Cohort III
International Pain Policy Fellows
Bangladesh Opioid
Availability Action Plan
Madison, Wisconsin, USA
10 August 2012
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
1: State the 3-5 problems that lead to inadequate patient access to
opioid analgesics – Be as specific as you can
Problem 1:
Absence of palliative care policy and guideline
Problem 2:
Current Narcotics Law is a barrier to prescribing and
accessing opioids
Problem 3:
Lack of health care professionals trained in
pain relief and palliative care
Problem 4:
Absence of immediate release oral morphine
Problem 5:
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Step 1 – Develop the Action Plan
• Section A: State the 3-5 problems that lead to inadequate patient access to
opioid analgesics.
• Section B: State the objective(s) that would address the problem. (WHAT)
• Section C: List the action steps needed to achieve the objectives. (HOW)
• Section D: List those who have the authority/responsibility to take the
necessary action. (WHO)
• Section E: Indicate an approximate timeline for completion of the action
steps. (WHEN)
• Section F: State the assistance (technical, financial) that will be needed to
achieve each objective. (HOW MUCH)
• Section G: Expected outputs, and how measured
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Drug Distribution System Model
Level 1: International Narcotics Control Board
Level 2: National Competent Authority
Level 3. Importer/Manufacturers/Distributors
Level 4. Hospitals/Pharmacies/Hospice/PC
programs
Level 5. Physicians/Pharmacists/Other
Medication
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Level 6. PATIENTS
Information
Action Plan for:
BANGLADESH
Prepared by:
Dr.Rumana Dowla
Dr.Farzana Khan
Dr. Eric Krakauer
Marty Skemp Brown
10 August 2012
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
PROBLEM 1
A:
Absence of palliative care policy and guidelines
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
B: State the objective(s) that would address the problem. Which
objectives are the top priorities? (What?)
1.
2.
Pain relief and palliative care policy approved by MoHFP that guides implementation of, and
promotes access to, pain relief and palliative care nationwide.
National pain relief and palliative care clinical guidelines approved by MoHFP.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
C: What action steps are needed to achieve the objectives? (How?)
1.Ask MoHFP to convene ad hoc committee to create:
a)National pain relief and palliative policy (concise)
b) National pain relief and palliative care clnical guidelines
2. Convene National Pain Relief & PC Policy Committee
2.Draft National Pain Relief & Palliative Care Policy
3.Draft National Pain Relief and Palliative Care Clinical Guidelines
4.Obtain approval from MoHFP for the two documents.
D: List those who have the authority and/or responsibility to take the
necessary action; and with whom they should collaborate. (Who?)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Minister of Health
Secretary of Health
Director General of Narcotics
Director General of Drug Administration
Prof. Nezamuddin Ahmad
IPPF Mentors
IPPF Fellows
MoHFP ad hoc pain relief and palliative care committee.
WHO representative
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
Q Q Q Q
Name of activities
1 2 3 4
E: Timeline for completion of action steps. (When?)
Obtain permission from MoHFP to convene
x
ad hoc committee to create:
a)National pain relief and palliative policy
(concise)
b).Natl pain relief & pc clinical guidelines
Convene committee
x
Draft National Pain Relief & Palliative Care
Policy
x
x
Draft National Pain Relief and Palliative Care
Clinical Guidelines.
x
x
x
x
x
Obtain approval for National Pain Relief &
Palliative Care Policy
Obtain approval National Pain Relief and
Palliative Care Clinical Guidelines.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
x x
QQ Q Q
5 6 7 8
F: What assistance (technical, financial) will be needed to achieve each
objective under part “B”? (How much?)
1. Funds for per diem: TA (travel allowance) and DA (daily allowance)
2. Funds for refreshment
3. Palliative care technical assistance from mentors and other IPPF staff
4. Funds for picking up and taking home ad hoc committee members
5. Funds for overseas travel for mentors
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
G: Expected outputs, and how measured
1.
2.
3.
Approved National Pain Relief and Palliative Care Policy
Approved National Pain Relief And Palliative Care Clinical Guideline
Electronics copy of the above documents on DGHS (Director General Health
Services) website
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
PROBLEM 2
A:
Current Narcotics Law is a barrier to
prescribing and accessing opioids
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
B: State the objective(s) that would address the problem. Which
objectives are the top priorities? (What?)
