title: Access to controlled medicines for anesthesia and surgical care in low-income countries: a narrative review of international drug control systems and policies.
abstract: OBJECTIVE
  This article describes the functioning of the international drug control system, its integration into national legislation and policy, and the collective impact on access to medicines.
  
  
  METHODS
  We conducted a review of the three international drug control conventions, peer-reviewed articles, and grey literature known to the authors that describes national and international drug control systems and their impact on access to controlled medicines. This review was supplemented with literature derived from a structured search of MEDLINE®for articles relating to medical uses of ketamine in low- and middle-income countries conducted to strengthen an advocacy campaign. We illustrate the impact of the drug control system on access to medicines through an analysis of current levels of availability of opioids in many countries as well as through a description of the ongoing advocacy work to ensure the availability of ketamine for medical care in low-income countries.
  
  
  RESULTS
  The complexity of the international drug control system, along with health providers' lack of knowledge regarding key provisions, presents a barrier to improving access to safe anesthesia care in low- and middle-income countries. Fifteen of the 46 essential medicines of potential relevance to perioperative care are listed under one or more of the schedules of the three international drug control conventions and, subsequently, are required to be under national controls, potentially decreasing their availability for medical use.
  
  
  CONCLUSIONS
  Improving the capacity and quality of anesthesia care in low- and middle-income countries requires attention to improving access to controlled medicines. Anesthesiologists and others involved in global health work should collaborate with policymakers and others to improve national and international drug control legislation to ensure that attempts to thwart illicit drug trafficking and use do not compromise availability of controlled medicines.
authors.affiliation: Bruyère Research Institute, 85 Primrose Ave., Ottawa, ON, K1R 6M1, Canada. jason@jasonnickerson.ca.
authors.forename: Jason W
authors.initials: JW
authors.lastname: Nickerson
authors.affiliation: International Association for Hospice and Palliative Care, Houston, TX, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Pettus
authors.affiliation: Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Kathleen E
authors.initials: KE
authors.lastname: Wheeler
authors.affiliation: Global Drug Policy Observatory, Research Institute for Arts and Humanities, Swansea, Wales, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: Hallam
authors.affiliation: Global Drug Policy Observatory, Research Institute for Arts and Humanities, Swansea, Wales, UK.
authors.forename: David R
authors.initials: DR
authors.lastname: Bewley-Taylor
authors.affiliation: Faculties of Law and Medicine, University of Ottawa, Ottawa, ON, Canada.
authors.forename: Amir
authors.initials: A
authors.lastname: Attaran
authors.affiliation: Department of Anesthesia & Perioperative Care, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Adrian W
authors.initials: AW
authors.lastname: Gelb
mesh_terms: D000758:Anesthesia; D003906:Developing Countries; D004335:Drug and Narcotic Control; D006801:Humans; D019990:Perioperative Care; D013514:Surgical Procedures, Operative