Side event: Access to Controlled Medicines During COVID-19: meeting the needs of patients around the world

Organized by Belgium with the support of Australia, Canada, El Salvador, France, Lithuania, the Russian Federation, Switzerland and the United Kingdom, and the UNODC Prevention, Treatment and Rehabilitation Section, the International Association of Hospice and Palliative Care, the International Narcotics Control Board, the Union for Cancer Control, the Vienna NGO Committee on Drugs and the World Health Organization

H.E. Richard Sadleir, Ambassador and Permanent Representative of Australia, Moderator: Our virtual discussion today describe how the ongoing global covid 19 pandemic reminds us that people’s health and wellbeing are an absolute and fundamental concern. Advancing the welfare of people worldwide is the aim of both the 1961 and 71 conventions. We must remind ourselves that the medical use of narcotic drugs, which is critical for the relief of pain and suffering, is directed squarely at the welfare wellbeing and health of people. So it is a source of deep concern that 80% of the world’s population live in regions which still don’t have adequate access to treatment for pain. I hope today’s discussion brings us to step closer to addressing some of the barriers to adequate access that exist. It is now my great pleasure to introduce Her Excellency Meryame Kitir, Belgian minister of development and cooperation, who will provide us with our opening remarks via video message.

UNODC, Ghada Waly, Executive Director: Ladies and gentlemen, I thank Australia and Belgium for co organising this important event and mobilising an impressive group of Member States, international organisations and NGO partners who care deeply about the issue of unequal access to control drugs for medical purposes. Low and middle income countries which are home to 88% of the global poverty ration, consume less than 10% of all opioids available for the management of pain or palliative care services, including for cancer and HIV/AIDS. Analysis based on INCB data shows a multitude of reasons that impedes access to controlled medicines, which can be linked to regulations, attitudes, resources, the main buyer having a lack of training and awareness. The way we’re able to realise the right to help achieve sustainability goal 3.8 on universal health coverage and essential medicines. At this session of the Commission on narcotics drugs, we are marking the 60th year anniversary of the single convention on narcotic drugs and the 50th anniversary of the Convention on psychotropic substances. The conventions provide the framework for ensuring that governments make adequate provisions for the access to medicines for relief of pain and suffering. In commemorating these anniversaries, Member States must take the opportunity to do more and to do better in line with the conventions. I’m pleased to note that focus on this priority has increased in recent years. Comprehensive approaches have been outlined in the 2016 UNGASS outcome document, and in a number of CND resolutions. The latest introducing a welcome emphasis on awareness raising, education and training. UnODC supports member states in fulfilling their commitments, with the goal of increasing the number of patients receiving adequate pain relief and palliative care, while preventing the abuse and misuse of controlled substances. Together with WHO and the Union for International cancer control, we are working to promote patient centred approaches under the joint global programme launched in 2013 and supported by Australia and Belgium. To date, the program’s work has benefited close to 20 countries in Africa, Latin America, as well as central and Southeast Asia and its activities have included the expansion and strengthening of the palliative care network. The development of national policy documents and tools in Nigeria and building a national education curriculum for health providers in the Democratic Republic of Congo. UNODC’s strategy for the next five years includes a renewed focus on access to essential control methods. Since through the joint global programme as well as other Partnerships, notably with INCB. Increasing access to control drugs for medical purposes is also another objective of your UNODC’s strategic vision for Africa 2030. UNODC framework will expand assistance to help countries adapt their legislation and policies, build the capacity of healthcare professionals and help bring supply chains in line of the health needs of the people. We call our Member States to increase their support to this work, sustained efforts are needed now more than ever, as the covid-19 pandemic has further limited the availability of controlled medicines to people under medical care. UNODC joined INCB and WHO in calling on governments to leverage international instruments and work together to remedy this situation. Ladies and gentlemen, with health equity high on the international agenda, we need to seize the opportunity to increase advocacy to mobilise investment and provide adequate pain relief and palliative care for all those who need it. At this crucial time, UNODC is stepping up efforts to improve access to control drugs for medical purposes and promoting greater cooperation and solidarity in the field of health care.

