Affordable oral morphine crucial component of palliative care in Africa

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Published: 8 Dec 2015
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Dr Anne Merriman - Founder of Hospice Africa Uganda

Dr Merriman talks to ecancertv at AORTIC 2015 about the importance of pain management in palliative care.

She outlines the history of palliative care and pain relief in Africa. 

The stress on addiction, she says, has been very damaging as people who need morphine haven't had access to it in many African countries.

She explains that the price of oral affordable morphine in Uganda has gone up due to health and safety concerns but still remains cheap, safe, and effective.

We need to better educate undergraduates training to be doctors on the importance of pain control, she argues, as doctors inform government policy.

Hospice Africa was founded with a vision for the whole of Africa and actually it has moved very quickly and the reason why is because we’re managing pain and that’s what I’ve come to talk to you about today on behalf of Dr Eddie who is in charge of the morphine production unit at the moment in Hospice Africa Uganda in Uganda.

What are the  key issues of morphine production?

The reason that palliative care hadn’t reached Africa for many years was because the medication for severe pain was very, very expensive. Approximately 85% of patients with cancer will have very severe pain and will require opioids or similar strong analgesics. The WHO have recommended that morphine is not only the best one but it is the most available and it can be the most affordable. But unfortunately when it’s manufactured in other countries there’s always a middle man that puts the price right up and that was not affordable in African countries, mainly because of the economies.

There were two African countries that could afford it and that was Zimbabwe and South Africa. Zimbabwe started palliative care in 1979 followed closely by South Africa in 1980 so they had it for ten years when I came out to Nairobi to be their first Medical Director. I told them I wouldn’t come unless we had affordable morphine and we had actually made a formula for affordable morphine in Singapore, where I was working previously. So that was the first time that we brought that formula, they said OK, and within six months they had the affordable morphine in Nairobi and I came there and worked there.

Then when the vision for the whole of Africa was obvious that it was something that needed to be spread throughout Africa because now there were only three countries in the whole of Africa with any form of palliative care, most of it localised. It was then that we said, right, we need a model in a country that’s willing to train others so that it will move throughout Africa. So that started in ’93 and now, since then, 35 countries are talking about palliative care, know about it. Only 15 have the affordable oral morphine and this is mainly because governments are following the International Narcotics Control Board which is stressing more the problem of addiction versus the need for therapeutic morphine. This stress on addiction has really made paranoid the governments throughout Africa who worry that if they allow morphine in they will be called people who help addicts to get this dose. Now, the morphine, as we use it, oral affordable morphine in the strengths we have, it’s not addictive at all. We, in Uganda now, just at hospice alone, we have treated 27,000 people, 25,000 of those at least have been on oral morphine, we’ve never had addiction or diversion of the oral affordable morphine. We actually haven’t used an injection for about 15 years and we manage the pain completely with oral affordable morphine.

What challenges are you facing with palliative care and morphine in Africa?

We must keep the price down because if the price goes up that is the end of palliative care in Africa. When we first made it at the kitchen sink the cost was the price of one loaf of bread. We did that for 17 years and then in 2011 the government asked us to take on making morphine for the whole country from our own place within the hospice in Kampala. When we did this we had to form a contract with them and we got the National Drug Authority, of course, who had always been in control of what we did, now they insisted that we wear caps, gowns, masks, boots, a big sterile environment. We had to upgrade the whole… it’s only one room actually, and then we got a lot of equipment from America to make more because we’re making it for the whole country.

Remember that Uganda is the only country where nurses can prescribe morphine so the government pays for the morphine and it is free to anybody that is prescribed by a recognised prescriber and that includes the doctors, the clinical officers that have been trained, and the nurses that have been trained by Hospice Africa Uganda. So we use probably more morphine than most African countries per head of population.

So now that we’re having to use… we always used recycled water bottles, that was when it was costing one loaf of bread and we made the labels ourselves. Now the labels have to be printed, the bottles have to be made of glass, of dark… no, sorry, they’re made of plastic still, but they’ve got to be dark so they have to be manufactured so all this adds to the cost. Also there’s certain testing that has to be done on it, testing the extended shelf life, making sure that the product is always right. So now it’s costing at least two loaves of bread and, of course, we have people employed to help us make it so that also puts up the cost whereas before just the dispenser in the pharmacy was making it. So the price has gone up to two loaves of bread but it’s still affordable and the government is still paying for it for the whole country.

Where are the raw ingredients sourced from?

The raw morphine, for years we were getting it from Scotland actually, from Edinburgh. What happens is that the morphine is grown in any particular country and then certain manufacturers are allowed to import that morphine product and there they will test it to make sure that it’s pure. Then you can buy it from them. Now, like we do for all drugs, we have to check the prices throughout the world. Now they’re actually getting it from Hungary through Kenya, through Nairobi. There’s an Indian man in Kenya who imports it there and we get it from there, apparently because it’s cheaper and the price seems to be going down, probably because more people are using it. It’s now round $2,000 per kilogram and it was about $4,000 when we started out.

Is it possible for you to grow poppies and manufacture morphine in Uganda?

I understand that if you’ve got the permission and we had the controls in place we could actually it and that would make it even cheaper still, you know? But then we’d have to have people to make sure that it was pure and that it was refined properly and all the rest of it and I don’t know how much that would cost. But I understand from the powers that be that it is possible to grow it anywhere as long as the International Narcotics Control Board have approved that that country can grow it. So at the moment it probably is mostly coming from Afghanistan and those areas around there, yes.

Any further key points?

To enable countries to have it more we need to get into the governments. Now the governments are advised by doctors; the doctors are afraid to use it because of the story I’ve told you, they’d be afraid they’d be called addicts etc. or that they’re tending to be addicts. The only way to stop doctors thinking like that, because if you’re an old doctor you don’t want to learn new tricks, I don’t want to learn new tricks anymore either, but for the young doctors you have to get to the undergraduates and train them in palliative care and the use of morphine and pain control. Now, we started training the undergraduates in 1993, now most of our doctors know what we’re talking about and they’ve no problems about prescribing it. But in the other countries it’s taking a long time to get it into the undergraduate curriculum, doctors, nurses, all health professionals need to know about it. So education is the key to getting that in. Those doctors then will be advising the government and we will change the government policies. But it is very difficult, it’s an uphill job. We’re 22 years at it and only 15 countries using the affordable morphine. It’s difficult, yes.