Treatment of RCC in Asia-Pacific Region by l990juh

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       Boracay Island, Philippines, 19-21 April 2008
                                                PAISAL PUANGNIYOM1
                                           MORAKOT JAROONWATTANA1
                               RACHANEEKORN JEVPRASESPHANT2
                                              SAKON SINGHA3
                                                SUDSAWAT LAOHAVINIJ4
                                            KANOKPORN JAISATHAPORN5
                                       CHUTHAMANAEE SUTHISISANG6
                                 JUNPORN KONGWATCHARAPONG7
                                 PONGPARADEE CHAUDAKSHETRIN7

             THAILAND: Report on Opioid Availability

                        1.   Narcotics Control Division, Ministry of Public Health
                        2.   Government Pharmaceutical organization
                        3.   Palliative Care Unit, Prince of Songkla University
                        4.   Oncology unit, Rajavithi Hospital
                        5.   Oncology Unit, NCI
                        6.   Faculty of Pharmacy ,Mahidol University
                        7.   Faculty of Medicine Siriraj Hospital . Mahidol University
 In Thailand, consumption of opioid analgesics
  remains extremely low in comparison to medical
  need, compare to many Asian countries.


                          Average daily consumption of defined daily doses of
                          morphine per million inhabitants, 2003-2005: countries
                          of Central, South and East Asia
                                         Japan                                                                      131

                                   Hong Kong                                                       91

                            Korea (Republic of)                                     49

                                    Singapore                             28

                                      Mongolia                           26

                                        Macau                       22

                                      Malaysia                      21

                                      Thailand                15


         THAILAND                    Sri Lanka

                                         China            8
                                                              13



                                    Philippines           6

                                      Vietnam         3

                                         Nepal        1

                                    Myanmar,          1

                                      Pakistan    0

                                          India   0

                                   Bangladesh     0

                                     Indonesia    0

                                                  0            20              40        60   80        100   120     140
1. Social Culture Values (i.e. Fear of addicts,
   reluctance to report pain)
2. Healthcare System (i.e. Lack of training and Fear
   of legal consequence)
 OPIOPHOBIA = failure to legimate opioid analgesics
   because of a fear of power of this drug to produce
   addiction
3. Economic
4. Drug Regulation (i.e. Government Policy-limit the
   quantity and duration of opioid prescription,
   National health priorities may not include cancer
   pain relief)
1.   Mild – ASA, Acetaminophen, NSAIDS,
     Antidepressant drugs

2.   Moderate – Codeine, Hydrocodone, Oxycodone,
     Dihydrocodeine, Tramadol

3.   Severe – Morphine, Hydromorphone,
     Methadone, Levorphanol, Fentanyl, Oxycodone
1.   Short-acting (3-4 hours): Morphine sulfate, Codeine,
     Hydrocodone, Oxycodone, Hydromorphone,
     Oxymorphone

2.   Pharmacologically long acting (6-8 hours):
     Methadone, Levophanol

3.   Pharmaceutically long acting (12-24, 72 hours)

     Morphine SR, Oxycodone SR, Fentanyl transdermal
     patches
  Narcotic drugs in Thailand

1. Morphine
2. Pethidine
3. Fentanyl
4. Methadone
5. Codeine
           1. Morphine
                             For Oral form
2 Preperations

                             Injection form

                 1. Morphine sulfate 10 mg Inj
                       (With Preservative)


                 2. Morphine sulfate 10 mg Inj
                       (Preservative Free)

10/11/52
                 Morphine (2)
      For Oral form
1. Sustained release capsule
   (Kapanol®)
  : 3 strengths
20 mg, 50 mg และ 100 mg

2. Continous Tablet
(MST Continous Tablet)
  : 3 strengths
10 mg, 30 mg และ 60 mg


10/11/52
               2.Pethidine

     Preperation             Injection form



                    Pethidine HCL 50 mg/ml Inj
                          (1 ml)




10/11/52
               3. Fentanyl
                             TTS form(Transdermal
                              Therapeutic System)
     Preperation

                               Injetion form


                   Fentanyl citrate Inj 2 ml


                   Fentanyl citrate Inj 10 ml

10/11/52
                     Fentanyl (2)

     TTS form(Transdermal Therapeutic System)


                              : 3 strengths
                           1. Fentanyl TTS 12 mcg/hour *
                           2. Fentanyl TTS 25 mcg/hour
                           3. Fentanyl TTS 50 mcg/hour




•Fentanyl TTS 12 mcg/hour : first import in Thailand
                             at June 1997
  10/11/52
                  4. Methadone
        For Oral form

1. Methadone HCL
  5 mg/tab (Pain release
not use to treat addicts)
2. Methadone HCL
  Oral Solution 10 mg/ml
 (For medical institutes of
treating addicts)


  10/11/52
                    5. Codeine
           Preperation
   1. Single formula             N2
  Codeine PO4     15 mg

  Codeine PO4     30 mg




  2. As ingredients in medicinal formula

  Anti-tussive , Analgesic          N3
10/11/52
Trends of Consumptions
     Graph 1 COMPARE TOTAL QUANTITY OF MORPHINE
     BETWEEN LIMIT AND CONSUMPTION (2001-2006)

      Kg.base
70

60

50

40                                           limit
30                                           consump.

