Situation analysis in Kyrgyzstan Making Opioids Available in Eastern Europe and Central Asia March 5-6, 2013 Vienna

Opioid analgesics are currently registered in the country WHO List Codeine - Morphine inject form 10 mg + Morphine oral immediate and sustained release - IAHPC List Codeine - Fentanyl - Methadone + Morphine (immediate release) + Morphine (sustained release) - Oxycodone - Tramadol +

List of medicines for cancer patients under State Guarantee Program on preferential terms Code and of Medicine form Cost of reimbursement for 1 piece (in som) Code and Brand name of Medicines Medicine’s form Dosage mg, etc. number

The system of drug control Ministry of Health Statistics on controlled drug usage annually Than chief nurse reports to regional Health Department Doctor reports to Chief Nurse the list of prescriptions with patient’s name KG State Agency for Drug Control Annually Estimate For 2013 – April 2012 International Narcotic Control Board Has access to SADC data base

Patient Barriers Special prescription form Four stamps and two signs Pharmacy Warehouse Storage Pharmacy Medical Practitioner Prescription Patient Health Insurance Fund Copayment Pharmaceutical Distribution Company Department of Medicines Supply and Medical Equipment of the Ministry of Health Registration State Agency for Drug Control Get approval and include to the Register List Customs Customs Clearance Hospital (Oncology Center) 3. The process of testing and registration, importation, warehousing, distribution, storage, prescribing, dispensing, monitoring of prescription usage, etc. Barriers Special prescription form Four stamps and two signs Pharmacy dispense limit time (9:00 am – 4:30 pm) Limit on q-ty (20 vials of morphine) Limit time – prescription form works 10 days

2 hospices for HIV/AIDS patients National Oncology Center PC Department (25 beds) Opioids are always available in specialized hospitals (oncology centers) Morphine is allowed to prescribe to patients with cancer on 4th stage only In other cases, doctors prescribe Tramadol and Promedol Inter oblast Oncology Center PC Department Pharmacy Length of Rx is 10 days 1. Morphine in 10 mg injection form 2. Promedolum in 20 mg injection form 3. Tramadolum 4. What are the restrictions on prescribing, i.e. route of administration, dose, length of prescription? PC Department in National cancer center serves arround 500 patients per year, 42.2% of of them die in the first year of the disease (one-year mortality rate) Family Medicine Center Maximum amount of: Morphine for on prescription form - 20 vials Tramadol - 10 vials Family Medicine Center Diploma of a physician or feldsher. Family Medicine Center

Opioid accessibility

The cost of medications and health insurance coverage Health Insurance Fund covers cost of medicines by two ways: Additional Package – for all insured people according to the list of medicines State Guaranty Program (SGP) – for 5 types of monitored diseases, including cancer on 4th stage only The cost of one vial of Morphine – 25,73 KGS (0.53 USD) one vial of Promedol – 42,73 KGS (0.91 USD) Reimbursement by Health Insurance Fund – 97% Limits of SGP for cancer patients: Ketoprophen – 36000 mg or 360 vials Promedol – 4800 mg or 240 vials Morphine – 3000 mg or 300 vials

Coverage by State Guarantee program of preference patients (9 months of 2012, number of preference patients , % of coverages)

The volume of sold medicines (during 9 months 2012)

Opioid prescription’s forms 5. Who can write opioid prescriptions, i.e. an oncologist?

Prescribed opioids registration book Patient chart and list of opioids injection chart

1. References for pharmacy registration book for taking opioids 2 1. References for pharmacy registration book for taking opioids 2. Sample of reference form

The registration book of used opioid’s ampoules   The registration book of used opioid’s ampoules    

1. Registration book of certificates damaging empty ampoules of opioids 2. Sample of certificate

6. What is the projected need for morphine in the country by dosage form (IR, SR, and injectable) Mortality: Cancer - 3400 AIDS - 100 TB – 600 Need in Palliative Care – 4100 Need in morphine – 24,9 kg