Chair: I welcome our panelists. We all know how severe this issue is – medicines are unavailable or unaffordable. This is for a variety of reasons, some of it is regulatory – lets not forget that there is a lot of weork done to optimize legislation. There is also often a lack of professional knowledge. This is also a key element. There is also the difference in attitudes across cultures and financial limitations. So I would like to hear from the panelists, what do you think are the main obstacles? Could you also touch on the work that you are doing in this arena?
Nigeria (Ms.Usomugha): First, thank you for this event, Chair. I work with the main regulatory body for food and drugs in Nigeria. In the last few years, we had an EU funded project implemented by the UNODC – we have identified a number of obstacles and one of the first things was providing a regulatory and administrative framework to improve access. We carried out a quantification exercise so health facilities also understand the barriers – one of the major challenges was regarding acquiring controlled medicines. There is only one importer in Nigeria, the federal ministry of health themselves. So we attempted to decentralize this system. It is an ongoing project, we have set up several warehouses in lieu of the one central we used to have. We still have the issue of the capacity of health workers, their capacities and attitude included. We are working on changing the prescription system and design training and support their implementation.
Chair: You mentioned prescribing patterns – could you expand a little on that?
Ms. Usomugha: In the facilities, patients with moderate to severe pain can get opioid analgesics prescribed but other issues have very minor substances as first line medication.
UNODC (Mr. Tettey): We have a combination of barriers, some already mentioned today that can be observed in all countries. The conventions are not about locking the substances away, it also includes regulatory issues… when a medicine is not profitable, you have issues getting it on the market. The prescription issues is often due to the lack of training, but it is often a result of stigma, cultural beliefs and traditions. From the UNODC´s point of view, a good practice includes working with people across arenas, you have to bring civil society, law enforcement and the patients themselves on board. We are keen to work in South-East Asia and the Pacific where these issues are even more accelerated.
Chair: You are the chief of the laboratories and science branch – could you explain what are the key scientific challenges and how do you advise MS?
UNODC (Mr. Tettey): When we talk about access, we often are limited to medical use but there is a component of scientific use. We are looking at very dangerous substances, so for a forensic scientist it is necessary to recognize these substances – for that we need samples and comparison. It is very expensive, some countries lose several hundred dollars on each sample, so think of the limitations on your offices.
Chair: Thank you, now I invite Mr. Rerat to the microphone.
WHO (Mr. Rerat): We are working on this issue, as you know, in a holistic approach. We are looking at the lack of access to medicine and diagnostic products on a holistic level, not just in the sense of legal control. Legislative and logistical frameworks are just as essential as the health worker´s approach. A bit of a forecasting mechanism is also important, we have a lack of data to quantify and plan appropriately. The different stages of the supply chain (…) we don’t know the actual need, we have to improve our reporting. We are currently working on the development of a forecasting tool that will help the commission to improve the availability of countries to quantify what they are experiencing. One institution alone cannot achieve substantial success, so I want to emphasize the importance of partnerships. We are actually finalizing a global study on the access to morphine that will be released early next year. So, clearly, I think the most important issue is that we need to know exactly what the problem looks like on all levels.
Chair: Thank you.
INCB (Dr. Zingela): I am delighted to participate in this discussion. I would like to highlight the actions taken by INCB to support MS. There is a focus on availability of controlled substances for medical use. Since the beginning of the pandemic, we have been in close contact with governments, particularly those that are in dire lack of pain medication. The increasing estimates have been updated. We have been in contact with manufacturing MS and encouraged (…) We have issued letters for simplified control measures, to expedite access to controlled substances and resulted in many hospitals identifying and prioritizing medications they need (and improving access?) and ensured processes such as permission of critical substances for home delivery. We have set up e-learning programmes for MS to take practical action in response to the increased number of emergency situations. These modules are free of charge and are available unlimited, so I encourage you all to take advantage of this tool and introduce your experts in your countries to our resources.
