Pharma giants to pay $590 mn to US Native Americans over opioids

Yahoo – AFP, John Biers, with Chris Stein in Washington, 1 February 2022 

Pharmaceutical companies and distributors have agreed to pay $590 million to
settle litigation related to opioid addiction in the Native American population
(AFP/Eric BARADAT) (Eric BARADAT)

A group of pharmaceutical companies and distributors agreed to pay $590 million to settle lawsuits connected to opioid addiction among Native American tribe members, according to a US court filing released Tuesday. 

The agreement is the latest amid a deluge of litigation spawned by the US opioid crisis, which has claimed more than 500,000 lives over the last 20 years and ensnared some of the largest firms in the world of American medicine. 

Pharmaceutical companies McKesson, AmerisourceBergen and Cardinal Health had already struck a separate deal with the Cherokee tribe last September for $75 million. 

According to documents filed in an Ohio federal court Tuesday by a committee of plaintiffs, the companies agreed to pay another $440 million over seven years to other Native American tribes. 

The pharmaceutical group Johnson & Johnson, for its part, agreed to pay $150 million over two years to all the tribes, of which $18 million are destined for the Cherokee. 

Native Americans have "suffered some of the worst consequences of the opioid epidemic of any population in the United States," including the highest per-capita rate of opioid overdoses compared to other racial groups, according to the filing from the Plaintiffs' Tribal Leadership Committee. 

"The burden of paying these increased costs has diverted scarce funds from other needs and has imposed severe financial burdens on the tribal plaintiffs." 

Johnson & Johnson, McKesson and the other two companies in the accord -- AmerisourceBergen and Cardinal Health -- previously agreed to a $26 billion global settlement on opioid cases. 

J&J said Tuesday the $150 million it agreed to pay in the Native American case has been deducted from what it owes in the global settlement. 

"This settlement is not an admission of any liability or wrongdoing and the company will continue to defend against any litigation that the final agreement does not resolve," the company said. 

It was unclear if the other companies would take their portion under the latest agreement from the global settlement. 

'Measure of justice' 

Robins Kaplan, a law firm negotiating on the behalf of the plaintiffs, said the agreement still must be approved by the Native American tribes. 

"This initial settlement for tribes in the national opioid litigation is a crucial first step in delivering some measure of justice to the tribes and reservation communities across the United States that have been ground zero for the opioid epidemic," Tara Sutton, an attorney at the firm, said in a statement. 

Douglas Yankton, chairman of the North Dakota-based Spirit Lake Nation, said the money from the settlement would "help fund crucial, on-reservation, culturally appropriate opioid treatment services." 

Steven Skikos, an attorney representing the tribes, told AFP the group is pursuing claims against other drugmakers. 

"This is hopefully the first two of many other settlements," he said. 

Every tribe recognized by the US government, 574 in all, will be able to participate in the agreement, even if they have not filed lawsuits. 

Many of the lawsuits regarding the opioid crisis have centered on Purdue Pharma, the manufacturer of OxyContin, a highly addictive prescription painkiller blamed for causing a spike in addiction. 

A judge in December overturned the company's bankruptcy plan because it provided some immunity for the owners of the company in exchange for a $4.5 billion payout to victims of the opioid crisis. 

The litigation wave has also swamped pharmacies owned by Walmart, Walgreens and CVS, which a jury found in November bear responsibility for the opioid crisis in two counties in Ohio.

US sues Walmart over opioid crisis

France24 – AFP, 22 Decemberb 2020

The Justice Department sued Walmart, alleging it worsened the
opioid crisis Paul Ratje AFP/File 2 min New York (AFP)

The US Justice Department sued Walmart over its role in the opioid crisis on Tuesday, alleging the giant retailer wrongly filled prescriptions and worsened a public health disaster.

The suit accuses Walmart of irresponsible handling of orders, filling thousands of "invalid" prescriptions. 

 Authorities could seek up to billions of dollars in penalties, in the litigation that followed a multi-year investigation, the Justice Department said in a press release.

"As one of the largest pharmacy chains and wholesale drug distributors in the country, Walmart had the responsibility and the means to help prevent the diversion of prescription opioids," said Jeffrey Bossert Clark, acting head of DOJ's civil division. 

