Good day Dr Mulenga
Thank you for your posting on the use of Morphine in palliative care.
There is a lot of resistance in the use of morphine, especially at the high doses used in the palliative care setting.The anxiety among caregivers and health practitioners is usually that they will overdose the client.
For caregivers, this is mostly in the home setting which is where most of the clients in LMICs receive end of life care.
However to try and overcome this, practise has been to involve one key family member in the management of the client. This member is then educated on the importance of pain medication and its administration. However, in some cases, they face challenges from family members depending on their cultural set up.
Another issue is access and availability of morphine. Clients are sent to their rural homes when they fall ill and in that set up most will have access, if at all, to paracetamol which is widely available at all rural health centres. This could be overcome by having morphine available at district level (in our setting here in Zimbabwe) so that rural health centres can access as per need.
From the health practitioner perspective, there is a challenge of opioid phobhia as well. Specialists can prescribe high doses as needed but the majority of practitioners may not be well informed or are reluctant to prescribe morphine in the community setting.
There is only a handful of health practitioners who have specialised in palliative care and most practise in the urban areas. The move now in Zimbabwe has been to train cadres, drawn from all levels of health centres, called Palliative Care Champions to try and enhance delivery of palliative care and in the process address issues of access to morphine. Also,legislation has been ammended to allow nurses trained in Palliative care to prescribe morphine.
Supply chain challenges do hinder access to morphine. There are issues of stock outs and high costs.
To address access to morphine it is critical to come up and implement models that look holistically at:
2. Capacitation of health professionals in all settings.
3. Supply chain issues.
4. Addressing availability of information to caregivers.
From my experience in the private pharmacy retail setting, we can have morphine available but no scripts come through for it or if they do, the client may not afford. At the end of the day the morphine expires and the legislation creates a nightmare for the pharmacist in terms of disposal. Also caregivers sometimes bring back what the client has not used and the pharmacist has to consider issues of disposal. As a result, few are then keen to stock morphine.
If client passes on without using some of the morphine there is a danger of other family members using or abusing the medicine. Mechanisms need to be put in place to follow up, retrieve and dispose of the unused morphine and other medicines in the community setting. Perhaps models that already tap into the existing structures of Community Health Workers and Village Health Workers.
It may be critical to carry out research to back up some of the observation made in the use of morphine then findings can be used to advocate for policy change and also for coming up with interventions that will ensure that no one dies in pain.
In my opinion, access to pain medication is a human right. No one in the palliative care setting should die in pain. lt is traumatic for the patient and those left behind.
HIFA profile: Venus Mushininga is a pharmacist with the Ministry of Health and Childcare in Zimbabwe. She is a founder and President of the Zimbabwe Society of Oncology Pharmacy and the Zimbabewan delegate to the European Society of Oncology Pharmacy. Professional interests: Oncology, Dissemination of information through to Health Professionals and the public, Research. She is co-coordinator of the HIFA working group on information for Prescribers and Users of Medicines.
Email: vmushininga AT gmail.com