Lancet Commission (Dr. Knaul): As a cancer patient myself, I would like to thank you, Chair for bringing this issue to the forefront of our international debates. I had the honor of co-chairing the Lances Commission on Palliative Care and Pain Relief – the data from INCB was a key resource in our work. One of the largest barriers researchers face is the lack of access to data, so we are very thankful for your provision of all these information so we can succeed in our work. Access has only gotten worse, since we started analyzing data. About 1% of morphine equivalent medicines are held in the 50% of the world, the poorest countries. The rest is held in the wealthiest countries. If we think about all the different requirements for surgery and palliative care, most policy makers don’t know this data and very few consider this a major issue for global health. The Lancet Commission showed that access without access is in fact a health and equity imperative, but is not recognized as such. Another big barrier is ignorance in the use of evidence… If we think about obesity and the lack of nutrition, we would never suggest that the solution for obesity is starvation, yet this is what is happening in regards to medication. When we went through a metric evaluation, over 90% of papers were on availability and only 10% on access. We see a frequent radical change in political progress, it is also a huge barrier. The Lancet Commission put forward a package, at the heart of which is generic non patent morphine but because of its low price, there is little incentive to produce. Another barrier is this – the profit motive, so MS purchases other medications. Columbia is a great case study that we published a year ago, they have a national fund for narcotics that ensures access to generic opiates. Training our physicians and all medical professionals plus a plethora of institutional places is also key. We have to strengthen our human resource but in a much more innovative way. Uganda is a good example for the importation of powdered morphine and the use of nurses in stepping up administration.
Chair: In your personal experience, what is the answer ?
Lancet Commission (Dr. Knaul): I think we need to strongly focus on moving away from paper prescriptions to e-prescriptions. I know this causes discomfort – I remember Mexico a few years ago, we had terrific crime including radioactive material that helped us understand the importance of monitoring prescriptions.
Union for International Cancer Control, UICC (Dr. Cleary): Adequate provisions must be made. I have attended CND for 16 years and I am happy to see this access issue brought to the forefront. Pain Policy Fellowship, we work with clinicians and (…) and so we learned that the barriers are very different across countries, so MS need to learn the local specifics and identify their barriers before designing the responses. I think one of the biggest barriers is what goes on in Vienna – we are not making access a priority as the conventions had set it out for us. Once we understand this, we can make huge progress.
Chair: As long as medicines remain inaccessible, patients will suffer. However there is also the issue of overprescription that can easily lead to diversion. We have plenty of data on this.
UICC (dr. Cleary): It is fascinating that the concept of balance is written into the conventions, but it comes from a document that the WHO put forward in the 80s. It was to make up for the lack of access to pain medication for cancer patients. In the US, we have a very imbalanced situation that some call overprescription, but we have not established what is the appropriate prescription. but we know there are a lot of abuses. Patients use much less than what is prescribed to them, we have public data on this. If I use my daughters opioids for my tooth pain instead of getting my prescription, that is abuse as well… so this is a very complex issue. We have data that shows that 10% of prescribed pain meds are actually used post surgery by cancer patients.
Lancet Commission (Dr. Knaul): I did something similar, I used my daughters leftover oxy from her dentist, after my breast cancer surgery. So yes, I can concur. I want to be bold and suggest a pilot work in some countries. I would love to see the openness of some MS and the funding available to see what it actually means to implement the Lancet´s proposal. I think the LatAm region is ideal for this project – there are successes in innovation in Mexico, Colombia, Costa Rica, Argentina. These countries are also at a high risk of drug trafficking related difficulties.
Global partnerships facilitate necessary learning – we are here and we want to work with any country that is willing to try this.
INCB (Dr. Zingela): We rely on data we receive from countries – one the one side, we have to ensure that this is accurate and at the same time, we have to be flexible to adapt to changing needs. More importantly, changes in prescription habits or surges that imply some diversion is taking place, we have to be in the know early. I would like to stress the need for efficient training as well.
WHO: I am very supportive of what has been said. This balance is not easy to find. The ´61 and ´71 conventions are very explicit in giving a mandate to WHO so I think the opportunity here is to leverage that for partnerships and implement guidelines. There is a lot of information available for decision makers regarding regulations, administration and more technical activities.
