Saturday, September 04, 2010

The politics of pain - BMJ

Pain relief is often taken for granted in the Western world, but in about 150 countries the use of morphine is severely restricted. Tatum Anderson investigates how this has come about, and what steps are being taken to stop patients living and dying in extreme pain.

Dozens of recycled plastic mineral water bottles are filled with brightly coloured solutions. The bottles are full of oral morphine, colour coded for different strengths—green for the weakest, then pink, and blue for the strongest. Every day, teams of nurses take them to paediatric and cancer wards and patients living at home near Kampala, Uganda.

In a country where fewer than 5% of cancer patients ever receive radiotherapy or chemotherapy, and with a high HIV/AIDS prevalence, the need for pain relief is crucial, says Anne Merriman, an Irish palliative care specialist who set up Hospice Africa there in 1993.

She agreed to establish the service on condition the government changed its rules on morphine provision. Previously only doctors, dentists, and vets were allowed to prescribe opioids—although midwives could prescribe pethidine. In the early 1990s oral morphine was used only rarely, and with a shortage of doctors, few patients ever met a health worker allowed to prescribe it. In 1992 the government agreed to allow nurses and clinical officers trained in palliative care at Hospice Uganda to prescribe oral morphine. "The government had seen so much suffering with the AIDS epidemic. Everyone had a family member who had died in agony," says Dr Merriman.

Lack of oral morphine

Today, despite Hospice Africa's attempts to export the model, widely available oral morphine remains an exception rather than the rule. In about 150 countries,1including Indonesia and India, severe restrictions on the use of morphine for pain relief means patients are still living and dying in severe pain.

Although WHO guidelines for the treatment of moderate to severe pain in cancer state there can be no substitute for [strong] opioid analgesics such as morphine,2weaker drugs are often used to treat pain in people with terminal cancer and HIV/AIDs patients. Gabriel Madiye, executive director of the Shepherd's Hospice in Sierra Leone says: "We have tried codeine [a weak opioid], diclofenac, and paracetamol. They are not enough."

Recently WHO estimated that 5.5 million people with terminal cancer, a million late stage HIV/AIDS patients, and 800 000 patients with unintentional injuries or injuries caused by violence are not receiving the pain relief they need. Also, many patients with conditions, such as sickle cell anaemia, those recovering from surgery, and HIV/AIDs patients on antiretrovirals, require relief but do not get it. Controlled drugs that are used to treat drug addiction or obstetric complications, such as ergometrine, are severely restricted too.3

Most countries do not have bans on opioids for medical use, but their policies and rules are so onerous the result is lack of access for patients. In some countries only oncologists and palliative care specialists are allowed to prescribe opioids, or they can only prescribe extremely limited amounts. Some formulations, such as oral morphine, are not allowed (see box 1). Indian pharmacies require so many licences to stock controlled drugs that many do not bother (see box 2). Nigeria and Cameroon each have just one government pharmacy stocking oral morphine, says Faith Mwangi-Powell, executive director of the African Palliative Care Association, which is studying the African opioid supply chain.

Injectable morphine is not an option—too many safety problems are associated with it because it needs to be administered in controlled conditions. The same issues apply to controlled release forms of morphine.

Even countries that have embarked on strategies to change laws and increase palliative care provision, such as Malaysia, have run into problems. Too few doctors are trained to prescribe morphine says Ednin Hamzah, chief executive officer of Hospis Malaysia. "We organise many workshops and have started to get some palliative care content into undergraduate education, but it is very little."

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