2019; Volume 20, No 3, March

Progress Reports (from Around the World)

We at IAHPC know that advocating for, and implementing, palliative care programs is challenging, uphill work. This is why we love to celebrate your successes and inspire our readers, who can learn from your experience. This section focuses on the successes and challenges of your regional, national, and local palliative care programs. Submissions are welcome; email [email protected]

Six Years, Six Actions: How we changed Bangladesh’s opioid legislation

By Dr. Farzana Khan, Dhaka, Bangladesh
Founder, President & CEO, Fasiuddin Khan Research Foundation

On one of the last days of December 2018, Bangladesh accomplished a crucial step toward accessibility and availability of opioids for medical use with the enactment of its revised Narcotics Control Act.

Previously, physicians needed explicit written approval for each prescription. Now, special authorization is no longer necessary for opioid prescription. The 28-year-old law has been adjusted in line with UN conventions on drug trafficking and narcotics control, to which Bangladesh is a party.

This is the story of how the new legislation came to be.

Painfully necessary

Pain management in Bangladesh is wrong by every measure. Cancer accounts for 150,000 deaths annually, and a further 130,000 people — with moderate to severe pain — are diagnosed yearly, but opioid use is among Southeast Asia’s lowest: just 0.05 mg/capita.

How it all began

On a crisp morning in August 2012, a moment of purity and beauty, this dream and sacred trust began. Rumana Dowla and I started evaluating our national policy as Pain Policy Study Group (PPSG) Bangladesh fellows with an aim to relieve the suffering and unmet pain of incurable ills.

The problem was the1990 Narcotics Control Act, Section 13, which stated that: ‘No physician shall prescribe an A?Class or B-Class narcotic as medicine without written approval of the Director General.’¹

How we did it

What a great journey it’s been! What made it possible? Teamwork? Hard work? Grit? From 2012 to 2018 was a time of intense learning, acquisition of knowledge, and targeting the crucial change. To achieve our goal, we made several high-impact interventions using multi-sectoral involvement, taking every opportunity:

1. Collaborative teamwork with passion, persistence, and hard work. It required six years of intense collaboration between the Centre for Palliative Care, Bangabandhu Sheikh Mujib Medical University; the Department of Narcotics Control; and the Bangladesh Medical Research Council along with two Bangladesh fellows of PPSG. The change resulted from constant discussion, argument, advocacy meetings, workshops, and collaboration between many people and organizations with different talents, knowledge, and perspectives.
2. Workshops for narcotics officials. Patient access is not possible unless opioids are available in the country and in the distribution system. To circulate the message we organized four workshops in late 2012 that helped us stake out the direction of our future work. The workshops made it apparent to us that there was no coordination between physicians and narcotics and other law enforcement officials.
3. Attendees of the narcotics workshop.
   Seminars for all stakeholders. The seminar, titled ‘Seminar on Opioid Availability and Accessibility to the End-Users,’ was jointly organized by the collaborative partners to create strategies to facilitate the necessary policy amendment, and to ensure an adequate and reliable supply of safe, cost-effective essential opioid medications of an acceptable quality to patients in need.
4. Local production of an immediate-release morphine tablet and syrup for the first time.
5. National situation analysis of palliative care. The National Institute of Population Research and Training and the Ministry of Health and Family Welfare assessed the background for the development of national palliative care guidelines by addressing primary needs and gaps, including opioid-related
   law, regulation, policies, and training guidelines.
6. Research. A survey titled ‘Physicians’ knowledge and attitude of opioid availability, accessibility and use in pain management in Bangladesh’ was conducted. Researchers interviewed 1,000 physicians with pain management responsibilities practicing in 47 districts in Bangladesh.

What’s next?

Having a revised law is a wonderful base for improving pain management. But we need more awareness and training for clinicians across the country. And that's where I'm going to end my remarks, because that's where we need national and international cooperation again. That is the work that stands before us.

Reference:

1. Department of Narcotics Control. Narcotics Control Act, Section 13. 1990, p.

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