UNODC (Dr. Tettey): Opiates, they are excellent medication but by their very nature, if you go beyond their prescribed amount, you risk dependence. So, talking about balance, in the interest of the conventions, we should move further and look at the balance of health and access. We could look at a realistic system for estimates as to what a particular country needs. Then we can look into a system of rational prescribing. When I look at UNODC´s work, we don’t just push info on access, but also have a system in place to prevent harmful drug use. We need to prevent people turning to the black market when they cant have legitimate access to their drugs. We have to work with pharmaceutical companies.
Dr. Usomugha: We have a similar situation as what dr.Cleary described. In Nigeria, issues related to access are embedded in our larger frameworks with the 2 other pillars: supply and demand reduction. We are also working on record keeping tools, the easing of administration to facilitate better attitudes of health workers. We have to make sure there is rational prescribing, rational use and streamlined, well kept records.
Chair: Emergency Situation – I want to put it to the panelists: we have seen during COVID how the World struggles and we have seen that the importance of opioids access is very important outside of cancer/palliative situations as well. How have these affected the availability to controlled medicines and what lessons can be drawn from that?
IUCC (Dr. Knaul): There is a tsunami of noncommunicable diseases in their late-detection after the pandemic. We have a lot of late-stage detections that result in a much larger need for pain management tools that we were not prepared for. Countries need to be able to think about this. The tremendous suffering and loss of life resulted in fundamental changes in how we undertake healthcare. Telemedicine covered by insurance companies, just as an example of accelerated progress – we have to harness these. The systems that are required to solve this issue, we have to think about education, higher education, and professional training. If MS had taken our recommendations to hear (about training) before COVID, they would have been much better prepared to meet the pandemic caused challenges. Three Lancet Commission came up with the same three recommendations (on death and opioids in North America).
dr. Cleary: I speak on behalf of dr. Zhingela. The earthquake in Haiti resulted in a huge need for opioids. INCB has a good mechanism to get opioids into a country when such things happen. It is not the international prohibition board, their mandate is about control, so it is also their responsibility to support the logistics of getting medicines into a country when something like this happens.
INCB (Dr. Zingela): Yes, we have a very specific role. We have a document by WHO, with our input, that highlights what systems competent authorities can follow for access in emergency situations. There are instances that don’t make the headlines, so we encourage our partners to notify us of all emergency needs. We have recently added a module to our e-training specifically on this. More practical steps would be implementing simplified measures. Pandemic preparedness is a great move as well – very clear protocols for response and prevention of deterioration of diseases.
Chair: I see a lot of raised plates. Let´s do one in person, one online…
Switzerland: I am interested in the role of other stakeholders, such as civil society, in ensuring access?
Czechia: As a physician and psychiatrist, I was very pleased to hear the representatives of our institutions and other panelists addressing the global crisis as a prevaligin result of the global drug control system. The data on restricted access or inadequate access is dire. The countries with the highest access see an interesting result – gradual disappearance of black heroin market. I am highlighting this because in many aspects, we know the solutions, the global commission on drug policy that I am privileged to be a part of, has clearly shared since 2011 this sad reality, the accessibility of controlled substances. Some Ms have close to 0 access. So my question is, what happened in the last 10 years? I am the former mayor of Prague and Drug Tzar, but I see another problem here than the lack of pain relief. We are facing a mental health crisis. Pandemic, armed conflicts, recession… the drug overdose deaths have been in clinical research, renewed investigations are taking place into, we call them psychedelics, to address many mental health issues. The key part of my comment is that Czechia has decades of experience in research, we feel this is our obligation to share this so people around the world have access to MDMA, DMT, Ketamine, Psilocybin, etc. for medical use. We look for the support of like-minded countries to remove barriers and really leave no one behind. Psychedelics should be withdrawn from the prohibition list and experts shall be invited to CND to share their research. UNODC shall promote access to controlled substances that can address mental health issues.
Singapore: COVID excerberate challenges, we had to be innovative: we have stepped up our telemedicine program and revised our misuse regulations to allow nurses and pharmacists to be able to work with controlled substances. It is clear that we need a balanced approach. We encourage authorities to share data on their import/export. Our discussions today shows that our work is cut out for us as this issue is a priority for us all.
Dr. Knaul: I would like to respond to the question about civil society. In 2012 and 2017 Mexico had two NGOs sitting down at the National Health Institution for an inter-institutional conversation. This was quite unique. We are very willing to be there. Our capacities to bring all institutional actors is absolutely key. When we talk about non-governmental entities, palliative care NGOs are the most organized and we all work together.