INCB, Cornelis de Joncheere, President: It’s a great pleasure for me to speak on behalf of the board on access to controlled medicines during the COVID-19. And let me thank very much the governments of Belgium and Australia for organising this event with the many co sponsors and the invitation to speak on the joint effort of The board, WHO and UNODC. Soon after the COVID-19 pandemic started last year, many countries restricted travel and announced lockdowns and as the impact of COVID continues to spread across the world, the ability of the International community to ensure access to controlled medicines has been put under test. On the supply side, countries were confronted with the disruption in manufacture and international transport, while at the same time, we saw an increase in the demand for controlled medicines like fentany that are necessary for the treatment of COVID patients in intensive care. In close contact with countries, the board has closely monitored this situation and provided assistance to countries foreseeing or experiencing shortages of control medicines This was gotten through facilitating the communication between importing and exporting countries through the swift approval of revised estimates and assessments by supporting countries in issuing Electronic authorization. By organising meetings with authorities on the application of simplified control measures. During the emergency situation, ensuring the availability to access controlled medicines to meet the patient needs is a prime aim of the international drug control framework and as always is being at the heart of the board’s work.

Since the publication of our first report in 2010, Subsequent Reports in 2015 and 2018, the board has expressed its concerns over low levels of use of controlled medicines in many parts of the world. We indicated that the substances may be almost inaccessible large part of the population and describe the to such imbalance. In order to assist countries in collecting national consumption data, the board has compiled the most used methodology and made them available on our website this year. We hope to strengthen the national processes on estimating the requirements for control medicines. In August last year, the board together with WHO and UNODC issued a joint statement on the importance of ensuring access to controlled medicines during COVID-19. The statement refers to the needs of COVID-19 patients but also to the people who require controlled substances for other medical canditions, including the management of pain and palliative Care, surgical care and anaesthesia, mental health and neurological conditions and the treatment of drug use disorders. Covid-19 pandemic is not under control yet. We may see new waves of infections. National lockdown and problems in accessing health services might put these people with mental conditions, Cancer And with drug use disorders in an even more precarious situation As the world prioritized resources to address the acute needs of the COVID-19 patients, it is important not to forget the needs of the non COVID-19 patients who need controlled medicines for the other health conditions. Sharing personal experiences by representatives from patient groups which we shall will surely help us to understand this better. The covid 19 pandemic has shown us how important is to have a robust supply chain that can deliver medicines in a timely way to people in need. It has also taught us that no man is an island, and this can only be addressed through strong national health systems, effective international collaboration among countries, international organisations, the private sector and civil society. The joint statement issued by the board, WHO and UNODC during the covid 19 pandemic, really supports our collective attempt to close the gap in access to control matters. Since between the haves and haves not In this world. I look forward to a fruitful discussion and to concrete proposals on how together we can improve the situation on access to controlled medicines.

IAEA, Lisa Stevens, Director of the Programme of Action for Cancer Therapy – PACT: Good afternoon excellencies ladies and gentlemen. I’m pleased to join fellow co peers and panellists in this important event on access to controlled medicine. I plan to highlight how the programme of action for cancer therapy or PACT work together with partners to Support member states and improving access to controlled medicines for the control of pain and symptom relief for cancer patients. I would first provide background on the programmes to illustrate how this is achieved. PACT works with member states and partners to provide comprehensive review of cancer services. These assessments called impact reviews are initiated with a formal request from the Ministry of Health. The impact reviews, evaluate the end higher cancer spectrum of cancer control In Member States. Prevention, screening early diagnose, assisted treatment. Palliative Care, survivorship care and all includes cancer surveillance. We work with WHO at the headquarters and relevant regional and country offices and also the International Agency for Research on cancer, in planning and delivering these reviews. No single UN entity has the mandate and expertise to cover the entire cancer continuum. When expertise is needed to review access to controlled medicines to best support cancer patients, we turn to our sister UN agency, UNODC to support the discussions on access to controlled medicines as part  of the impact review. We rely on the network of UNODC national stakeholders working on palliative care in countries where we’re conducting impact reviews. In this way, key partners of UNODC both at policy decision making level and also the service delivery for access to medicines are consulted in the In-country discussions during the reviews. We recently revised the assessments used to gather data from facilities during impact review. In addition to exploring where services for palliative care are available, the assessments include questions to better understand the involvement of the National Drug Control Agency and planning cancer policy. If there is a National Drug Policy, if so does the plan or policy include medicine controlled under the international drug control treaties, such as opioid analgesics. Finally the assessment asks Member States to indicates what medicines for palliative care including oral morphine, are on the National essential medicines list. Following the review, the report is developed with evidence based care commendations to be considered by The member states. The report has a section on palliative care that incorporates the baseline information, as well as specific recommendations to improve services and access to medicine. Recommendations from the review can be used to inform programmatic support. During the COVID pandemic, WHO have conducted services on the disruption in cancer services. Despite the disruptions, member states have indicated this needs to continue to to improve access to cancer services. Last year, international experts delivered these recommendations to three member states through virtual impact reviews and this year, two additional reviews are advancing. We encourage member states to internalise these recommendations and implement. So that cancer patients have access to quality services including the pain relief that they need. Thank you.