"Instead, for years, it did the opposite -- filling thousands of invalid prescriptions at its pharmacies and failing to report suspicious orders of opioids and other drugs placed by those pharmacies." 

Walmart did not immediately respond to a request for comment, but the company, the world's biggest retailer, filed its own lawsuit against the Justice Department in October that argued that the US crackdown put it in a no-win position. 

Pharmacists "must make a difficult decision" of either accepting a doctor's "medical judgment and fill the opioid prescription, or second-guess the doctor's judgment and refuse to fill it," Walmart said in its suit. 

"Either decision puts the pharmacist and pharmacy at great risk," the company argued. It said 

it faces potential federal action if prosecutors say an order was wrongly filled, or the chance of having a pharmacist license "stripped for the unauthorized practice of medicine, not to mention the potential harm to patients in need of their medicine."

Ministry introduces code word ‘Masker 19’ for domestic abuse

DutchNews, May 1, 2020

Photo: Depositphotos.com

As of Friday victims of domestic violence can use the code word ‘masker 19’ (mask 19) at pharmacies so staff can help them contact social services, the health ministry has announced. 

The same code is already being used in France and Spain. Although no figures are available as yet, help organisations in the Netherlands are afraid incidents of domestic violence have been increasing in the Netherlands over the past weeks because the lockdown is forcing people to spend more time in the home. ‘

Pharmacies provide a safe and trusted environment, pharmacy association KNMP chair Aris Prins told broadcaster NOS. ‘Questions about masks are common and if people ask for ‘masker 19’ it won’t attract much attention,’ he said 

The scheme will make it easier for people to ask for help, Prins said. If they are accompanied by others, staff will contact the relevant service on their behalf. 

Last week, the ministry launched an information campaign aimed urging victims to ask for advice by contacting domestic violence prevention organisation Veilig Thuis (0800 2000). The organisation has also added a chat function to its internet site. 

But not everyone is able to use the phone without alerting an abusive partner so a ‘low threshold method is needed to alert help victims of domestic violence in a particularly difficult time’, health minister Hugo de Jonge said. 

People who are in immediate danger must call the police at 112, the ministry said.

US pharma bosses charged with fueling opioid crisis

Yahoo – AFP, April 24, 2019

A 5 milliliter dose of liquid oxycodone, a medicine at the epicenter of the US opioid
crisis that has claimed tens of thousands of lives (AFP Photo/EVA HAMBACH)

New York (AFP) - Two former executives of a major US pharmaceutical company were charged Tuesday with fulfilling orders they knew to be fraudulent during the opioid epidemic that has claimed tens of thousands of lives.

It was the first time that senior or former executives have faced criminal charges in connection with distributing powerful prescription painkillers like oxycodone and fentanyl that carry a high risk of addiction and overdose.

The company where the executives worked, Rochester Drug Cooperative (RDC), is one of the country's largest distributors of prescription opioids.

It has entered into a non-prosecution agreement with the US Attorney's office in New York and agreed to pay a $20 million fine.

As result, the company will not be prosecuted and will be allowed to retain its license to distribute drugs, while promising to reform its practices.

In a statement, RDC admitted that between 2012 and 2017 it had failed to report shipments of drugs it recognized as suspicious, as required by law.

"This prosecution is the first of its kind," US Attorney Geoffrey Berman said in a statement.

"Executives of a pharmaceutical distributor and the distributor itself have been charged with drug trafficking, trafficking the same drugs that are fueling the opioid epidemic that is ravaging this country."

RDC distributes to some 1,300 pharmacies and with an annual turnover of more than $1 billion, according to documents released by prosecutors.

Investigators found that it had failed to report at least 2,000 suspicious orders of drugs whose distribution is overseen by the Drug Enforcement Administration (DEA).

The defendants were named as former CEO Laurence Doud, 75, and William Pietruszewski, 53, who had served as chief compliance officer.

"RDC's employees, including in conversations with Doud and Pietruszewski, described some of the company's customers as 'very suspicious,' and even characterized particular pharmacies as a 'DEA investigation in the making' or 'like a stick of dynamite waiting for (the) DEA to light the fuse,'" the New York prosecutors said.