UNODC (Dr. Tettey): The drafters of the convenstin put in place measures that allow the transport of substances in emergency situations. So how do you get to a disaster zone? It took the COVID pandemic for us to understand that so much of this is up to us. I applaud the INCB for coming up with a simplified process for this. So why does it have to be a crisis for us to work efficiently? Let us look beyond emergency situations.
Ecuador: We are grateful for this session. My country approved the 10th version of the list of essential medicines. This list covers 95% of the epidemiological profile of the country. Our electronic systems allow purchases integrated into the public health network. In times of crises, national agencies ensure availability of medicines and devices following a handbook. UNGASS outcome document emphasizes medical access as a key issue.
Mexico: We would appreciate the input of Angela Me here. We have given too little attention to the lack of access to medicine – as demonstrated by some of our panelists. Apparently, many patients will die because of the lack of access to medicine and not their illness. Can we measure this somehow?
Australia: We are committed to (…) SDGs particularly target 3.8. Access is one of the fundamental principles of our global drug control framework. Increasing availability and preventing diversion are concerned with the protection of public safety, however a balance must be found. We note with concern the global disparity in the availability of opioids for medical use. Humanitarian emergencies and the COVID 19 pandemic exacerbate pre existing challenges. MS need to move beyond words and take practical action – there are several tools to be used. We appreciate the INCB learning program and their communications to states about the practical steps they can take. We heard today, a multitude of barriers exist beyond supply issues, such as regulatory systems and attitudes. Civil society is vital in overcoming these. We encourage all MS to work together with each other, INCB, WHO, CND and civil society.
Peru (online): Regulation of therapeutic use has been a priority for us. We have reviewed our legislations to allow registered patients to have access to medicinal cannabis. Electronic prescription for better monitoring has been implemented. I call on all MS to consider the importance of scheduled substances´ use in medicine. It is our common and shared responsibility.
Peru (in person): The national coca company of Peru is the commercial body overseeing coca manufacture and import/export. We have been facing transport issues. In 2020, KLM cargo discontinued the transportation of any narcotic product. We consulted with other operators without success. Our supply chain and the international pharmaceutical industry is suffering as a result. We are facing legislatory challenges despite having the necessary administration and safety procedures in place.
Japan: Opioids are essential in health-care, but the use in Japan is relatively low compared to other countries mainly because of its negative image and the fear of addiction by patients. Strictly controlled substances need guidance in their use, prescription, handling, logistics, etc. as there are many barriers to address on these issues. INCB identified specific areas and we welcome their resources.
Colombia: Today´s forum is very timely. We have implemented a number of measures that we identify as best practice: state funding for the production of opioid analgesic stimulant and anticonvulsants even though commercial interest remains low; regional institutions joined efforts to guarantee access; civil society initiatives have been supported by national funds; trainings for medical professionals – support for clinical practice guidelines for diagnosis and prescription; electronic prescription and monitoring system.
Venezuela: It is easy for us to identify our own barriers, so thank you for sharing some solutions today as well. Patients that most need them, don’t have access to essential drugs. My country has an additional barrier, the unilateral coercive measures. We are happy to count on multilateralism in overcoming this, but how do you support MS regarding prices? We heard today that the poorest countries and populations are most affected, but how about the developing countries, like mine? How are they affected globally? Also, mr. Chair, today´s event is excellent, next time maybe we can dedicate more than one day.
Iran: The international community has made this decision many times to provide access to controlled medicines for medical and scientific reasons. Yet, many MS face barriers in providing these substances. Unilateral coercive measures are a major issue. Some countries have legal restrictions for medicines as confirmed by the World Drug Report, mostly in low income countries. We encourage MS to remove all barriers to equitable access to medicines. Countries with greater resources and high levels of technological advances should offer support to lower income MS.
Pakistan: The effective implementation of the three drug control conventions is a cornerstone of the international drug control scheme. All existing barriers, including those relating to legislations, systems, awareness and training, are (…) We are experiencing an exceptional climate in Pakistan in terms of the healthcare needs of affected people – we welcome the support of INCB and highlight the need for symplified processes. We call all MS to continue efforts towards maximum outreach. An inclusive framework in consonance with international protokolls has been in effect in Pakistan that ensures access while avoiding diversion. Capacity building and technical guidance as well as technological assistance would be useful going forward.
