Potential & Actual Opioid Diversion in Vietnam, Methods of Preventing Diversion, and Barriers to “Balance” Eric Krakauer, MD, PhD Harvard Medical School Center for Palliative Care Massachusetts General Hospital Copyright © 2012 Eric L Krakauer & Massachusetts General Hospital All rights reserved Outline • Background: Opioid use & abuse in Vietnam: past & present – Vietnamese opiophobia • Prevention of diversion – Laws & regulations – Discretionary control of opioid prescribing by healthcare leaders • Evidence of diversion of controlled medicines • Ways forward History of Opioids in Vietnam … • Opium trade controlled by French colonial regime in 19th & early 20th centuries – Major source of revenue – Means of social control – ”Village quotas” • Opium trafficking by CIA 1950 – 1970s as means of financing clandestine operations & war (Laos) • Heroin use by US & ARVN soldiers • Current epidemic of injected heroin dependence driving Vietnam’s HIV/AIDS epidemic Illicit opioid use – now mainly injected heroin – is a major problem in Vietnam: ~170,000 IDU …History of Opioids in Vietnam • Results: – Profound cultural OPIOPHOBIA Association of opioids with Western tyranny and “social evils.” – Negative language about opioids throughout Vietnamese law – Strict regulatory control of opioid prescribing: • Limits on prescribers: – Right to prescribe, dose, duration – Reluctance / refusal by healthcare leaders to permit staff to prescribe opioids • Limits on pharmacists Opioid Availability in Vietnam: Progress through partnerships and policy reform • Before 2008 – – – – – – – Max Rx period days Max Rx 30 mg/5 days No CA/AIDS=no opioid Records years Insuff IR morphine Limited pt access No guidelines – Inadequate PC training – Hospital directors decide who can Rx • Starting in 2008 – – – – – – – – – 30 days No max dose No CA/AIDS=7 day Rx years Increased domestic mfg District avail plan MoH PC guidelines MoH PC Train Program Hospital directors still decide who can Rx Recent Evidence of Diversion of Controlled Medicines • 2000: nurses at National Cancer Hospital (Hanoi) sentenced to years in prison for collecting ~100 dispensed but unused vials of diazepam, selling it to private pharmacies • 2006: pharmacists from Kien Giang Province sentenced to years in prison for stealing ketamine & selling it to interested individuals • No confirmed reports of opioid diversion Results of Diversion of Controlled Medicines • Changes in regulatory policy: Diazepam briefly classified as “narcotic:” Very secure storage Restrictions on prescribing that limited access (It is now considered again a psychotropic drug with less strict regulations for storage and prescribing.) • Prison terms for all diverters • Probably greater fear among MDs that they will be held responsible if a patient diverts At HCMC Cancer Hospital, rumor of a patient’s family selling morphine –> Hospital Director reduced maximum outpatient opioid prescription length to days Ways Forward Toward Balance • Avoid unnecessarily risky practices – Eg.: Stocking morphine at HIV OPCs with no pharmacist • MoH certification in pain relief & pc – Certified MDs should be able to prescribe opioids – At least – MDs certified in pc at each district hospital • Oral IR morphine available in all districts as planned • Scale-up palliative home care – health insurance must cover home care • Opioid contracts required for patients with risk factors for “dependence syndrome” or diversion • Routine monitoring: – Of opioid consumption – For diversion (models?)