H.E. Meryame Kitir, Belgian Minister of Development Cooperation: Ladies and gentlemen, health related suffering, for some it is easily relieved by a visit to the pharmacy or a doctor, but not for everyone. In 2015 it was estimated more than 61 million people experienced serious health related suffering due to a lack of access to painkillers. Within this, children are disproportionally impacted. More than 80% of these people live in low and middle income countries. In a majority of low income countries, there is limited access to basic palliative. Painkillers remain Limited or non existent. And unfortunately, it has a perverse effect. Falsified medical products appear on Markets. This represent a growing threat to human health. For many years, balancing supports national efforts of the United Nations Office on Drugs and Crime. We do this to improve access to control things such as neurotics But also the relief of pain and suffering. Belgian Development Corporation for example, and Democratic Republic of Congo strengthen capacities and means of national regulatory authorities. This helps to fight falsified and substandard medical products. Recognising the gap and Access to pain care, Belgian international cooperation promotes the capacity building of health on these topics with the help of UNODC. A number of countries have Been working to create a more efficient framework to ensure this access. I can tell you the results have Good so far. I hereby encourage member states, UN agency, civil society organisations and other stakeholders to join us  in Our efforts and to make the voice of people impacted by this issue at the international level. Last year, we adopted the resolution on how enhanced awareness raising education and training can have a sustainable impact on this issue. This side events aims at showcasing the work done by different actors and also highlighting the tools are available to improve the situation. First Steps can already make big improvements.

Dr. Emmanuel Luyirika, Executive Director, African Palliative Care Association (APCA): Focus on some of the innovations during But also some of the experience on the ground. As a response to meet The impact of COVID on palliative care services, the African palliative care Association focused on strengthening partnerships in research, communications, programming, funding and education, we also share info with palliative care service providers in national associations and ministries of health. We conducted a survey to established the emerging need For palliative care providers, patients and their families across Africa. And you can see a copy of that publication. We shared the needs of patients and service providers with donors to prioritise the needs and facilitated funding. We also restructured sub grants on ongoing funding to focus on the key staff and patient needs and supplies during the pandemic. We work with hospices and national associations on costing With key consumers because of the pandemic, we also strengthen national online platforms so that these national associations and other providers had access to at that moment. We also worked to ensure That there are resources that Our partners could be used for example, a webinar on access to controlled medicines, we worked on advisories to the minerals in Africa with devote radio public service announcements together with our partners, including at Indiana University, so that this could be shared on social media and FM radio stations, we also developed a seven step infographic to protect and care for family members as well as health workers and these were both in English and in French. Despite the innovations, controlled medicines and palliative care during the covid 19 pandemic has remained major challenge. The following are some of the stories from patients and health workers. Ethiopia was also affected by Limited access resulting from interrupted supply. One of the members there talked about the stock outs two months in a row in difficulty in accessing the medicines And patients were forced to divide the only available 30 milligramme tablet instead of what they should. We also had patient in severe pain And the husband had divorced her because of her condition, the employer Fire there Because of the fear of spread of COVID, and the treatment costs. She had to spend Three times more money than the usual in order to access the medicines that are needed. So COVID-19 is titled burden on the healthcare system does have an intensive part on delivery of palliative care in Ethiopia like other countries, Uganda, we saw that despite Promotion being free. The total lockdown meant patients couldn’t access what they needed. In conclusion, COVID-19 pandemic met an already bad situation in Africa. Especially when it comes to palliative care and controlled medicines, having medicines in stock at facilities was not enough. Various innovations as regards COVID Occasionally supporting providers and you use of technology being triggered by the crisis.