1. Amend or clarify Narcotics Law so as to establish balanced system for certifying
physicians by Dept of Narcotics Control (NCA) to prescribe A-class and B-class
narcotics for medical and scientific use.
2. Enable DNC certification of adequate number of trained physicians to make opioid
analgesia universally accessible to patients in need in Bangladesh.
3. Revise incorrect or misleading items in Narcotics Control Law of 1990 that may
create barriers to accessibility of opioids for medical or scientific use (items 5e, 7 – 1,
13 – 1).
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
C: What action steps are needed to achieve the objectives? (How?)
1.Draft proposal for DNC certification of physicians to prescribe A-class and B-class
narcotic medicines
Note: Physicians who have completed a basic training course (at least 6 days) in pain
relief and palliative care from a training centre recognized by the MoH (or an equivalent
training as determined by the director of an MoH-approved course) and passed the MoH
examination in basic pain relief and palliative care will receive certification endorsed by
the Ministry of Health AND separate narcotics prescribing certification from the Director
General of Narcotics (as per amendment of item 13 1 of Narcotics Act of 1990). Each
MoH-approved training center would submit to the MoH each year a list of physician who
had passed the examination..
2. Meet with the following to discuss the easiest method for amending (or clarifying) item
13.1 (and other items) of the Narcotics Act 1990 and, if appropriate, to discuss our draft
proposal.
a) Prof.Modasser Ali
b) DG Narcotics
c) Minister of Home Affairs (Police)
d) Prof.Arup Ratan Chowdhury
3.Pursue process of change agreed upon in the above discussions.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
D: List those who have the authority and/or responsibility to take the
necessary action; and with whom they should collaborate. (Who?)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Home Minister
Minister of Health
Health Secretary MOHFP
Director General of Narcotics
Director General of Drug Administration
Prof. Nezamuddin Ahmad
IPPF Mentors
IPPF Fellows
MoH ad hoc pain relief and palliative care committee.
WHO representative
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
E: Timeline for completion of action steps. (When?)
Q1 Q2
Name of activities
.Draft proposal for DNC
certification to prescribe Class A
and Class B(Now)
x
Meet with key officials to discuss
the easiest method for amending
item 13.1 Narcotics Act 1990
-discussion on proposed draft
/method
x
x
.Pursue the process of change
X
X
University of Wisconsin Pain & Policy Studies Group
Generate
annual
report Center
for forMOH
World Health
Organization Collaborating
Pain Policy and Palliative Care
Q
3
Q4 Q5
Q6
X
X
X
X
Q7
Q8
X
X
F: What assistance (technical, financial) will be needed to achieve each
objective under part “B”? (How much?)
1.
Per diem for government officials involved in discussing amending or clarifying the
Narcotics Law when appropriate according to government regulations
2.
IPPF staff and mentors
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
G: Expected outputs, and how measured
1.
Revised item 13 1 (and items 5e, 7 – 1, 13 – 1) of Narcotics Control Act of 1990
2.
Approved, rational, and balanced method for certifying physicians to prescribe Aclass and B-class narcotics for medical or scientific use.
3.
MoH approved basic and advanced training curriculum in pain relief and palliative
care that includes training on diversion and dependence syndrome and addresses
problem of impaired physicians (see Problem 3 below).
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
PROBLEM 3
Lack of trained health care professionals in pain relief and palliative
care.
A:
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
B: State the objective(s) that would address the problem. Which
objectives are the top priorities? (What?)
MoH approved basic and advanced curricula in pain relief and palliative
medicine based on WHO (and MoH) guidelines.
MoH approved basic and advanced courses in pain relief and palliative care
held at least twice a year somewhere in the country.
MoH approved basic and advanced courses in pain relief and palliative care
offered in each state within three year.
At least one trained pain relief and palliative care trainer (trained by BSMMU
TOT curriculum) in each of the six divisions (like states) within three years.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
C: What action steps are needed to achieve the objectives? (How?)
•
Draft basic and advanced curricula in pain relief and palliative care based on existing
curricula (BSMMU, Harvard / Vietnam MoH)
•
Identify physicians from each of the six divisions to receive at least basic training (6
days) in pain relief and palliative care.
•
Identify at least one physician from each division who are committed to devoting at
least part of their careers to teaching and practicing pain relief and palliative care to
receive TOT training in pain relief and palliative care.
