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

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.

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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
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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
driving Vietnam’s HIV/AIDS epidemic
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Illicit opioid use – now mainly injected heroin – is a
major problem in Vietnam: ~170,000 IDU

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…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
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Opioid Availability in Vietnam:
Progress through partnerships and policy reform

• Before 2008
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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

–
–
–
–
–
–
–
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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
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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.
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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.
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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?)
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