from making morphine unavailable, while alternatives are unaffordable. We need an answer, we need immediate action, otherwise cancer patients will die from their suffering. Thank you.

El Salvador. We have invested in training processes to improve access for licit purposes. We carry out annual estimates of the amount of narcotic substances for medical purposes, using data and statistics from public and private health clinics. We have reduced response times for requests to import and commercialise substances as this was one of the impediments. We monitor imports and exports online. We have the international support from the UN on the prevention of diversion of precursors in Latin America and the Caribbean. This enables us to better control imports, exports, sales and use of precursors. With the support of the national council for the control of narcotics in Ecuador, we are implementing the system of control and business balances. We have used an online prescription download system in pharmacies, enabling us to guarantee availability so that our population has access to controlled substances for health problems. This helps us carry out effective controls. We have managed to improve controls on imports, exports, trade of precursors and have good trainings, but we need to improve our law on precursors. We need to also implement an IT system for the import, export, training and use of controlled substances and precursors. We need to strengthen the capacity of law enforcement officials.

Spain. We support the aim of UNGASS of guaranteeing access while avoiding diversion for illicit purposes. In Spain, substances can only be accessed in pharmacies with a prescription by a doctor. The doctor had to issue a 2nd prescription for narcotics or psychotropics. However, to facilitate the distribution of these medicines, a royal decree was issued to regulate official prescriptions for human and veterinary access. We use new technologies to avoid diversion. Five years since this new policy was introduced, we see an improvement for those in need. Prescriptions now last 3 months, compared to 1 month before. It’s also easier to write prescriptions now that we don’t need the 2nd prescription. The administrative process is easier, and in the national health system we use electronic prescriptions and you have e-prescriptions for narcotics and psychotropics thanks to the royal decree. This enables us to control the movement of the medicines. And finally, for the health administration, this means more efficient control since everything is computerised and registered. We think that Spain is complying with the dual aim of the UNGASS.

Malaysia. The drug situation remains alarming with increasing supply of drugs. We consider drug problems as an immediate threat to security. According to the 3 conventions, Malaysia respects its international obligations within its borders and at regional and international level. We continue to enforce stringent drug laws, and monitor all import and exports. We have a series of drug legislations on drugs. Our import and export of precursors are controlled, as well as pharmaceutical preparations. We have also issued the requirement of importing certain substances since 2011. We use the INCB online systems for import/export precursors. We appreciate the online tools that enhance intelligence sharing. Taking into account the national capacities of each country, we look forward to further efforts, information sharing, training and other effective activities.

USA. The issue of access to controlled substances for medical purposes is another example of how the UN is working comprehensively on global issues. We recognise UNODC, WHO and the Union for International Cancer Control and their work to ensure access while avoiding diversion. We work towards improving the wellbeing of citizens globally. In the USA, we have undertaken efforts to avoid diversion and misuse through doctors’ education, and best practices on prescribing opiates. We also continue to evaluate current databases on use, misuse and toxicity, access to pain management services, identifying new sources of data. The USA supports efforts, including through the joint global programme to improve access to evidence based pain killers.

Busi Nkosi, International Childrens’ Palliative Care Network. The availability of opioids is a challenge for children in Sub-Saharan Africa. Both children and adults die because of diseases that could be cured in many high-income countries because opioids are not available. This is because of lack of availability, training and awareness. Legislation creates barriers to accessibility. Out of 50 countries, only 4 allow prescriptions from others than doctors (e.g. nurses), this prevents prescription of opioids. Concerns on diversion create a barrier to access. Sometimes, special authorisations and signatures also are a barrier. There is also negligence. Morphine is often not available because pharmacies don’t keep it in stock. Often, morphine is not available in small dosages for children. There are also myths, for example in Sudan on the use of morphine in children. There needs to be efforts made to improve access to children: review laws, easy prescribing, develop and improve supplies to properly estimate needs for controlled opioids and ensuring balance at national level, increase the number of prescribers through training of nurses, financial assistance including private sector investments for countries with little financial capabilities, update lists of essential medicines regularly.

Slovenia. We strongly support the Estonian statement. I want to add a few words here. Outside of this room, there are many people suffering from pain all over the world. I am a medical doctor and my job is the treatment of pain. A lot of these people would pass away in a few days because of pain. Pain is one of the worst feelings in our lives. People in some countries can get treatment with opioids, while others cannot. Drugs can still be used for medical purposes. This is also highlighted in the report of the INCB. Do not be afraid to prescribe opioids, this is being done in many countries around the world.

We support the Estonian statement. The UN drug conventions commit us all to ensuring access to controlled substances for medical purposes while preventing diversion. This is repeated in the UNGASS outcome document and the SDGs. Up to 5.5 billion people live in countries with little or no access to pain medication. The presentations today have shown us how stark the situation is, and it is unacceptable. Supporting countries to improve their health systems is one of the UK’s top priorities. We have heard from the panel what UNODC, INCB and WHO are doing to lead this work. The UK works to improve access to medicines in the developing world through other initiatives working with the World Bank, WHO, the New Partnership for Development. We promote stronger approaches for dispensing and prescribing medicines, providing transparency and stronger systems. We will continue to work with international organisations and civil society.

