Death – the high price of illegal medicine in Asia

The recent death of a man shortly after receiving an injection in a private clinic is troubling and has received significant public attention. Without commenting directly on the case reported in the Cambodia Daily, private clinics in Cambodia have an enormous issue in the procurement, storage and administration of high-risk illegal medicine, such as injectables.

Injectable medicine should be singled out as it presents some of the most significant dangers to patient safety. Injectable medicine needs to be kept in appropriate storage conditions and is very sensitive to expiry. The active ingredient will often become less effective and by-products may be formed as the medicine breaks down over time.

In addition, injectables by their very nature will involve piercing the skin and presenting an opportunity for infection. The reports of re-used syringes and administration of injectables by unqualified persons in Cambodia should not be discounted.

SMCS Risk has been investigating the trade in illegal medicine in Cambodia over the past 8 years, assisting the National Police of Cambodia, the Ministry of Health, Economic Police and leading pharmaceutical companies to minimise the risks to the public. During this time, our investigations have identified a broad range of injectable medicine that is expired, not registered to be in Cambodia, and potentially counterfeited. These illegal medicines have been seized from unqualified persons, often in highly contaminated environments.

In one investigation alone, the following injectable medicines were seized in an expired state:

Aminophylline: Aminophylline is an injectable medicine which is used in emergency situations, such as status asthmaticus. Aminophylline has a narrow therapeutic index, therefore cautious dosage determination is essential. Too low a dose may not be effective and if this low dose were not effective giving an additional dose to a patient could be very harmful. Healthcare professionals need to be confident that the amount administered is as stated on the product.

Ceftazidime: Ceftazidime is an injectable that is used in the treatment of severe illnesses such as meningitis and pneumonia, in all age groups including neonates. Injecting a potentially ineffective and contaminated medicine into such a vulnerable patient could be extremely harmful and potentially fatal.

Somatropin: Somatropin is an injectable product (powder and solvent for solution for injection) which may be used in young children. This is a biological product. These products are subject to an array of degradative processes that may impact on product quality and potency. Use of this product in expired form poses the risk that contaminated and unstable drugs would be injected into young children, which may also not be effective for treatment.

Epoetin Beta: Epoetin Beta is an injectable used in a very vulnerable patient group (patients suffering from anaemia due to kidney failure) for a serious illness. A potentially contaminated, unstable, ineffective medicine could be very harmful to the patient.

Atenolol: Atenolol (both injectable and oral at different stages) is used in the treatment of myocardial infarction. In this emergency situation, an accurate dose is essential.

Due to their application in life-saving situations, often in highly vulnerable patient groups, the utmost care must be taken with injectable medicine in Cambodia. Private clinics and pharmacies must not take the risk of providing expired or contaminated product. Patients need to be extremely cautious when receiving injectable medicine from private clinics and pharmacies, particularly in provincial locations.

SMCS Risk will be revealing further details on the investigation of illegal medicine in Cambodia in the coming weeks. Due to the patient safety risks, this is an area of brand protection that is absolutely critical and is one area that are we very passionate about. Many of the issues in this area confronted by the pharmaceutical industry are shared by other industries, particularly in agriculture, food and beverage, and cosmetics.