The International Narcotics Control Board^21,22has published the following figures for the consumption of narcotic drugs in Turkey during 2002: codeine 1117 kg (down from 1784 kg in 1999); morphine 16 kg (down from 22 kg in 1999); pethidine 132 kg (up from 121 kg in 1999).²³

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)²⁴ in Turkey was 7. This compares with other countries in the Middle East region as follows: Cyprus 46; Egypt 2; Israel 253; Jordan 11. The Palestinian Authority reported no morphine consumption during 2000-2002 (Table 2).

Opioid preparations are available for patients at the end of life. Turkey has a colour coded prescription system; red prescription sheets for opioids, green for sedatives and opioid derivatives like Tramadol. White prescription sheets are used for all other drugs. There is a dosage limit of no higher than 400mg morphine in any one dose. Supply is limited to no more than 10 ampoules of morphine per prescription, no more than 24 tablets of codeine 40mg, and no more than 3 packs of drugs over 7-10 days.²⁵

Deniz Yamac, Medical Oncologist at Gazi Hospital explains that they use a full range of medications including MST, morphine; oral, injectable, and pumps as IV infusion, Fentanyl [transdermal patches], Sevredol and Oxycodone. The Department of Algology at Gazi uses intrathecal injections but the unit do not use subcutaneous infusions.²⁶

Table 2 Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002: the six MECC²⁷ 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.

Dr Seref Komurçu, Medical Oncologist at Gulhane Military Academy reports that in addition to oral opioids they use epidural catheter in some patients.²⁸

Professor Serdar Erdine explains that although they can prescribe Fentanyl patches, slow release oral morphine and tramadol: ‘short acting opioids are not available, like methadone.’ In his algology department in the Medical Faculty of Istanbul he reports:

‘We implant [morphine] pumps (intrathecal, epidural) for cancer. In our centre [since the mid 1990s] we have performed more than 1000 [insertions of pumps] for cancer. Plus, we do all types of nerve blocks. In a year we see 1000 patients with cancer, but we do only 100 [nerve blocks] for cancer. We obey the rules of the WHO step system. Not much use of the subcutaneous infusion because we see patients before the end of life, [although] the oncology departments are aware of our pain department and refer patients, and usually they are at a very late stage when diagnosed.’²⁹

Prof Erdine has seen a change since the transdermal patches became available in Turkey. Before patches were available he saw more patients for pain relief at an earlier stage in their treatment, but now the oncology department only refer patients to the pain department who, for example, are no longer having their pain relieved by the patches.