Kenya. Since 2009, we have had the Kenyan hospice and palliative care association which supports all aspects of palliative care. This has led to some success in 2011, when two companies were allowed to import but the quantities were too limited. Three years later, the MoH was able to import more morphine (47kg at the time) to ensure better distribution of medication to those who needed it. The Kenya Association, in collaboration with the hospitals and authorities have worked on the reconstitution of morphine, and produced a medicine which passed the safety procedures. We now have liquid morphine in hospitals (government and missionary), this is the first time it is happening. We have also increased efforts to implement palliative care education and training. In collaboration with Oxford in the UK, we have developed a course in palliative care provision. Since 2009, the end of life national education programme has provided training to health educators who return to their own institutions to train nurses in palliative care. There is also an 18 month higher education distance course on palliative care. There are advances in pain relief medications too. The government has accepted the single convention and the WHO list of essential medicines which includes morphine and codeine. We also now have national palliative care guidelines created by the MoH and hospice and palliative care association. The Kenyan Medical Supplies Authorities has removed its tax on morphine. Morphine consumption has increased more than 3 fold in Kenya between 2010 and 2014. But it remains largely unavailable and unaffordable because of restricted regulations. But the situation has improved and it is our hope it will continue to improve.

Katherine Pettus, International Association for Hospice and Palliative Care. I recently returned from Uganda where I spoke at the 50th anniversary of the Uganda Cancer Institute and conference on palliative care. This was organised because of a 2015 law, passed pre-UNGASS. There is now a barrier to nurses prescribing morphine. In Sub-Saharan Africa morphine and palliative care medicines are nurse driven as there are so few doctors and physicians. So care in patients is down to nurses. Uganda has pioneered nurse prescribing in morphine and there are courses offered now on palliative care. The problem is that the new narcotics control law says that prescribing and dispensing can only be done by a registered medical practitioner. And this is not the case for nurses in Uganda. So it criminalises all nurse prescribers of morphine as traffickers. The good part of the story is that the narcotics commissioner is a convert to palliative care and when one of his officers arrested a nurse who was carrying morphine, he was contacted by the national palliative care association which said that the nurse was allowed to prescribe in a 2004 law. The association, practitioners, civil society, etc. were at the conference, but also people from the MoH and narcotics commissioners. At the end of the meeting, it was decided that the narcotics board would review the 2015 law. I highlighted the fact that this approach was in line with the UNGASS outcome document. This is a backstory of the video that is now going to be showed.

[VIDEO]

Ecuador. The government is currently developing a comprehensive plan on drug abuse. Illicit activities on trafficking of narcotics and precursors are dynamic. We need an international system to combat transnational organised crime. This must be tackled by international cooperation. We have developed control mechanisms following the guidelines of the INCB and other bodies. We are constantly in line with these guidelines for controlled substances and we always take into account regional security and national interests. Our technical committee for drug prevention is responsible for import, export, storage, distribution, it provides industrial services.

Post-UNGASS Facilitator. Several panellists left the room, but I will ask others to address the meeting at the end of the session.

Professor David Oliver. It is critical that all we have heard today is about accessibility. It’s closely linked to the development of palliative care, not for cancer patients only but for all those with life threatening illness, in particular for the end of life. The memory of those who have died remain in the memory of those who live on. So those who die in pain remain in our memories.

Elizabeth Mattfeld. The discussions today make it clear that the issue is complex. UNODC look forward to working with you, especially on the guidelines we are preparing to reflect strategies on the ground. I want to reflect on the healthcare system. In many places where we go, improving access and availability is an issue of the way the healthcare system works. This is an opportunity to build or enhance the healthcare system in a way that addresses the issues of access through the existing system. UNODC stands ready to provide technical support and facilitation to member states.

Kurt Doms. I will be very short. It’s a good sign that so many countries are working on a balanced approach. I want to highlight the issue of capacity building. It is a key element and a continuous challenge on prescription, use, patients, their families, training for authorities, etc. A lot of good practices exist at UN level, but also at national level and at the level of civil society.

H.E. Michael Adipo Okoth Oyugu. I am speaking here having joined the discussions as a diplomat. We have seen rich participation by experts, hands-on people who are medical professionals, civil society, advocacy groups and so on. I have been on a learning trip as an ambassador. I don’t usually get the opportunity to get this information, so I want to express my appreciation and engage advocacy groups not to relent. Advocacy by civil society has achieved a lot. I welcome the opportunity to continue to learn from you all.

Post-UNGASS Facilitator. We are now at the end of this session, we will continue the discussions tomorrow and focus on chapter 4 on human rights.

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