"Nonetheless, throughout the period in question, RDC, at the direction of Doud, increased its sales of oxycodone and fentanyl exponentially," the statement added.

Doud and Pietruszewski were charged with conspiracy to distribute controlled substances, which carries a maximum sentence of life in prison and a minimum of 10 years.

Doud was arrested Tuesday and appeared before a federal judge, who ordered his release on a $500,000 bond.

Pietruszewski pleaded guilty to the same two counts, as well as breaches of his duty to report to the authorities.

Around 47,600 people died in 2017 from an opiate overdose in the United States, according Centers for Disease Control and Prevention figures.

"This epidemic has been driven by greed," Berman told a news conference, adding that Doud had seen his salary more than double between 2012 and 2016.

Two US pharmaceutical bosses are charged with drug trafficking and fulfilling orders they knew to be fraudulent -- fueling the opioid epidemic that has claimed tens of thousands of liveshttps://t.co/KxmBwM4f3O @AFPgraphics pic.twitter.com/33K4TPLBT3

— AFP news agency (@AFP) 24 april 2019

Dutch hospital can make cheaper version of drug, health inspector say

DutchNews, November 28, 2018

Photo: DutchNews.nl 

Amsterdam’s AMC teaching hospital can make its own version of a licenced drug to treat a rare metabolic disorder but must adapt its production methods, health ministry inspectors said on Wednesday. 

The inspectors were responding to a complaint by by Italian pharmaceuticals company Leadiant, which produces the drug henodeoxycholic acid or CDCA, used to treat a rare metabolic disorder.

The hospital began making its own version of the drug in April because it was no longer covered by health insurance after the price shot up. That month Leadiant ramped up the price by around 500% so it now costs some €200,000 per patient per year. 

The hospital said at the time it could produce the drug for €25,000. 

In August the hospital was ordered to recall the drug by health inspectors because of fears the raw materials might contain impurities, a worry which turned out to be true. 

However, rather than ban the hospital from picking up production again, the inspectorate has said it can continue, if it changes the production process. It must also stop ‘advertising’ the drug – by promoting it to other patients via the media, a second complaint submitted by Leadiant. 

Hospital pharmacies make their own medicines more often but this case is unusual because of the financial considerations. The hospital is offering ‘a social and economically-responsible alternative to a registered medicine which is so expensive that it is inaccessible to patients,’ the AMC said in April. 

Just 60 patients in the Netherlands suffer from the disease CTX which the drug is used to treat.

US biopharmaceutical company Gilead plans Hoofddorp production unit

DutchNews, May 16, 2018

Cancer cells. Photo: Depositphotos.com 

California-based biopharmaceuticals group Gilead plans to build a production unit in Hoofddorp near Schiphol airport, the Financieele Dagblad reported on Wednesday. 

The facility will produce cell therapies used against cancer and will serve all of Europe from 2020, the paper said. It will employ at least 300 people. 

Gilead was set up in 1987 and booked 2017 revenues of more than $28bn. Its primary therapeutic focus continues to be in antiviral medicines and the company approval of cell therapy treatments in Europe later this year, the FD said. 

The cell therapy developed by Gilead and its subsidiary Kite was designed for the treatment of until now incurable forms of lymphoma. Gilead expects its CAR-T cell therapy will eventually be used in the treatment of many other forms of cancer. 

Gilead said it is essential to have a European production unit because treatments are tailor made for individual patients and speed of delivery is crucial. 

Gilead’s subsidiary Kite acquired T-Cell Factory, an Amsterdam biotech firm three years ago and paid $425 million for a 15% equity stake in Belgo-Dutch biotech firm Galapagos in 2016.

Uruguay pharmacies start selling marijuana

Yahoo – AFP, Mauricio RABUFFETTI, July 19, 2017

A man shows two envelopes containing marijuana he just purchased at a
pharmacy in Montevideo, on July 19, 2017 (AFP Photo/MIGUEL ROJO)

Montevideo (AFP) - Pharmacies in Uruguay started selling marijuana Wednesday under a four-year-old law that has made the small South American country the first in the world to legalize pot from production to sale.