INCB: I appreciate the statement of Venezuela and we are looking forward to further fruitful collaboration with all of you.
UNODC: We all agree no one should live with untreated pain but we are only a very few countries supporting capacity building (eg. EU, Belgium). There are a few things we can do to improve knowledge and access, but it requires support from you – funding, training, implementation.
WHO: We have to build on what we have done in the last two years, the accelerated production of vaccines, antivirals, etc. have been a positive result of the pandemic, so we know we can do it… we just have to have will.
INCB: Availability is critical. The highlighted cases today are very useful for all of us to learn, but I think looking back could also be useful… developed countries included various stakeholders including civil society and came a long way during the AIDS epidemic for example. I thank you for today’s discussion.
Lancet Commission (Dr. Knaul): Palliative care can not be used as an excuse for healthcare facilities not doing their absolute best to avoid fatalities. We need to do a better job along the entirety of the care. Regarding the middle-income prices, we have a very small base, so we have to think about aggregating demand. I think this is how we can bring down prices. The importance of civil society and global health actors cannot be overstated. I am very grateful for your efforts in prioritizing this topic and organizing a quality event such as today.
IUCC (dr. Cleary): It is always interesting to be talking at the commission of NARCOTIC DRUGS, but we are talking about MEDICINES… this is something very important to keep in mind. I have worked a lot in Africa and we need to sustain support, we need sustained funding and we need good health-care. I look forward to the ongoing interaction.
Chair: Thank you to UNODC and all our panelists and participants. Today was a davos-like session in Vienna, I thoroughly enjoyed it. See you very shortly for the afternoon panel.
Chair: Welcome back. Let’s start with why it is important to engage stakeholders and are there any good practices you would like to share with us?
Belgium (Mr. Kananga): Today is an exercise for me to speak English, so I will be slow. I had the privilege to work in both Belgium and Congo on the ground. In DRC, it is crucial to work with stakeholders for sustainable approaches to pain management. Four years ago, we set up mobile palliative units in 5 different hospitals. This unit made it possible for us to collect data on chronic pain and we interviewed around 60 professionals to inform our work and create a concept “pain-free hospitals” to then convey to decision makers. Without the practitioner’s involvement, we have a very limited understanding of the issue at hand.
Addiction Treatment Center, Slovenia (dr. Kastelic): I want to bring in an other aspect about opioid treatments. When I had my own accident and lied in hospital without any pain medication, the only reason I managed to get some Tramadol is because I am a doctor myself. Practitioners are still afraid to prescribe opiates in Eastern Europe. In custodial settings, I saw an enormous need for (buprenorphine) yet many EU countries have very limited programs or are only now developing pilot projects. We should not forget that one of the main aims of these treatments is to keep people alive. We can reduce and control infections and also reduce criminal behavior. But we also should prioritize the reduction of suffering. Addiction is often not considered a chronic disease, it is still the concept of “bad behavior”. Even colleagues on the addiction field understand this issue so… as a result, they withhold appropriate care in prisons. We must ensure proper treatment throughout the entire process of a person, during arrest, pre-trial and so forth. There are people with other issues, so for example sex workers and immigrants and other minorities are difficult to reach. We cannot leave the treatment of these people to the mafia.
Chair: So how can we best approach the training of practitioners?
Addiction Treatment Center, Slovenia (dr. Kastelic): As a physician, I see some things as over-controlled, but I know there are some countries where the doctors do whatever they want… doctors in my country I think are overprescribing Tramadol for example.