Dr. Odette Spruijt, Founder and Chair of the Australasian Palliative Link International: If I could start with a brief background story to The founding of Australasian Palliative Link International. As a young Doctor in the late 1980s I volunteered in Calcutta at Mother Teresa’s home for the day. It was there that I realised the importance of a bridge between the world of volunteers from high income countries, and the world of the poorest of the poor which this home created. Fast forward a few years to the end 1990s, and training in palliative care in England where the director of cancer and palliative care urged us trainees that if we were to apply the existing knowledge and pain management and palliative care. It’s so much of the series health related suffering in the world be relieved, even without further research at that time. So these early inspirations led to the development 1996. Our aim is to foster links between palliative care Australia and colleagues in the low and middle income countries in the Asian Pacific and from the outset, our main connection has been with the Indian palliative care community so in 2010, we  developed a collaboration called Project hum Rahi with the Indian National Indian Charitable Trust. This project experienced Australians palliative care and oncologist clinicians are linked to new palliative care services in India. Each link site has a doctor nurse Team visit annually. For three or more years, staying for At least a week as we know the importance of education and training of the healthcare workforce as well recognised as a key strategy to improve global access to medicines. Such is the fear among healthcare professionals unfamiliar with prescribing and monitoring opioids that simple lectures and Adaptive teaching simply is not enough. We hope that establishing a colleague relationship to stay And over time had greater impact. Now from the outset there was some tension discussion about terminology as the term mentor sat uncomfortably and suggested a hierarchical relationship and A one way flow Learning. We have been Settled on defining the mentor for this project as a fellow traveller, one who is seeking to expand one’s personal understanding of palliative care in a new and unfamiliar environment. And in as much as the mentor is an advisor, counsellor and teacher The local provider isn’t also a counsellor teacher it to the mentor. Today there have been 50 visits to 20 different sites and 32 mentors. 14 doctors, 15 nurses, a pharmacist and a counsellor. Of course Unfortunately in the past Year with COVID, all in person stopped so we are exploring new ways to maintain relationships and develop new ones particularly looking at tele mentoring options. So returning to my earlier experience at the home for the dying. We hope this fellow traveller project has provided a bridge across different worlds at experience. I recently completed project evaluation emphasise mutual learning and growth, which occurs. There were definitely challenges including programming complexities, availability of the mentees during the week of the visit , language barriers and For the mentors, An exposure to an intensity of suffering that what they usually see in Australia. Project Hum Raji creates a dialogue which means to welcome difference to welcome the other. An English professor in Vancouver, Canada in writing about intercultural exchange reflects that there are two critical aspects of dialogue-the  hospitality of reception and The reciprocity of response. She writes that the ethical response to another is to have a hospitable orientation of Openness, vulnerability and receptability. Mentors may bring expertise, but they’re never experts in the new culture and in fact are very vulnerable in this unfamiliar setting. mentees are open To learn and willing to be vulnerable and sharing their concerns and areas of the And this mutual vulnerability for Is the development of a space for both To learn and grow. For the mentors, the immersion into a different culture is valuable, bringing a new appreciation of underserved populations in high income countries as well as in low and middle income, namely the poor those with mental health issues. Those living in remote areas, the incarcerated. also brings an appreciation of the cultural dimensions of dying. The differences in communication, different understanding of privacy of autonomy, The essential and demanding nature of palliative care when resources are limited, the injustice of unreal pain and suffering when controlled medicines are not available. In the last few moments, I’d like to introduce the new development, that of the Western Pacific palliative care Advocacy Network which was convened in late 2020 to advocate to governments and institutions in the western Pacific region about ensuring access to controlled medicines and palliative care in this region. One of our participants shared that last month, March 2021, Fiji and therefore Tuvalu and Kiribati had no oral morphine for the entire month. Normally, this is the only formulation of oral opioids available in those countries. This interruption and supply was likely due to COVID as it had not happened before In her experience, the Fiji and the Pacific nations are regarded as close neighbours and friends of Australia and New Zealand, that patients there is subjected to such unnecessary suffering and denied the human right to pain relief is of great concern. We hope that through knowledge sharing, advocacy, training and networking that we can provide a voice for these patients and our neighbours. To help to realise the ethical imperative underpinning the side event. That is ensuring that all people in the world are able to access essential medicines when and where they need them. Thank you.

