Potential Actual Opioid Diversion in Vietnam,Methods of Preventing Diversion,and Barriers to “Balance”

Potential & Actual Opioid Diversionin Vietnam, Methods of Preventing Diversion, and Barriers to “Balance” Eric Krakauer, MD, PhD Harvard Medical School Center for Palliative Care Massach

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

• 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

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

Opioid Availability in Vietnam:

Progress through partnerships and policy reform

• Before 2008

– Max Rx period 7 days

– Max Rx 30 mg/5 days

– No CA/AIDS=no opioid

– Records 5 years

– Insuff IR morphine

– Limited pt access

– No guidelines

– Inadequate PC training

• Starting in 2008

– 30 days – No max dose – No CA/AIDS=7 day Rx – 2 years

– Increased domestic mfg – District avail plan

– MoH PC guidelines – MoH PC Train Program

Recent Evidence of Diversion of

Controlled Medicines

• 2000: 2 nurses at National Cancer Hospital

(Hanoi) sentenced to 2 years in prison for

collecting ~100 dispensed but unused vials of diazepam, selling it to private pharmacies.

• 2006: 2 pharmacists from Kien Giang Province sentenced to 7 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:”

(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 5

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 1 – 2 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