UNODC (Ms. Campello): We had a nice discussion this morning that already raised the most important issues. Maybe they are worth repeating but I will not touch on the global stage… On the country level, if you don’t involve stakeholders, put very simply, you will not get anywhere. In the countries that we work in, civil society partnerships were absolutely instrumental. Our experience has been that it is great to work with regulatory agencies, ministries of health, but we need much more than that. We need the drug control people, who are often very hesitant – they are usually very powerful people, involved in criminal justice or law enforcement and they are very hesitant. So we must be patient to slowly bring all stakeholders to the table who will be able to develop policies that improve the situation, like we have seen in Nigeria. The best way we found to bring all those people together was data collection – I used to not be so fond of data collection as it is often an excuse to not take any action, but I learned that without a proper assessment, we will not know what to do. We are hoping to replicate the successes we have achieved in Nigeria and DRC. We will assess the supply chain in further low income countries. Once you have your stakeholders at one table, you can identify a comprehensive solution.
Chair: Reliable data collection, training of staff and close cooperation on the field with civil society – these are clear points, just to summarize.
INCB (Mr. De Jonchere): The topic of today’s event is critically important. We have a long way to go in order to really make progress. Thank you for taking the initiative on this forum. I agree with the point about data, the need for data – since 2016, we have produced several supplements in the INCB annual report to look into the availability of controlled substances. We will have an additional supplement on controlled medicines in the upcoming report as well. We are not moving fast enough in this area. If we look at the problem of access, the first step is to have these medicines available, so we need producers, suppliers, etc. This all does not mean patience access them however. For that, we need governments who make conscious decisions to make money available to buy these medicines. We need in-country logistical systems that bring medicines to remote clinics and not only academic urban centers. This financing system is key. We also need to make sure doctors and health personnel are appropriately trained, we need patients to be well informed, we need pharmacists who are able to store these substances safely and monitor them. We have seen that inappropriate prescribing is an issue with the non-schedules medicines as well at times, so it is essential to have a legislative framework that streamlines appropriate use.
Belgium (Mr. Kananga): In a huge country like DRC, they have many concerns. They think this issue is not an urgency among the other many problems. I was faced with this a lot. In one of our projects, the professional stakeholders from Uganda came and they said pain management is not essential because they are used to living with pain. So to go back to the point about governments purchasing substances, I called a few hours ago (…) and they said they usually order 20kg of heroin for medicinal use annually but only use about 1kg. It is a cultural problem. We conducted a survey in DRC and found that the myths around morphine are still very alive also in academic circles.
Chair: Yes, we have a long way to go and I hope forums like this will help shifting the attitudes.
International Association for Hospice and Palliative Care, IAHPC (Dr. Radbruch): Stakeholder engagement is important for data collection both on the national and international level. Sometimes even if the country has imported opioids, they are not available to all patients and sometimes they are so expensive that they are just not affordable. We set up a price-watch to monitor this, but one guy had to look up 19 pharmacies until he found appropriate pain medication and then found out that one month’s supply of morphine is very much out of reach for people on minimum wage. I think additionally to the data, you need stories. We have to tell the stories of patients. So for example when the father of a famous football player died of cancer in South Africa, his teammates have spoken out publicly about how important it was for the dad to die peacefully and without pain. This generated a huge public discourse and policy decisions. Palliative care needs to be included in the continuum of care and we have to allocate resources to this accordingly. I would just like to add, in closing, that when we talk about the disparity of availability, it is not the dosage of opioids that need to be discussed but more the duration and corresponding elements of care.
Médecins Sans Frontières (dr. Aloudat): It is refreshing to see this conversation happening more and more frequently. It is very interesting when it comes to humanitarian settings, because whatever system has existed, it is usually very restrictive in emergency settings. Witnesses are key stakeholders, so I appreciate dr. Radbruch mentioning the impact of stories. These are very important in shifting culture, but cannot always be translated into policy decisions. Obviously, policy makers are important stakeholders, but healthcare providers and individual nurses, doctors and patients themselves are just as essential to be involved if we want to achieve change. Physicians prescribing pain management are very affected by stigma. We often convince ourselves that the pain is not that severe. The few kilos of national availability does not equal use by patients in the same volume. In the past few years, we worked on providing guidelines to catalyze the easing of responsible use of controlled medicines.
Chair: I think you illustrated really well that we are in the thick of the problem here but the issues are situated at the level of interaction between patients and their carers. We have not discussed overdoses and nonmedical use ýet, so I open this topic to the panelists. How can healthcare providers deal with nonmedical use and what would you recommend to policy makers to implement international measures ensuring adequate pain treatment while preventing diversion. This is a tough question, I know, but I invite you to share your expert opinions.
