The Bhutanese Leading the way.
The controlled drug, Morphine, used on cancer patients to relieve pain, has gone out of stock in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH). Morphine tablets collected from other hospitals in the country are also finished.
The substitute drugs, Pethidine, Codeine, Tramadol, that are less potent than Morphine, is available in limited stock. JDWNRH is soon to run out of Pethidine and Tramadol.
According to a health official in JDWNRH, the hospital received its annual stock of Fentanyl. Fentanyl can be used as a painkiller. The mechanism is similar to Morphine but the duration is shorter, and therefore, less potent.
The doctors at JDWNRH are worried as they do not have any choice but to use the substitutes.
“We have asked doctors to adjust with Fentanyl for now,” said the health official. Codeine, which is less potent, is given orally. “We are running out of Codeine too,” the official said. A stock of codeine lasts for few weeks only.
“The supplier said Morphine would reach here by 13 November, but I don’t think it will reach by next month. Morphine tablets were supposed to reach by end of September or first week of October,” said the health official.
The patients are given substitute painkillers for one or two weeks depending on their distance while the doctors recommend taking the medicine for a month. The official said there are many cancer patients in palliative care and this has caused inconvenience and impact in the service, said the official.
Morphine is mainly used by cancer patients and also non-cancer patients, and the requirement is according to the severity of the pain with no such maximum dose limit. So each cancer patient would require 3 Morphine tablets to 5 tablets in a day and sometimes it goes up to 15 tablets.
The shortage was reached due to the disqualification of local suppliers, KMT and Paras. Their licenses were cancelled by the Drug Regulatory Authority (DRA) in July this year. Consequently, the health ministry has cancelled all the supplies from the local suppliers.
In 2014, there was a similar incident and it was resolved after they sourced the drugs directly from the manufacturers. “So we have suggested the same to Department of Medical Supplies and Health Infrastructure (DMSHI) in the last meeting,” the official said
In an earlier story on Morphine shortage, Medical Superintendent, Dr Gosar Pemba, said there is an increase in the usage of Morphine for cancer patients as they are now treated in JDWNRH, as radiotherapy and chemotherapy is done in-country.
In December 2018, JDWNRH received 40,000 Morphine tablets. As per the 2018 records, there were more than 2,000 cancer cases registered in the last four years. At least 500 new cancer cases are reported every year.
“We are expecting 50,000 morphine tablets with an additional increase of 20 percent extra tablets this year until next supply. So every year, there is an increase,” said Dr Gosar Pemba.
He said, in the palliative care, the usage of morphine is high since it is the end of life where there is no hope for recovery and to is used make the patients’ lives more comfortable without any pain.
He also said that the supply of controlled drugs takes time and if the supply is late then there might be a crisis. Therefore, a request has been made to DMSHI to expedite the supply, and to avoid the crisis situation.
“Since almost all our controlled drugs are purchased by DMSHI, we are worried if the supply is late and also the controlled drugs cannot be bought anytime or anywhere and it is only bought in bulk once in the year,” said an official of JDWNRH.
However, DRA gives exemption for non-registered medicines if it is really required by the government or if it is essential medicines. The procurement can made using an alternative arrangement.