20

10

0                                     year
      2001 2002 2003 2004 2005 2006
          Graph 2 TRENDS OF CONSUMPTION FOR
                  ORAL MORPHINE ( 2003-2007)
 Capsule/tablet

1400000
1200000
1000000                                                Kapanol 20
                                                       Kapanol 50
800000                                                 Kapanol 100

600000                                                 MST 10
                                                       MST 30
400000                                                 MST 60

200000
      0
           2546
          2003      2547
                   2004    2548
                           2005   2549
                                  2006   2550
                                         2007   Year
          Graph 3 TRENDS OF CONSUMPTION FOR
            INJECTION MORPHINE ( 2003-2007)
 Ampule

1400000
1200000
1000000                                           Morphine inj 10 mg (Preservativ e
 800000                                           Free)
 600000                                           Morphine inj 10 mg (With
 400000                                           Preservativ e)
 200000
      0
          2546
          2003    2547
                 2004    2548
                         2005    2549
                                2006     2550
                                        2007    Year
 Graph 4 COMPARE TOTAL QUANTITY OF PETHIDINE
 BETWEEN LIMIT AND CONSUMPTION (2001-2006)

      Kg.base
200
180
160
140
120
                                              limit
100
                                              consump.
80
60
40
20
 0
                                       year
       2001 2002 2003 2004 2005 2006
   Graph 5 TRENDS OF CONSUMPTION FOR PETHIDINE
                    (2003-2007)

Ampule
1800000

1750000
1700000
1650000                                              Pethidine HCl Injection
1600000
1550000

1500000
           2546
          2003     2547
                  2004     2548
                          2005     2549
                                  2006     2550
                                          2007    Year
  Graph 6 COMPARE TOTAL QUANTITY OF FENTANYL
  BETWEEN LIMIT AND CONSUMPTION (2001-2006)

      Kg.base
0.6

0.5

0.4
                                             limit
0.3
                                             consump.
0.2

0.1

 0
      2001 2002 2003 2004 2005 2006   year
Graph 7 TRENDS OF CONSUMPTION FOR FENTANYL INJ.
                 (2003-2007)
 Ampule
800,000
700,000
600,000
500,000
                                                    2 ml
400,000                                             10 ml
300,000
200,000
100,000
      0
          2003   2004   2005   2006   2007   year
Graph 8 TRENDS OF CONSUMPTION FOR FENTANYL TTS
                 (2003-2007)
Piece


70000

60000

50000

40000                                       12 mcg/hour
                                            25 mcg/hour
30000                                       50 mcg/hour

20000

10000

    0
                                           year
        2003   2004   2005   2006   2007
Graph 8 COMPARE TOTAL QUANTITY OF METHADONE
 BETWEEN LIMIT AND CONSUMPTION (2001-2006)

  Kg.base
120

100

80
                                             limit
60
                                             consump.
40

20

 0                                    year
      2001 2002 2003 2004 2005 2006
Graph 9 TRENDS OF CONSUMPTION FOR METHADONE
                (2003-2007)
 gm
55000

50000

45000

40000

35000

30000                                         Solution (kg)
25000                                         Tablet (kg)

20000

15000

10000

5000

   0
        2003   2004   2005   2006   2007   year
 Graph 10 COMPARE TOTAL QUANTITY OF CODEINE
 BETWEEN LIMIT AND CONSUMPTION (2001-2006)
 Kg.base

3000

2500

2000
                                              limit
1500
                                              consump.
1000

500

   0
                                       year
       2001 2002 2003 2004 2005 2006
        Increase Opioids Accessibility
1. Amendment the regulation and solve the obstacle of
   narcotic analgesics purchasing and availability.
2. Recommended opioid analgesic by WHO is included in
   National Essential Drug List.
3. Analgesics and opioid analgesics in National Essential Drug
   List are available in pharmacy of every General hospital.
4. Thai FDA produces and distributes opioid analgesics
   especially oral opioid in Thailand.
5. Provide narcotic quota for each form and strength of
   narcotic analgesics separately eg. oral, solution, patch, and
   injection
    Problem about Opioids Accessibility in Thailand

Prob 1. Physician education and attitudes

Action Plan
   Apply pain and palliative care into curriculum
    (both undergraduate and postgraduate students ) to
    cover pain, palliative care and professionalism
   Continuing pharmaceutical and nurse education
   Mobile advocating unit to educate in whole country
    Problem about Opioids Accessibility in Thailand

Prob 2. Accessibility, availability and affordability of opioid
     formulations (National Insurance Institute)


Action Plan
    Meeting up with GPO board committee about
     available morphine formulation
    Meeting with National Health Insurance Institute for
     the subsiding policy
    Problem on Opioids Accessibility in Thailand

Prob 3. Pediatric cancer pain is undertreated

Action Plan
 More research projects on pediatric need assessment
 Encourage task force to deal with pediatric palliative
   care
 Availability of pediatric formula for pediatric (dosage
   form and formula i.e. Morphine oral solution
   10mg/5ml, 5mg/5ml)
 Special hospital for children
 Problem on Opioids Accessibility in Indonesia & Philippines


 Pain management for cancer and HIV/AIDS are low
  priorities (i.e. Indonesia)
 Not all of hospital and pharmacy have a stock of
  opioids
 Shortage of opioid for cancer pain, HIV/AIDS

 Physician license

 Problem on education and information

								
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