At a pharmacy in Montevideo's Old Town, five customers were waiting to buy when the store shutters went up at the start of the day, and lines grew longer as the day went on.

"I've been smoking since I was 14. Let's give it a try," said a 37-year-old man who would not give his name.

"It's funny," a pharmacy employee told AFP on grounds of anonymity. "In two hours we filled only three prescriptions, but 30 people came to buy marijuana."

Some pharmacies saw as many as 20 people lining up to make their first legal pot purchase.

"We did not expect this kind of movement," said Sebastian Scafo, 33, a pharmacy manager.

In all, 16 pharmacies have been authorized to sell marijuana under state controls, barely enough to cover a country of 3.5 million people.

No major pharmacy chain has agreed to sell the drug.

Many pharmacies have been unwilling to participate in the scheme because of concerns about security and doubts that the small market of registered users is worth the trouble.

Only about 5,000 people, most of them age 30 to 44, have signed up as prospective buyers since Uruguay's state registry opened in early May.

Walk-in sales are not allowed under the law, and only residents of Uruguay can register to buy pot -- thereby preventing marijuana tourism.

Graphic on estimated prevalance of cannabis use around the world (AFP 

Photo/John SAEKI, Laurence CHU, Adrian LEUNG)

Blow to drug-dealers?

Among those trying the new legal distribution system was Xavier Ferreyra, a 32-year-old city employee, who was making his first purchase at a pharmacy in Montevideo's Old Town.

He said he saw two main advantages to the new approach: "safety and the quality" of the drug, adding, "I no longer have to go buy it in some slum."

Pharmacy sales are the last of three phases set out under the 2013 law.

Under the early phases, nearly 7,000 people registered to grow weed at home, and more than 60 smokers' clubs were authorized.

Only two companies were authorized to produce marijuana for pharmacies -- under military protection, and with no public access.

The state Institute for the Regulation and Control of Cannabis (IRCC) has authorized the sale of two types of marijuana, to be sold in five-gram packets.

On Monday, the National Drugs Council tweeted an image of what the packages would look like: blue-and-white sealed sachets that look something like condom packets.

An "Alfa I" package contains "Alfa I variety cannabis hybrid with Indica predominant."

Another sort has "Beta I variety cannabis" with Sativa. The levels of THC -- the psychotropic constituent in cannabis -- are given on the outside, for consumer information.

The packets also bear a "Warnings" section about the risks of consuming marijuana and recommendations on how to do it more safely.

People line up in front of a pharmacy to buy marijuana in Montevideo, on 

July 19, 2017 (AFP Photo/MIGUEL ROJO)

'A marvelous plant'

The buyers who talked to AFP reporters all said they had bought 10 grams of pot, a packet of each variety on sale.

The packets are being retailed at $6.60 each, according to the IRCCA.

Customers are identified through a digital fingerprint reader, which allows them to buy without having to show other forms of identification in the store.

Uruguay's goal in legalizing the sale of marijuana for recreational use is to cut down on illegal smuggling.

Camila Berro, a 24-year-old business student, walked out of a pharmacy smiling, two packets of pot in hand.

"I feel very lucky to be able to get it legally," she said. "I have friends in other countries who were imprisoned for smoking a joint."

To Ferreyra, the municipal worker, "Uruguay has taken a very big step... I hope one day they can legalize a lot more drugs."

And former President Jose Mujica, who enacted the marijuana reforms while in office from 2010 to 2015, said that while "no addiction is good," it was "horrible to condemn a marvelous plant."

Uruguay, he added, is "trying a new path."

The Netherlands to increase exports medical marijuana

DutchNews, December 2, 2016

The Netherlands is poised to increase its export of medical marijuana, cabinet sources have told the Telegraaf. 

The paper said the cabinet is ready to give the green light to an increase in exports to meet the growing demand for medical marijuana in Germany. 

Medical marijuana, grown by a government agency, is currently exported to Italy, Finland and Germany, the paper said. 

The current export limit is 100 kilos but this will soon be increased 350 kilos and go up again to 700 kilos in 2019, the Telegraaf said. 

