The International Narcotics Control Board (INCB)¹⁷ has published the following figures for the consumption of narcotic drugs in Thailand during 2005: codeine 368 kg; morphine 40 kg; dextropropoxyphene 23 kg; diphenoxylate 6 kg; methadone 19 kg; pethidine 86 kg; and cocaine 1 kg.

For the years 2003-2005, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)¹⁸ in Thailand was 15. This compares with other countries in the region as follows: Japan 131; Korea 49; Sri Lanka 13; and Nepal 1. No morphine consumption was reported to the INCB for four countries (Table 2).

A range of non-steroidal anti-inflammatory drugs (NSAIDs) are used in Thailand, including salicylic acid, indomathacin, ibuprofen, naproxen, diclofenac, piroxicam and meloxicam.

Pongparadee Chaudakshetrin, director of Siriraj Hospital’s pain clinic, has had a long-standing interest in pain relief. In her 1993 paper Thailand: Cancer Pain and Palliative Care¹⁹ she lists the barriers to cancer pain management at the beginning of the 1990s. These include: a lack of education for health professionals; the detrimental impact of strict government drug controls; hardened public attitudes regarding the use of opioids for medical purposes; fears about the addictive effects of opioids; poor access to opioid drugs and inadequate supplies. In 1990, she states that five kilos of morphine were consumed in Thailand against an estimated national need of 15 kilos.

Table 2 Average daily consumption of defined daily doses of morphine per million inhabitants, 2003-2005: countries of Central, South and East Asia

Source: INCB, 2007

Speaking in 2007, Pongparadee recalls her early involvement in the drive to make morphine more accessible for medical use:

‘It was in 1985 that I went to London to learn some of the methods that help with pain relief. Then, when I came back to my hospital, I tried to establish oral morphine, both here and in the country. But not only me; one of my colleagues was offered seven kilos of MST tablets by a drug company, to be used for our patients. Meanwhile I tried to work on the availability of morphine syrup. So I got the pharmacy to make fresh preparations for our patients and since 1987, we have had morphine syrup available here.

‘But at that time, the health care system was not like it is today, because in those years people were not insured for their health. So most of the patients in our hospital could not pay for their medicines and the hospital had to absorb the expense. So by making morphine syrup available, we tried to reduce the cost of imported morphine.

‘After we worked on pain relief, we tried to educate our medical students, our residents and some of the non-pain physicians outside of anaesthesiology. We collaborated with the Thai Pain Society, now called the Thai Association for the Study of Pain, and we invited many outsiders like Professor Charles Cleeland [of the University of Texas MD Anderson Cancer Centre] to lecture and educate our hospital physicians. But we also had to run many workshops and write many articles to show that cancer pain relief has to be done in a proper way.’²⁰

Against this background, new inroads have been made into pain management. Pain medicine has been incorporated into undergraduate and postgraduate medical curricula. Nine pain centres have been established countrywide. These cancer centres have developed more effective treatment for cancer pain and acute pain services are moving towards a countrywide reach.²¹

Nevertheless, there is insufficient provision for chronic non-cancer pain. And despite 40 kilos of morphine being consumed in 2005, the drug remains largely inaccessible to patients in the community. Writing in 2003 after visiting Rayong’s Camillian Social Centre, the Australian nurse, Meg Spencer, observes:

As the centre is not a hospital, it is not legally able to be supplied, stock or administer opioids, under Thailand’s strict policies governing drug administration. Tramadol is therefore the centre’s only analgesic option … I was unable to find any guidelines or legislation for the prescribing of opioids in Thailand.²²

This situation still exists in 2007. According to staff at the centre:

Morphine and all other opioid drugs are only available through the doctors in the hospital that our patients attend when necessary. Therefore our access to them is still very restricted. When we need to consult a doctor we take our patients to the district or provincial hospital … [however] access to antiretrovirals has improved as of June this year. All Thai citizens in the health care programme are entitled to the first two lines of cocktails that are manufactured in Thailand.²³