The International Narcotics Control Board^21,22has published the following figures for the consumption of narcotic drugs in Cyprus during 2002: codeine 6 kg (down from 20 kg in 2001); morphine 1 kg (down from 2 kg in 2001 but was 1 kg in 1998); pethidine 4 kg (down from 6 kg in 2001).

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)²³ in Cyprus was 46. This compares with other countries in the Middle East region as follows: Egypt 2; Israel 253 ; Jordan 11 ; Turkey 7; no reported morphine consumption in the Palestinian Authority during 2000-2002 (see Table 4).

Opioids and other related medications are available throughout the south of Cyprus. Where necessary, opioids are given by injection and syringe drivers are used for pain relief in home care patients.

Table 4: Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002 of the six MECC member countries in the Middle East region.

Source: International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations, 2004.

There are, however, still some problems accessing oral opioid preparations in larger dosages. As Sophia Pantekhi explains:

‘We’re trying to follow the guidelines from the pain step ladder of the World Health Organisation (WHO). We have enough medication for pain control: MST, Sevredol, Oromorph, and Fentanyl patches. We don’t have any other kind of morphine like Oxycodone or Hydromorphone. If we want to improve pain control, we need higher dosages of Sevredol tablets, at the moment we only have Sevredol 10 and 20mg. We need to increase awareness in health care professionals about how and when to prescribe opioids for their patients.’²⁵

The problem of ensuring that opioid medications are prescribed safely has required that the specialist trained palliative care teams educate health professionals (physicians, pharmacists and nurses) throughout the health system, as well giving clear instructions to the patient.²⁶ Jane Kakas describes the shift in understanding that took place in 1997, following a conference on palliative care pain relief:

‘After the Cancer Pain conference in ’97 here in Limassol, we met many worldwide palliative care specialists and some people from the WHO, including David Joranson - we realized that we have to be not just a cancer association, we have to look at palliative care issues. One of the issues was that we didn’t have enough basic formulations of opioids in Cyprus. So we got together a presentation and we presented to oncologists, government doctors, pharmacists and any other doctors, anyone that was remotely connected, drug reps, anaesthetists. We told them that although there are many options of new drugs on the market we believe you only need to have a small handful of drugs. So we suggested five formulations and an alternative opioid. Janssen was there already introducing Durogesic anyway. And we took this forward and with the backup of one specific oncologist and government pharmacists who understood what we were saying – we presented it to the government and they said yes and they ordered them for us. So we got of MST 10 mg and 100 mg, morphine in 30 ml ampoules of (we don’t have diamorphine here), and we needed this morphine for the syringe drivers. We also got morphine suppositories and MST 30 mg in sachets for easy swallowing. We tried to influence doctors and nurses about how to use these new drugs, and even the pharmacists – I always mention the pharmacists because pharmacists play a huge role, and they have to know why somebody’s going to the hospital to collect so many ampoules of morphine for the syringe driver. If they’re not aware of what a syringe driver is and that’s why we require a large dose of morphine regularly, they question the patient and sometimes send them away and tell them, “Why do you need all this? You had some three days ago. You can’t come back for more.” We just need to convince the policy makers understand that it’s okay and the pharmacists should have adequate information and education. So the achievement, I think, was to get the medications imported and dispensed by the government pharmacies. For us in home care who knew how to use them it was great because we were suggesting to the doctors to please prescribe that and we were very happy as they were, mostly, willing to cooperate with us.’

As Jane Kakas points out there is still a great need to develop a protocol and continue to provide basic education in palliative pain control:

‘We need to have some protocols and education for the selection of patients that go onto Fentanyl because sometimes patients who are not stable on their pain control are prescribed Fentanyl. Some doctors aren’t sure of the basic WHO ladder, they’re not aware of breakthrough pain, they’re certainly not aware of breakthrough pain dosages when using Durogesic, so there’s a huge amount of work to be done still on very basic symptom control. Now I know there are great opportunities for Oxycodone and all these other things. But I think we are not ready to handle more opioids than we already have. There’s a risk of confusing people, and the stuff we’ve got, they don’t know how to use that yet. So there’s a lot of basic education still needs to be done on that front.’²⁷