Until now, the production of medical marijuana has cost more than is reaped in sales but the increase in exports will generate cash for the treasury, the Telegraaf said. 

Medical marijuana is not an official medicine in the Netherlands and is not included in the basic health insurance policy. However, the five licenced brands on the Dutch market, produced by the Bedrocan company, are distributed via pharmacies.

Related Article:

VVD changes sides on marijuana cultivation, clears way for regulation

Uruguay to sign up smokers to buy state marijuana

Yahoo – AFP, July 7, 2016

Uruguay government aims to begin registering users by the end of the month
authorizing them to purchase marijuana in pharmacies in an effort to undermine
drug-trafficking gangs (AFP Photo/Luis Robayo)

Montevideo (AFP) - Uruguay will this month start signing up smokers to buy marijuana from pharmacies in the world's first scheme for state-production and sale of the drug, an official source said Wednesday.

The leftist government has begun harvesting its own marijuana and aims to start selling it in mid-August, the source told AFP.

The marijuana leaves have been grown under heavy security at privately operated, state-supervised farms.

"It is being harvested and dried," said the source, who asked not to be named.

The government will buy the drug from the producers and sell it on to the pharmacies. But the amount released for sale will depend on how many users register.

The government aims to start registering users by the end of this month, the source said.

Under a law passed in 2013, Uruguay already allows users to grow marijuana if they register as members of state-regulated clubs.

In this June 30, 2016 photo, a pharmacy attends a client at Capurro neighborhood

 in Montevideo, Uruguay. Uruguay's government is planning to sell marijuana at 50

pharmacies throughout the country. (AP Photo/Matilde Campodonico)

The state will now expand that initiative to regulate the sale of the drug in pharmacies.

The law allows for users to buy up to 40 grams (1.4 ounces) a month. Authorized buyers will be identified by their fingerprints.

The scheme is being overseen by the state Cannabis Regulation and Control Institute.

Officials have not ruled out extending sales to establishments other than pharmacies.

The initiative was launched by former president Jose Mujica as a way to undermine drug-trafficking gangs.

A poll at the time indicated that nearly two thirds of Uruguayans were opposed to the law.

US rejects pharmacists' religious rights appeal over contraceptives

The US Supreme Court has said it won't hear an appeal from Washington state pharmacists with religious objections to dispensing emergency contraceptives. It leaves in place rules first adopted nearly a decade ago.

Deutsche Welle, 29 June 2016

Tuesday's ruling leaves in place regulations adopted in 2007, following reports several women were denied access to emergency contraceptives. The rules stipulate that pharmacies must fill lawful prescriptions, but individual pharmacists with moral objections can refer patients to another pharmacist in the same store.

The case

Stormans - owners of Ralph's Thriftway in Olympia, a Washington state grocery store and pharmacy, sued, as did two pharmacists who said the rules required them to breach their religious beliefs.

"The state needs to not make a value judgment that a religiously-motivated referral is not permissible when other referrals are," Kristen Waggoner, the lead attorney for Stormans in the case said. She added that another lawsuit could happen if the state doesn't enforce the rules "in an even-handed manner."

Washington state Attorney General Bob Ferguson praised the high court's decision to not hear the case.

"Patients should know that when they need medication, they won't be refused based on the personal views of a particular pharmacy owner," Ferguson added. "The appeals court ruling upheld today protects that principle."

Splits in the high court

Meanwhile, Chief Justice John Roberts and Justices Samuel Alito and Clarence Thomas said they would have heard the appeal. Alito wrote a 15-page dissent for the three dissenting justices: "If this is a sign of how religious liberty claims will be treated in the years ahead, those who value religious freedom have cause for great concern."

Plan B

Sold as Plan B, emergency contraception is a high dose of the drug found in many regular birth-control pills. It can lower the risk of pregnancy by as much as 89 percent if taken within 72 hours of unprotected sex.

jbh/jr (AP, Voice of America)

Related Articles:

Supreme Court delivers major victory for US abortion rights

Dutch health minister presses on with abortion pill plans, despite Christian opposition

Minister raises fine for drugs firms which create shortages 20-fold

DutchNews, June 23, 2016

Photo: Depositphotos.com

Dutch health minister Edith Schippers said on Thursday she plans to increase the fine payable by pharmaceutical companies which deliberately cause shortages of medicine to €820,000. 