Médecins Sans Frontières (dr. Aloudat): In humanitarian contexts, there is often the problem of people using injectable drugs or are in replacement therapy … We lose patients who are hospitalized for non-drug related diseases but we lose them because we are unable to provide them with replacement therapy. So they have multiple medical requirements, but we have to negotiate one of them… The global procedures about the importation of opiates can be positively affected by catastrophes, but it should not be so. Procedures to supply MS with medicine should never be too complicated to follow.
International Association for Hospice and Palliative Care, IAHPC (Dr. Radbruch): Pain and suffering is one aspect of this issue, but it is also a financial one. What if the breadwinner of the family has to take care of an ill family member in lieu of proper medical treatment? Pain in many cases is not only just a physical sensation, but there are many things tethered to that. Of course it depends on the type of pain… some only need pain medication, but lots of patients with chronic conditions probably don’t need opioids. There are fundamental differences between pain patient and pain patient. We have guidelines for long-term noncancer pain management in Germany that clearly states that for a time restricted therapeutic trial, you can use opioids, but there are guides for the exact how. So this is the basic training that healthcare providers need. There is a higher risk in not using opioids properly than anything else. When we drafted the essential package for the Lancet Commission on use and storage, we were thinking about that often mentioned balance between availability and safeguarding.
INCB (Mr. De Jonchere): You cannot watch a tv program or read a newspaper without being informed about the horrific situation in North America, so I don’t need to go into too much detail about the problem of overprescribing and the aggressive promotional tactics in combination with financial incentives. During COVID, the rates of death in America have reached scandalous numbers. This doesn’t need to be like this. There are other high-income countries with a more appropriate, more rational prescribing culture that doesn’t spill into the black market. Associations of patients and professionals have taken action to address the issue, but again, you need data and concerted efforts to properly control the dispensing of controlled drugs. Some say, this is what you get when you promote palliative care, that it gets out of hand so easily as in North America,but there are plenty of examples world-wide that it does not necessarily come to that. Benchmarks and proper education are necessary for crafting effective pathways.
UNODC (Ms. Campello): Very nicely put – the balance is absolutely achievable. The safe and effective prescription practices, guidelines for pharmacists, nurses and doctors are essential and electronic prescription can really facilitate a more regulated market. The concerns of policy makers are well understood and what dr. Jonchere said really resonated with me – any kind of dialogue about the situation in North America is very difficult with policy makers. Low access in itself can be a strong driver for the black market. The patients who are funneled to the black market in North America raise the question: where is the treatment system? This issue should not exist in a vacuum.
Addiction Treatment Center, Slovenia (dr. Kastelic): I would like to bring up the issue of Naloxone. Every death is not necessary at all. Such deaths in Europe are often a combination of several drugs and alcohol; in the US, it is typically fentanyl adulteration. We have an INTERPOL-supported early warning system to detect such trends in my country.
Chair: You are right to highlight the point regarding Naloxone.
Belgium (Mr. Kananga): I would like to reiterate one point. Tramadol is more used than morphine in Africa.
Chair: Yes, thank you, it has been raised by multiple organizations.
Some speakers have already made the link between COVID and the availability of controlled substances, so I open this issue to the panelists. Has this experience given us some lessons we can apply after the pandemic phase is over?
Addiction Treatment Center, Slovenia (dr. Kastelic): We found out that cooperation with NGOs can be very useful. Anything that could not be managed by the healthcare system, civil society took care of. This gave us the opportunity to work more openly with NGOs even when it comes to controlled medications. This is true for multiple countries in Europe actually.
