Katherine Irene Pettus, PhD, Advocacy Officer, International Association for Hospice and Palliative Care Association (IAHPC)
European member states of the Commission on Narcotic Drugs (CND), led by Switzerland and the Netherlands, are struggling to protect the World Health Organization’s mandate under the 1971 UN Convention on Psychotropic Drugs to make recommendations on the global availability of essential medicines. China, where some populations use ketamine as a party drug, is attempting to trump the WHO mandate by stirring up non-evidence-based fears of a potential global epidemic of ketamine misuse, and is asking the CND to place ketamine under international control. Ketamine, (in the words of internationally renowned palliative care physician, Dr MR Rajagopal, the “poor man’s anaesthetic”) is the most widely used agent in the lower- and middle-income countries. Placing it under international control would make it virtually inaccessible in lower- and middle-income countries (read more).
WHO lists ketamine as an ‘essential medicine’ for essential surgery, meaning it must be “accessible and available at all times.” Countries have the sovereign right to schedule (control) medicines domestically, and more than 60 countries already control ketamine, but international control of medicines creates entirely different sets of barriers. As the world has already seen with morphine, international scheduling drastically reduces use and increases global suffering.
The 1971 Convention mandates the WHO to evaluate psychotropic substances for their potential to cause harm to public health, and to weigh that potential against the beneficial medical and public health properties of the substance. If WHO decides, after a lengthy, peer-reviewed evaluation process, that a substance has a potential to damage public health, it can recommend that the CND place it in one of four international schedules, with greater or lesser controls depending on medical use. If WHO decides that the substance’s medical value outweighs potential public health damage, and that scheduling would create barriers to access, or aggravate public health harms, it will recommend against scheduling.
China, as per the provisions of the 1971 Convention on Psychotropic Drugs, has asked the World Health Organization’s Expert Committee on Drug Dependence (ECDD) to review ketamine three times in the past decade, most recently in 2014. Three times the ECDD has done so, weighing the evidence of misuse against the evidence of ketamine’s public health value. Three times WHO has declined to recommend that ketamine be placed in any one of the four schedules, citing its beneficial public health use and status as an essential medicine for essential surgery.
Despite that recommendation, the CND’s executive branch, the United Nations Office on Drugs and Crime (UNODC), opted in January this year to support China’s position against the WHO, and has scheduled a vote on the ketamine issue at the CND’s 58th Session March 9-26.
When UNODC announced the Chinese proposal to place ketamine under international control against the WHO’s explicit recommendation, Dr. Willem Scholten and I collaborated to draft a fact sheet for member states and concerned NGOs to inform them of the stakes of the debate. More than 57 concerned public health and medical organisations worldwide have now endorsed the fact sheet at the time of writing. It is currently in wide circulation and will also be distributed at the CND meeting in March.
The goal of this campaign supporting the WHO recommendation on ketamine is to have CND member states either abstain from the vote on March 13, or vote ‘no’ on an amended Chinese proposal to place it in either Schedule III or IV. Abstaining states would demonstrate their adherence to the ‘black letter law’ of the 1971 Convention, which instructs the CND to follow the WHO recommendation, which shall be “determinative as to medical and scientific matters.” States that vote ‘no’ on any scheduling recommendation would be showing that they accept the WHO’s substantive evaluation of ketamine’s value as an essential medicine.
The Commission on Narcotic Drugs has no authority to challenge the integrity of WHO’s expert review process for essential medicines. If China succeeds this year in having CND place ketamine under international control, another state could succeed in having tramadol scheduled next year, which would be another disaster for palliative care physicians in the lower- and middle-income countries. IAHPC is urging EAPC members to support the WHO public health mandate and recommend to their governments that all EU member states either abstain from voting, or vote against any Chinese proposal to place ketamine in any international schedule at the CND next week.
Dr Katherine Pettus is a regular contributor to the EAPC blog on advocacy matters. Click here to read more of her posts.