Currently, the maximum fine for drugs firms which create shortages is €45,000. Drugs firms with a trading licence can be fined if they fail to ensure sufficient supplies and report potential shortages on time. 

The decision follows last year’s crisis over the drug Thyrax which disappeared from pharmacy shelves after production was shifted from Oss in the Netherlands to Germany. 

Tens of thousands of people who take the drug were forced to use an alternative while stocks were replenished.

Limit opioid painkiller prescriptions, US regulators say

Yahoo – AFP, March 15, 2016

US health authorities issued guidelines Tuesday to limit prescribing opioid painkillers,

 in an attempt to help curb an epidemic of overdoses that kills more than 40 

Americans every day (AFP Photo/Philippe Huguen)

Washington (AFP) - US health authorities issued guidelines Tuesday to limit prescribing opioid painkillers, in an attempt to help curb an epidemic of overdoses that kills more than 40 Americans every day.

The recommendations, which are not binding for doctors, urge them to exercise more caution prescribing opioids in order to reduce the abuse of drugs that cause powerful addictions amid growing concerns about their use across the country.

Overdose deaths soared to 26,647 in 2014, a 14 percent increase from the year before. They represented 61 percent of all drug overdose deaths.

The Centers for Disease Control and Prevention (CDC), which published the guidelines in the Journal of the American Medical Association, has been under pressure to set national standards after a number of medical organizations and some states established their own restrictions.

Officials say the new guidelines' nationwide scope will encourage doctors to exercise more restraint in prescribing the powerful painkillers.

"It's become increasingly clear that opioids carry substantial risk but only uncertain benefits -- especially compared with other treatments for chronic pain," CDC Director Tom Frieden told reporters.

"More than 40 Americans die each day from prescription opioid overdoses, we must act now."

The guidelines, endorsed by many addiction experts, encourage physicians to first recommend non-opioid anti-inflammatory drugs such as ibuprofen and aspirin for chronic pain -- described as lasting longer than three months.

The CDC also recommends limiting opioid prescriptions for patients suffering short-term, acute pain to three days or less in most conditions.

More than seven days of opioid drug use will "rarely be needed," the CDC said.

Lawmakers have been hammering out legislation aimed at helping combat a crisis of

 addiction to heroin as well as painkiller opiates, which are related (AFP
Photo/Spencer Platt)

Urine tests to curb abuse

Doctors currently prescribe opiate painkillers for two weeks to a month.

The guidelines are intended primarily for general practitioners, who write half the prescriptions for opioid painkillers and often are not adequately trained in their use.

The CDC recommends patients take urine tests before receiving prescriptions and doctors to check prescription drug monitoring program data in order to ensure patients are not already receiving prescriptions from other doctors.

Although 49 states have such systems in place, only 16 require doctors use them.

The CDC guidelines do not apply to patients suffering from serious or terminal illnesses such as cancer.

The recommendations are meant as "a tool for doctors and for patients to chart a safer course," Frieden said, with the aim of balancing "the risks of addiction with the needs of patients to treat pain."

Doctors began generously prescribing opiate painkillers in the 1990s after pharmaceutical companies and medical experts deemed they could be used for back pain, arthritis and other conditions without fear of creating addictions.

Health care providers wrote 249 million prescriptions for opioid pain relievers in 2013, the CDC said.

The new guidelines come as lawmakers have been hammering out legislation aimed at helping combat a crisis of addiction to heroin as well as painkillers opiates, which are related.

The US Senate overwhelmingly passed a bill last week that would provide financial assistance to states and local authorities fighting the overdose epidemic.

Black market hormones one of many hurdles for Thai transgenders

Yahoo – AFP, Delphine Thouvenot and Ju Apilaporn, 21 February 2016

Thai transgender Chalit Pongpitakwiset, who is undergoing a hormone treatment to

change into a man, seen at his home in Bangkok (AFP Photo/Christophe Archambault)

Bangkok (AFP) - Chalit Pongpitakwiset has always felt like a man. Now the 25-year-old wants everyone else to see it too.