INCB (Mr. Joncheere): The pandemic took us by surprise, so the first part was very extreme in terms of supply chain interruptions and medicine availability. We have alerted all MS and issued the guides on simplified measures. We are not sure how many have actually used our offers – as has been mentioned earlier, systems should not be overly complicated but we are used to them so. Countries have the opportunity to excelerate imports with this mechanism. When we craft a pandemic preparedness convention, this shall be a priority on the agenda as well as medicines for treatment and not only vaccines. We have to clearly make sure that in our area of work, the people who are working at borders are aware of the accelerated procedures.
dr. Aloudat: (…) we are talking so much about the North American opioid issue… when we look at pain management and palliative care, we are looking at it with this North American perspective. I think it is very important to be aware of this, that we talk about any problem the way we perceive it but the most affected by it will probably have different understandings…
IAHPC (dr. Radbruch): Two major patient groups that have been most impacted during COVID. Breathlessness being the primary symptom of COVID… morphine is actually a very effective medication for this. So if a patient is not on a ventilator or decides not to want to be in intensive care or is not eligible for such care, they should be able to receive opiate pain management. The second group are the patients with palliative care needs even in high-income settings who faced barriers because of the social restrictions. The amount of anguish and suffering as a result of lack of access and emotional impact is much much underestimated. Dying patients should have had the opportunity to have relatives with them despite the fierce lockdown measures at least. We formulated a set of recommendations with a large research group actually – we think this should be considered in pandemic preparedness preparations.
UNODC (Ms. Campello): The distortions in the supply chain on the global level – this is an opportune time to think about this for future crises.
Belgium (Mr. Kananga): The pandemic has opened some eyes and policy are looking at options to locally regulate morphine in (France?)
USA: We applaud the theme of this discussion and thank all panelists for their contributions. The fundamental aim of the control conventions is to safeguard the health of humankind. No person should suffer from untreated pain. We have heard a lot today about balance. The treaties put a great importance on striking a balance between availability and prevention diversion. Our domestic situation has been devastating as a result of that balance being disrupted. Our country faces an overdose epidemic with most cases involving fentanyl. We have worked to educate prescribers on responsible opioid prescription. Pharmaceutical companies have been sued for the destruction they have caused – there have been and will continue to be settlements to communities and individuals. The financial implications of pain and suffering are costing our economy a great loss. We work towards better availability of replacement substances. During the pandemic, we introduced take-home programs and allowed patients to initiate such care online. A steady supply chain is a priority for the FDA and we maintain an emergency supply of medicines. We believe today’s topic is critical. While we spend much of our time at CND, we agree with the chair and panelists that we should double down on our efforts to enhance availability of medications.
Thailand:The pandemic has borne devastating consequences on our society. We align with UNGASS commitments and vow to leave noone behind. Criminalization (…poor audio quality…) We appreciate the work of the UNODC.
Chair: Dear colleagues, I see no more questions from the floor so I open the floor for the panelists to give their final thoughts.
Ecuador: The three conventions safeguard the wellbeing and health of all people. As said in the morning session, we have established a list of essential medicines and so we are consistent with our international commitments. It is the responsibility of relevant bodies to ensure appropriate accessibility to patients. We issued a handbook on regulation of medicines that are not included on the list. We are committed to providing timely and appropriate care to our citizens. These opportunities for cooperation and dialogue continue to be best practices for us. We continue to participate and support in the work of the CND as well as all international mechanisms to support the 2030 Agenda.
Colombia: During the pandemic, special measures were taken in Colombia to facilitate the uninterrupted import of medicines into the country. Our regulatory standards are currently being updated to involve increased measures and generation of data.
Chair: So, as a wrap-up question: What would you recommend the international community places on top of their priorities list?
Belgium (Mr. Kananga): To vow for concrete actions in the agenda. The practice we have in Belgium I consider a best practice to be followed.
Addiction Treatment Center, Slovenia (dr. Kastelic):The messages should be repeated, governments are changing, stakeholders are changing. What we talked about today has to be talked about again and again and again.
UNODC (Ms. Campello): I think sustained investment is very important. We have a remarkable consensus here, we know what to do. We need investment to do it.
INCB (dr. Joncheere): Keep this issue high on the political agenda is what we need to do, I agree. Also, trying to create feasible progress on country levels and share concrete best practices.
International Association for Hospice and Palliative Care, IAHPC (Dr. Radbruch): MS need to acknowledge palliate care as an integral part of the healthcare continuum. As the Lancet recommended, resources for the general public is an important element too.
Chair: Thank you everyone. I very much appreciate the steadfast support of the UNODC to put this issue to the forefront.
UNODC: (Closing remarks)
Chair: There seems to be outstanding consensus here but our work is only now starts. No patient should be left behind. (Thank yous)