The International Narcotics Control Board^16,17has published the following figures for the consumption of narcotic drugs in Jordan: codeine 35 kg (down from 79 kg in 1998); morphine 3 kg (up from 1 kg in 1999); pethidine 24 kg (up from 17 kg in 1998).

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)¹⁸ in Jordan was 11. This compares with other MECC member countries as follows: Cyprus 46; Egypt 2; Israel 253; Turkey 7; no reported morphine consumption in the Palestinian Authority during 2000-2002 (Table 5).

Table 5: Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002: the six MECC member countries in the Middle East region.¹⁹

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

Opioids and other related medications are available in Jordan, although the range of suitable preparations can be limited. Since 2003, the Ministry of Health has been developing a National Palliative Care Programme with the support of the World Health Organisation (WHO) . An important aspect of the programme is to facilitate appropriate policy on opioid prescription .²⁰ Dr Jan Stjernswärd of the WHO writes:

‘The Jordan Pain Relief and Palliative Care Initiative (JPRPCI) is a World Health Organization (WHO) Demonstration Project for the Middle East Region. Following negotiations with the Ministry of Health (MOH) and WHO, a public health approach was established, introducing the WHO foundation measures of education, drug availability and supporting policies. In August 2003, a MOH/WHO workshop was attended by leading national policy makers and clinicians who agreed to establish a National Programme Initiative.
Dr Samir Khleif, Director of King Hussein Cancer Center, has since been addressing policies, drug availability and educational issues. Already there have been changes in opioid prescribing policies and nationally produced, inexpensive generic immediate release morphine and slow release morphine tablets are about to come on the market, with a policy that over 80 per cent of the estimated increase in morphine use will be covered by these drugs.’ ²¹

Dr Bassam Hijawi, Director of Health Promotion and Protection in the Ministry of Health explains that, as of May 2005, improved legislation on opioid production and prescription policy is imminent, although there are still some issues to be resolved:

‘ We face a problem of legislation, prescription of drugs, production of drugs. Sometimes the manufacturers of the drugs are asked for a big amount of morphine, and they say that it is costly, you cost us more than 20,000 JD and we cannot supply this amount. So [the supply] expires and nobody [can] use it. Sometimes the hospitals ask for extra amounts, and nobody knows the exact amount. So the system is sometimes [a problem]. I hope now we are on the correct way and that we are now at the end [ready] to sign [and complete the policy]. His Excellency the Minister of Health [has] said, “I am ready to send these issues to parliament to change, to update the legislation that is suitable for our current position.’²²

Since the early 1990s, at the inception of the first palliative care service, difficulties around the provision of opioids, and the different modes of prescription that are suitable in palliative care, have been eased with support from the Royal Court, which recognised the specialist needs. For instance, as Rana Hammad, Director of Al Malath explains:

‘We have three morphine pumps now and they are the only three in Jordan. We’ve changed the regulations when it comes to narcotics. We were fortunate that crown Prince Hassan, at that time [in the early 1990s] helped us with one phone call. It became easier and we started having more ampoules, more pills, and for three years we managed to get the immediate release [morphine]. The first time I took the pump to Al Basheer Hospital, which was the centre for giving the morphine to patients, and I said, “I want 100 ampoule,” and they said, “What!?” I said, “Okay, 50, and they said maximum 5.” So “but 5 cannot prime the [pump]”. So it changed - it changed quickly.’²³

However, since the government committee on opioid regulations has been facilitating the policy on opioids, there is a wider range of opioid preparations available. As Nisreen Al Alfi, a nurse in the KHCC hospice team, describes, the team is now able to use:

‘mostly morphine, MST, for pain relief … also adjuncts to medications, like Paracetamol, Tramadol, Dexamethasone. We use Fentanyl [transdermal patches] sometimes. We keep them as a last resort, because not all our patients feel comfortable about that and sometimes symptoms of nausea and drowsiness are more prominent with the patches more than the morphine. Sometimes if we have to keep going up, up, up on the morphine, we use Fentanyl patch, or if the patient cannot swallow might just use the patch as an alternative. Sometimes it won’t work because the patient is really lacking subcutaneous tissue so there’s no absorption, so they’re not going to benefit on the patch.’²⁴

Al Malath home hospice also uses MST, and as Rana Hammad explains:

‘Now we have the immediate release [morphine] that I fought for ten years to get - we have it now. We do the Fentanyl patches. We use injectable morphine through the pumps, not through injections. We have also syrups for kids. And we have the weak opioids: Tramadol, codeine , all the range of weak opioids we use them… and the non-steroidals for pain. And for nerve pains we use the tricyclic anti-depressants , which we introduced - we were the first to use them or to apply them. Of course we have, for symptom management, our regular anti-fungals, anti-biotics, anti-diarrhoeals, all range of normal medications for symptoms. And of course we have the colloids for bedsores, and skin care products.’²⁵

The WHO reports that from 2004 there has been a demonstrable change in opioid use as a result of the training programmes and the change in opioid legislation. For instance, in 2004 KHCC was using 2.7kg morphine, that by 2005 had increased to 4.8 kg morphine. By 2005 Al Basheer Hospital reported increased levels of opioid use, 13,000mg prescribed as morphine sulphate10mg tablets.²⁶