V. The Middle East and North Africa
"Doctors are fearful of everything to do with opioids." – Oncologist, Jordan.
“[The prescription limitation of] seven days is not enough. It makes our work harder and forces patients to travel long distances to have access to morphine” – Professor of Oncology, Morocco.
The Middle East and North Africa region is characterized by vast differences in resources, containing some very poor and some very wealthy countries. These differences are clearly reflected in the availability of opioid analgesics. Four countries in the region — Iraq, Pakistan, Sudan, and Yemen — consume so few opioid medicines that even if all were used only to treat patients with terminal cancer and HIV/AIDS for pain, less than 10 percent of those patients could receive adequate pain treatment. Afghanistan and Somalia do not report opioid consumption to the INCB, and Djibouti reported no consumption for 2006 to 2008.
A number of oil-rich nations, such as Bahrain, Kuwait, Saudi Arabia, Qatar, and United Arab Emirates, also consume relatively few opioid medications. Iran stands out in the region for its high consumption of opioids, particularly methadone, but a significant proportion is used for treating drug dependence, not pain. In all, at least 180,000 patients in the region will die of cancer or HIV/AIDS each year without adequate pain treatment.
None of the countries surveyed from the region has a national palliative care policy, although survey respondents in Morocco expect one to be adopted soon. While the cancer control policies of four of the five countries surveyed include references to pain treatment or palliative care, HIV policies, where they exist, do not. Egypt and Iran are among just six of the forty countries surveyed that have not included oral morphine in their essential medicines list.  In fact, Iran is one of two of the forty countries surveyed where oral morphine is not a registered medicine and thus not available at all. Although an article in a peer-reviewed medical journal states that Iran’s cancer control policy covers palliative care, Iranian key informants we surveyed were unaware of this. 
As shown in Table 14, Egypt is the only country surveyed in the region to have any compulsory instruction on palliative care as part of undergraduate medical programs. Morocco and Jordan do not have any instruction on palliative care available in such programs. In Iran and Jordan, no post-graduate instruction on palliative care exists.
Supply and Distribution
While injectable morphine is available in most or all hospitals in Egypt, Iran, and Morocco, this is only the case in some hospitals in Jordan and Pakistan. The availability of oral morphine is particularly poor in the countries surveyed in the region. As mentioned above, in Iran it is altogether unavailable. In Pakistan, oral morphine is not available in any hospices and only in few pharmacies and health centers. In Jordan, while available in all hospices, no health centers have morphine and only few pharmacies. Of the countries surveyed, Egypt has the best availability of oral morphine, with the medication available in all hospices, most tertiary hospitals, and some pharmacies and health centers. Survey respondents from all countries surveyed said that it is harder to access morphine outside of major cities.
All countries surveyed in the region, except Pakistan, require special prescription forms for morphine. Survey respondents in Pakistan reported that some hospitals require the use of special prescription forms, even though they are not legally required. Four of the countries surveyed have limits on the length of time that a prescription can cover, again, all but Pakistan. In Iran, the limit is relatively generous at 30 days, but there are much shorter limits in Egypt (7 days), Jordan (10 days for cancer, 3 days for other patients), and Morocco (7 days).
Regulations also restrict who can prescribe morphine and to whom. In Iran, morphine can only be prescribed for home use for cancer patients. In Egypt, most doctors can only prescribe up to 14 morphine tablets. Only oncologists and pain specialists can prescribe more. In Morocco, general practitioners must obtain a license to prescribe morphine, while other doctors working in hospitals or larger clinics are covered by that facility’s license. In all of the counties surveyed, at least one respondent felt that fear of legal sanction was a deterrent to prescribing opioids. None of the countries surveyed allow nurse prescribing.
Table 16: Restrictive Regulation of Morphine Prescribing in the Middle East and North Africa
In the Middle East and North Africa, poor accessibility does not appear to be attributable to the cost of morphine. Respondents in all those countries surveyed reported that the morphine formulations available are generally inexpensive.
Developing Palliative Care: Jordan
Jordan is one country in this region that has made significant strides in the last decade in developing palliative care. Between 2001, when the reform efforts began, and 2008, the last year for which data is available, consumption of morphine increased 2.5 times. In 2004 the Jordanian government partially reformed drug regulations, removing a provision that limited morphine prescribing rights to oncologists and slightly increasing the number of days a prescription for cancer patients can cover from 3 to 10 days (although it remains 3 days for non-cancer patients). That same year, a local pharmaceutical company began producing low cost immediate release morphine tablets, leading to a significant decline in the costs of the medication and an increase in the number of formulations available.
Although there is still no instruction on palliative care available in undergraduate or post-graduate medical programs in Jordan, some progress has been made in educating health professionals. Through international fellowships, a handful of physicians have received in-depth training. These physicians are now conducting palliative care training in other major oncology units in Amman and elsewhere.
Jordan’s progress demonstrates how much is possible with government leadership and a coordinated effort by government agencies, healthcare workers, UN agencies, and civil society.
In 2001 the Jordanian government, WHO, healthcare workers, civil society, and the pharmaceutical industry came together and decided to establish the Jordan Palliative Care Initiative (JCPI), which was tasked with developing palliative care in the country and was designated a WHO Demonstration Project. In November that year, the Jordanian Ministry of Health and WHO agreed to work together to better integrate palliative care into the Jordanian health system. This lead to a joint workshop in 2003 to develop a national action plan and a National Palliative Care Committee.
These achievements should embolden Jordan’s government to raise palliative care availability to the next level by developing and implementing a national palliative care policy, expanding availability of morphine to more health facilities, further reforming its drug regulations, and introducing palliative care instruction into undergraduate and postgraduate medical and nursing curricula.
A further three countries (the United States, the United Kingdom, and Germany) reported that they do not have an essential medicine list, and there were conflicting responses from survey respondents in Mexico.
“Implementation of Comprehensive National Cancer Control Program in Iran: an experience in a developing country” Annals of Oncology, Vol. 19, No.2, February 2008. p. 399.
 Jan Stjernswärd et al., “Jordan Palliative Care Initiative: A WHO Demonstration Project,” Journal of Pain and Symptom Management, vol. 33, no. 5 (2007), p. 631.
 Amanda Bingley and David Clark, “A Comparative Review of Palliative Care Development in Six Countries Represented by the Middle East Cancer Consortium (MECC),” Journal of Pain and Symptom Management, vol. 37, no. 3 (2009) p. 291.
 Jan Stjernswärd et al., “Jordan Palliative Care Initiative: A WHO Demonstration Project,” Journal of Pain and Symptom Management, vol. 33, no. 5 (2007), p. 629.
 Ibid., p. 630