1. 1 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.

2. 2 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

3. 3 History of Opioids in Vietnam … Opium trade controlled by French colonial regime in 19 th & early 20 th 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

4. 4 Illicit opioid use – now mainly injected heroin – is a major problem in Vietnam: ~170,000 IDU

5. 5 …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

6. 6 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 –Hospital directors decide who can Rx 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 –Hospital directors still decide who can Rx

7. 7 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.

8. 8 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 5 days.

9. 9 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 –For diversion (models?)