•
Prepare list of physicians whom we would like to receive training in pain relief and
palliative care form all divisions. Send request to appropriate authority (probably
Divisional Health Service, Divisional Medical Colleges, or hospital directors) to grant
permission to these physicians to receive training in pain relief and palliative care.
•
Establish schedule within two years for holding basic palliative care course twice per
year and advanced course once per year.
Note :Development of TOT training curricula and initial TOT trainings to be funded by
existing University Grants Commission (UGC) grant.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
D: List those who have the authority and/or responsibility to take the
necessary action; and with whom they should collaborate. (Who?)
1.
2.
3.
4.
5.
6.
7.
8.
Minister of Health
Health Secretary of Ministry of Health
Vice Chancellor ,BSMMU
Director of Divisional Medical Colleges
Medical Directors of Private Hospitals
Prof. Nezamuddin Ahmad
IPPF mentors
IPPF Fellows
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
E: Timeline for completion of action steps. (When?)
Activities
Q1
Q2
Draft basic
and
advanced
curricula
X
X
Q3 Q4
Q5
Q6
Q7
Q8
Identify
physicians
committed to
pc
X
X
X
Send list of
physicians
X
X
X
X
X
X
X
Teach basic
palliative
care courses
twice
X
X
X
X
X
X
X
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
F: What assistance (technical, financial) will be needed to achieve each
objective under part “B”? (How much?)
1.
2.
3.
4.
TA from IPPF Mentors.
Approval from Secretary of Ministry of Health
Approval from Hon. Minister of Health
Approval of training candidates by directors of Divisional Medical Colleges and directors
of private hospitals.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
G: Expected outputs, and how measured
1. Basic and advanced curricula in pain relief and palliative medicine.
2. Approval by Minister of Health of basic and advanced curricula in pain relief and
palliative
medicine.
3. List of physicians interested in pain relief and palliative care from each of the divisional
medical
colleges .
4.Two courses in basic palliative care and one course in advanced palliative care taught.
5. One TOT trained trainer in pain and palliative care from each divisional medical
college.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
PROBLEM 4
A:
Absence of immediate release morphine
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
B: State the objective(s) that would address the problem. Which
objectives are the top priorities? (What?)
1.
Immediate release oral morphine accessible to Bangladeshi patients in need as
per Essential Medicine List of Bangladesh MoHFP 2008.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
C: What action steps are needed to achieve the objectives? (How?)
Plan A
1. Identify Bangladeshi pharmaceutical companies (at least two) willing to manufacture
immediate release oral morphine.
2. Clarify how many, if any, Bangladeshi pharmaceutical companies have registered
immediate release oral morphine.
3. If necessary, assist at least two Bangladeshi pharmaceutical companies to register
immediate release oral morphine.
4.Persuade at least one Bangladeshi pharmaceutical company to start manufacturing
IR oral morphine before August 2014.
Plan B
1. Begin planning to import IR oral morphine from Nepal or India (Cipla.)
2. Get import license
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
D: List those who have the authority and/or responsibility to take the
necessary action; and with whom they should collaborate. (Who?)
•
2.
3.
4.
5.
6.
7.
Director General of Drug Administration
Director General of Department of Narcotics Control
Managing Directors and Chief Operating Officers of pharmaceutical companies
Dr. Bishnu Paudal
IPPF mentors
Prof. Nezamuddin Ahmad (Chief of Dept of PC at BSMMU)
IPPF Fellows
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
E: Timeline for completion of action steps. (When?)
Activities
Q1
Q2
Identify Bangladeshi
Pharmaceuticals
company
X
X
Clarify how many if any
Bangladeshi
Pharmaceutical
registered
X
Q3
Q4
Q5
Q6
Q7
Q8
X
X
X
X
X
X
Plan A
Persuade at-least one
Bangladeshi
pharmaceutical
Plan B -import
X
?
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
F: What assistance (technical, financial) will be needed to achieve each
objective under part “B”? (How much?)
1. Approval from Director General of Drug Administration
2. Approval from Director General of Department of Narcotics Control
3. IPPF mentors
4. Prof. Nezamuddin Ahmad (Chief, Dept of PC, BSMMU)
5. IPPF Fellows
6. Funds for arranging seminars with representatives of pharmaceutical companies.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care
G: Expected outputs, and how measured
Immediate release oral morphine available and accessible for pain relief and palliative
care in Bangladesh.
University of Wisconsin Pain & Policy Studies Group
World Health Organization Collaborating Center for
Pain Policy and Palliative Care