MSF Letter to CND Member States - request to take a public health approach during scheduling discussions
MSF requests CND Member States to take a public health approach during scheduling discussions
14 March 2016, Geneva — MSF understands the issue of ketamine scheduling may be raised during the 59th Session of the Commission on Narcotic Drugs (CND) meeting being held March 14-22, 2016 in Vienna.
Ketamine is included on both the World Health Organization’s (WHO) Model List of Essential Medicines and MSF’s Essential Drugs Guidelines for induction and maintenance of general anaesthesia. MSF uses ketamine in surgery programs in low resource settings, as well as in emergencies, natural disasters and conflicts.
The advantages of ketamine in such settings are well documented: it is safe and effective without the need for oxygen, suction or monitoring, and its administration does not require the presence of a trained anaesthetist.1 It is fast-acting, and can be used for sedation, induction and maintenance of general anaesthesia, and post-operative analgesia. It does not depress breathing or blood pressure and has minimal side effects even when used in patients with trauma, lung diseases or septic shock. Due to its unique efficacy profile and important safety benefits, there is no therapeutic equivalent or alternative to ketamine. In the past three years, MSF has administered over 180,000 vials of ketamine for patients in surgical projects in 37 countries.2 In a recent review of anesthesia care in MSF field settings, about 45% of all surgeries were performed using general anaesthesia without intubation, which was only possible because of the use of ketamine, and had excellent efficacy and safety outcomes as a result.3
MSF’s position is firmly against any level of scheduling for ketamine – not just Schedule I. Indeed, any level of scheduling poses a serious threat to access due to increased and cumbersome regulatory, administrative and import-export procedures, including the now-proposed Schedule IV. We note the recurrent4 anti-scheduling recommendations of the WHO Expert Committee on Drug Dependence, as well as the same positions of the ICRC and the World Federation of Societies of Anesthesiologists.
We also note and commend the common African Union position from April 2015.5
AGENDA ITEM IV: THE PUBLIC HEALTH-DRUG CONTROL NEXUS 17. In addressing the public health-drug control nexus, the presentations by Dr Gilles Forte, WHO and Mr Gunashekar Rengaswamy, UNODC, highlighted the issue of access to internationally-controlled psychotropic substances, and the case of scheduling of ketamine and other substances and implications for health in Africa. The session highlighted that untreated / undertreated chronic pain has serious physical, emotional, social consequences that severely affects the quality of life. Pain is not a symptom: it’s a disease entity itself. Following the plenary discussion, the Ministers: Called upon Member States to unanimously support non-scheduling of ketamine internationally as it is very essential especially for trauma in emergency and in war situations, with limited alternatives available. The challenge is to ensure balance between access and control. Also called upon Member States to undertake legislative review, allow roles of doctors to be shifted to specifically trained nurses enabling them to prescribe oral morphine to patients in severe to moderate pain, and provide training for policy makers and health professionals, including allocation of funds to benefit larger population from AU.
MSF encourages Member States of the CND to resist any attempt to schedule this crucial medicine, and to take a public health approach when considering the implementation of the relevant international treaties to ensure they always facilitate, not impede, access to medicines. Member States have the opportunity to help ensure patients who need ketamine the most – those needing emergency surgery in complex, under-resourced settings – will continue to be able to access it, free of international controls and unnecessary scheduling.
Dr Manica Balasegaram Executive Director Access Campaign Médecins Sans Frontières
1. Burke T et al. A Safe-Anesthesia Innovation for Emergency and Life-Improving Surgeries When no Anesthetist is Available: A Descriptive Review of 193 Consecutive Surgeries. World J Surg 2015; Sep; 39 (9): 2147 – 52.
2. MSF Supply Centre data 2013 – 2015.
3. Ariyo et al. Providing Anesthesia Care in Resource-limited Settings. Anesthesiology 2016; 124: 561 – 9. Some intubated surgeries also use ketamine, bringing the total percentage of surgeries done in MSF which use ketamine up to about 55%.
4. 2006, 2012, 2014, 2015 WHO ECDD meetings: recommends against scheduling of ketamine