Ketamine: We Speak to Top Relief Agency Pharmacists About the Effects of International Control

"Any level of scheduling poses a risk that supplies of quality ketamine will not be available when it's needed to treat patients in the field."
- Stéphanie Arsac-Janvier, Head Pharmacist at the International Committee of the Red Cross

On Tuesday the World Health Organisation's Expert Committee on Drug Dependence (ECDD) again found that ketamine should not be placed under international control - for the fourth time since 2006. However, the battle is not yet won. This week the deciding Commission (the UN CND) will meet to discuss the issue in Vienna before making a final decision on the issue in March 2016.

Since we began our #KetamineIsMedicine campaign on social media last week, the WFSA has received hundreds of stories about ketamine use in a medical context worldwide. One key focus of these stories has been on conflict and disaster areas.

During natural disasters or wars, relief agencies rely on the anesthetic and pain killer ketamine to save lives. It is one of the first medicines supplied to emergencies. Relief agencies can ship it to emergencies as soon as it's needed, because it's not controlled by international drug schedules.

"It is indispensable for anaesthesia and pain relief in acute and chronic emergencies," says Christophe Perrin, the Pharmaceutical Coordinator of the Médicins Sans Frontières Access Campaign.

"Since January 2013, MSF's European Supply Centres have sent around 200,000 vials of ketamine, to 37 countries, such as Afghanistan, the Central African Republic, Chad, the Democratic Republic of Congo, South Sudan, Syria and Yemen."

It is much more complex for relief agencies to supply medicines containing substances which are on international drug control schedules, than medicines which are not controlled. Controlled medicines, like the essential medicine morphine, for example, are extremely difficult to deliver to emergency zones.

Stéphanie Arsac-Janvier, Head Pharmacist at the International Committee of the Red Cross (ICRC), says it is virtually impossible to supply controlled medicines swiftly to emergencies, regardless of whether they are on the strictest international schedule or the least strict.

"The best case scenario is that it will take weeks to authorize export and import of a controlled medicine," says Ms Arsac-Janvier. "We have had one case where we have been trying to deliver a shipment of the scheduled painkiller pethidine to a conflict zone for a year - and it's still not delivered, because of administrative hold ups."

Scheduling imposes strict controls on medicines

The supply of controlled medicines is subject to strict regulatory requirements, which require authorization from both the importing and exporting countries. Even for experienced relief agencies which ship thousands of tonnes of medicines each year to countries which have poor health care systems, or which have been struck by natural disasters or war, sending controlled substances can be an insurmountable logistical challenge.

Some countries do not have the ability to deliver an import licence, and in those that do, there are frequently administrative problems. Any mistake in the paperwork - a wrong address or medicine name - or the absence of an original version of a form, can lead to delays.

"Any level of scheduling poses a risk that supplies of quality ketamine will not be available when it's needed to treat patients in the field," says Ms Arsac-Janvier.

Delays increase risk of poor quality care

Delays in shipping medicines to a country may mean that they have to be procured locally. In some countries, the required medicine may not be produced locally, available quantities locally may not cover all the needs or quality cannot be easily assured.

"This can mean that physicians have to use substitutes or pharmaceutical formulations that aren't ideal as is already the case currently for medicines on the least restrictive schedule, Schedule IV, of the Convention on Psychotropic Substances," says Christophe Perrin. "There simply is no equivalent for ketamine, though. It's not clear what the substitute would be."