Dr. Tania Pastrana, International Association for Hospice and Palliative Care (IAHPC): As you rightly state, access is an ethical imperative for the healthcare system. When the pandemic hit Latin America, it hit our regulars already suffering from limited access to controlled, essential medicines. Our region is caused by long standing and pervasive inequity in income, healthcare and education and our healthcare systems are flagging. During 2016 and 2018, was 7mg per capita in comparison was 287mg per capita in western Europe So 40 times More By the way, there is no epidemic or non medical use In Western Europe. This Reduce the availability for palliative care Patients who needed them for pain And other distressing symptoms resulting in acute Suffering. A colleague of mine at a public hospitals in el Salvador told me that morphine was destinated for pain and palliative care. Now was to be used to manage breathlessness of COVID patients. These diversions resulted in Two months out stocks for both group of patients. thought With the pain and COVID the patient Collect from planet wide. Ecuador and Honduras also reported stock outs. For COVID patients were paralysed but aware while they were intubated. This could be described as a torture. Medazolam is an essential medicine in palliative care and critical care has been Limited in many healthcare systems. morphine is no longer available for homecare patients in Mexico, hospital pharmacies in Peru and Paraguay no longer dispensing dispense opioids and benzodiazepines to outpatients reserving for the inpatient use. meaning patients in the community cannot get essential meddicines. Many of my colleagues in Latin America are facing awful situations due to the Lack of essential medicines. Many are forced to use whatever medication are available, even if they are expired. some members states such as Colombia Took the steps to ensure access by allowing Home Delivery controlled medicines. This is by simplifying the descriptions requirements, colleagues from Argenitina and Panama have reported No problems with availability of opioid or benzodiazepine at the hospital level. So, suffering in that setting, at least can be alleviated but prevented it As in the pre pandemic way. Last year the international association for palliative care conducted an online survey on its members regarding the effects of the covid 19 pandemic. providers from 41 countries from all income groups responded. We asked among other things, how different they affected the availability  and On the access on essential medicine for pain relief and palliative care in the Work settings. All participants said initially was they were affected negatively. In high income countries, The situation was solved rapidly but in low and middle income countries the effect has been longest lasting. This funding underscores the inequity of the high burden of health related Suffering of the patient, the family but also us as healthcare providers. We recommend that going forward minister of health collaborate closely with palliative care and other clinical professionals to develop and use implement policies that strengthen supply chains and ensure access to All patient in need.

WHO, Dr. Mariangela Simao, Assistant Director-General: WHO was founded in 1948 with a conviction that Health is a human right, that should be enjoyed by all people, not just a few. The conviction remains as strong as it was When it was founded. opioid analgesics are used to alleviate the pain and suffering for a wide range of conditions like cancer. We also are very concerned that access is very uneven. medicine in many low income middle income countries, It’s very hard have access in this situation and has become more acute during this pandemic. Uninterrupted provision of health services and access to medicine is a big challenge right now for routine care for the most countries including high income countries. Controlled medicines right now are facing a different situation because they are in high demand also for the treatment of acute hospitalised in intensive care units that need respiratory support. At the same time they continue to be needed for the routine conditions like epilepsy. And it’s in everybody’s mind right now that equitable access to vaccines is not a reality in the world, but at the same time, we are facing very limited supply versus high demand for opioid.  There are several reasons that why disruptions occurred- could be because of export restrictions by the country where it’s being produced, or It could be because of the lockdown effects, the suspension of air traffic or local Transportation. INCB, WHO and UNODC have a joint statement to alert international community to the risk of disruption In the supply of a controlled medicine during this pandemic, but at the same time, we also have moved To more concrete support to countries in the Supply Chain disruption for example, in some cases, we Direct procurement of supplies needed. But at the same time that we deal with the pandemic week, we Still need to continue with our regular work and I’m happy to say WHO in 2020 has released the guidelines on management of Chronic pain And we are finalizing the guidelines on balanced national policies to ensure safe use of controlled medicines.

To finalise let me say that we’ll continue to collaborate with member states with UNODC, with INCB and civil society because we know that all crisis also Bring us some learning opportunities and we have seen some good excellent experiences coming out of countries initiatives to provide alternative ways to provide Service while there’s this disruption. I hope we can address some of our chronic problems in a better way in the future based on lessons learned during this COVID pandemic.

Video testimony of recipient of palliative care: I’m a medical doctor in Uganda. But I’m also living with HIV and In 2000, I had advanced HIV disease which caused me to have cancer and the final problem that made me need palliative care is I picked up meningitis. It’s caused me a lot of pain, and I was lucky that at that time I was introduced to morphine. I just wanted to say that palliative care is included in all healthcare provision for people who need it like me.

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