But unlike most transgender people in Asia, who are left to self-administer hormone supplements, Chalit is being helped by a pioneering clinic.

"I am in the hands of doctors," said Chalit, who was born female, but identifies as a man.

"I'm not doing it by myself, so it isn't dangerous," the software company worker said.

Several days after receiving his first testosterone injection, Chalit returned to get a blood test at Tangerine, the new clinic inside a Red Cross centre in downtown Bangkok.

The centre is a pilot programme that organisers hope could be replicated across Asia.

Its location is no accident -- Thailand has a large and visible transgender population and is one of the world's top destinations for sex-reassignment surgery.

Thai transgender Chalit Pongpitakwiset, who is undergoing a hormone treatment 

to change into a man, stretches at a park outside his home in Bangkok (AFP Photo/

Christophe Archambault)

But just like elsewhere in Asia-Pacific, a region home to more than nine million transgender people according UN estimates, long-term care for patients is patchy at best.

The clinic is a rare place providing follow-up treatment, both physical and mental, for those who have undergone sex-reassignment surgeries, procedures where patients are often at risk of infection.

"Most of the centres where the surgery is performed only provide short-term post-surgical care," explained Nittaya Phanuphak, the head doctor at Tangerine.

Unregulated hormones

In Thailand, hormones are commonly purchased on the Internet or in local pharmacies, and administered on advice gleaned from friends or web forums.

Recent university graduate Benyapon Chimsud, who was born a man but identifies as female, said she has been taking hormones for two years.

"I have been taking hormones by myself for two years, I consult with my friends," to determine the proper doses of contraceptive pills, she explains.

Thai transgender Chalit Pongpitakwiset (L), who is undergoing a hormone treatment 

to change into a man, pictured with his girlfriend as they wait for a boat at a pier 

in Bangkok (AFP Photo/Christophe Archambault)

She also gets monthly black market oestrogen injections at a rudimentary neighbourhood clinic.

That leaves her cut off from regulated healthcare, prone to receiving inaccurate medical advice and at risk of over-consuming hormones in a rush to see rapid results.

Chalit, on the other hand, met with a psychiatrist several times before receiving his first injection to prepare for the changes to his body.

"The psychiatrist asked me how long I've wanted to be a man, and whether my friends and other people around me would accept it if I changed," Chalit told AFP.

Now he is getting hormone injections every two weeks.

"The hormones will stop my periods, change my voice, give me a beard and moustache, and develop my muscles," he said. "All things that will help me no longer be a woman anymore."

That should insulate him from the dangers of taking the wrong doses of hormones which experts say can lead to liver and cardiovascular problems. HIV is also always a risk if needles are shared.

Rights groups like the Asia-Pacific Transgender Network (APTN) say this public health issue is largely neglected by the mainstream medical community.

"There are no official guidelines on the administration and monitoring of hormones among trans people," said Joe Wong of the Asia-Pacific Transgender Network (APTN).

Discrimination still commonplace

Although Thailand can appear tolerant on transgender issues from the outside, many segments of society remain deeply conservative.

Thai transgender Chalit Pongpitakwiset (L), who is undergoing a hormone treatment

 to change into a man, chats with his girlfriend at a playground outside their home 

in Bangkok (AFP Photo/Christophe Archambault)

The kingdom's transgenders, often men who become women and are known colloquially as "ladyboys," are over-represented in the entertainment and sex industries.

Despite high levels of education, many struggle to secure full-time work or prominent positions in the workplace.

Same sex marriage is also still not legally recognised, and up until 2012, transgenders were considered mentally ill by the army.

Tangerine doctor Nittaya says discrimination remains widespread in medical centres, making access to proper healthcare a challenge for many transgenders.

But Chalit is one of a small number of people to have been made aware of the dangers and commitment that comes with long-term hormonal therapy.

Several days after starting his treatment, Chalit, who is considering an operation, got a tattoo of the testosterone molecule on his arm.

"I have to take hormones for the rest of my life," he said. "This tattoo will also stay with me for the rest of my life."