Destined to live and die in pain

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Morphine is a safe, effective and cheap treatment for pain, yet, many people don’t have access to it, and in fact, many South Africans die in agonising pain because it is not made available to them.

‘Pain, pain, pain. The last two weeks of that man’s life was just pain from beginning to end,’ recalls Sister Delores Cano, a nurse at the Nightingale Hospice in De Aar in the Northern Cape. Cona had to stand by helplessly while a 49-year old cancer patient died in unbearable pain because the local health services refused to issue him with more morphine.

‘Doctors are scared to prescribe morphine and we have to put up a big fight to get it for our patients,’ says Cona, a stout woman with a kind face who speaks pure Afrikaans with a charming Cape accent. ‘And often when we get morphine, the doses isn’t enough to cover the pain for long.’

When a patient’s disease has progressed to a certain point, some medical professionals are of the opinion that they have done all they could and then stop treatment, often because they don’t want to spend any more money or resources on a patient who will die in a couple of days anyway, explains Cona.

‘But we [hospice] don’t work that way. The patient still needs everything. It is not in our hands to say he will die now, or die later.’

Proper pain management is an issue not only in the rural communities of South Africa, but all over the country, according to Dr Liz Gwyther, CEO of the Hospice Palliative Care Association of South Africa (HPCA).

Doctors have been taught that pain is a sign of something else, and in their quest to find and treat the cause, they often neglect to treat the pain, says Gwyther, who also teaches palliative care at the University of Cape Town. ‘They often don’t even assess the pain adequately.’

But there is hope for patients. A new law that will enable trained and registered nurses to prescribe scheduled medicine, including morphine, is expected to come into effect before the end of the year. This will mean that patients can be prescribed morphine at clinics that operate without doctors ‘ as most clinics in the country do. Although this new legislation will put patients one step closer to accessing pain treatment, there are still more barriers to overcome.

In 2009, at least 200 000 South Africans died while suffering moderate to severe pain, 111 307 of them without receiving any treatment for it. This is according to the Global Access to Pain Relief Initiative, who calculated these figures using South Africa’s cancer and HIV/Aids death statistics. These numbers therefore do not include traumatic injury, childbirth or other painful causes of death, and numbers are possibly much higher.

Even more alarming is that the number of cancer cases is estimated to double over the next 20 to 40 years, and the greatest increase is expected in low and middle-income countries, like South Africa. By 2030 it is predicted that there will be 26 million new cancer cases and 17 million cancer deaths per year.

‘People with cancer and HIV equate the illness with pain, and many don’t realise that treatment for pain should be available,’ says Gwyther

In South Africa, morphine is on the Essential Drug Lists (EDL) for clinics, hospitals and specialists, which means that its use is widely recommended by the Department of Health and should be available in all healthcare facilities in the country. However, stock outs occur regularly in hospitals, and many clinics do not even stock it.

‘When we ask the question why is the clinic not stocking morphine, the pharmacist will say the doctor is not prescribing it. And when we ask the doctor why he is not prescribing it, he will say it is because it isn’t kept in the clinic,’ says Gwyther, revealing some of the rationalisations they have heard while investigating morphine shortages at clinics.

Barriers to morphine use

The stigma and fear of morphine among doctors and other health-care workers is so common that an informal quip was created to describe it: ‘Opiophobia’. Morphine is an opioid, a psychoactive chemical which has been used for centuries to treat acute pain. Opioids have also been found to be invaluable in palliative care to alleviate the severe, chronic, disabling pain of terminal conditions such as cancer, and degenerative conditions such as rheumatoid arthritis.

Medical morphine is often associated with heroin, which is also a form of morphine and is highly addictive. However, various studies have shown that patients do not become addicted to morphine sulphate, which is used in South Africa for pain treatment. According to Gwyther, morphine sulphate doesn’t provide a feeling of euphoria. In fact, according to Gwyther ‘it gives you a kind of ‘out-of-it’ feeling that makes you feel stupid and sleepy ‘ in fact, many people don’t like that aspect of it.’

But despite the scientific evidence, many doctors still don’t prescribe morphine out of fear that patients may become addicted, Dr Milton Raff, president of Pain SA said in a talk at the South African Medical Association’s conference last year. He believes this is the result of inadequate education about pain management and opioid therapy.

Gwyther also is of the opinion that many South African doctors are insufficiently trained in pain management and assessment. ‘When I was at university I was taught that that morphine is dangerous, but actually it is not a dangerous drug. Morphine is simple, easy-to-use, very effective and inexpensive.’

The only time that morphine is dangerous is when it is given intravenously after an operation to someone who has never used it before. In these instances a single large dose can lead to respiratory problems. ‘And that is the only thing any doctor or nurse remembers about morphine: it is dangerous, it causes respiratory depression, and people can stop breathing.’

Another barrier to accessing morphine is the form in which it is available. In South Africa there are two types of oral morphine, a slow-acting tablet, and powder, which has to be prepared by a pharmacist and converted into a liquid that can be taken orally. ‘There is no commercial preparation available, so different strength solutions have to be compounded by pharmacists on a per-patient basis,’ explains Andy Gray, senior lecturer in Pharmaceutical Sciences at the University of Kwa-Zulu Natal. ‘Morphine oral liquid preparations will therefore not be available where there is no pharmacy service, which means many clinics and some community health clinics. The long-acting tablets are available in the state, but are expensive, and therefore access is limited to specialist clinics and services.’

Current legislation also hampers patients’ access to morphine. At the moment, morphine can only be prescribed by a doctor or dentist, with the result that morphine is not available at any health facility that does not have a doctor – which means most clinics. This creates problems for patients, like those being nursed by Cona in De Aar. The Northern Cape is vast and most of her patients live in rural areas and have to travel long distances to see a doctor for a prescription, often while they are sick and in a lot of pain.

‘The same legal restrictions prevent palliative care nurses from prescribing morphine to patients at home,’ says Gray. ‘Also, all Schedule 6 prescriptions are valid for only one issue, limited to a maximum of 30 days’ supply, which creates another barrier for patients with ongoing needs for pain relief.’

There is however some light at the end of the tunnel. Revisions to the Nursing Act have resulted in new legislation that will allow specifically trained and licensed nurses to prescribe opioids and other schedule drugs. Having nurses prescribe medicine fits into government’s plan to shift tasks from doctors to nurses in order to fill the gap in health resources. ‘Government’s initiative to have nurses initiate anti-retroviral treatment (ART) has been a good thing to piggy-back on,’ says Gwyther.

‘This will solve the problem [of access to pain medication] 100%,’ says Cona. But she warns that many nurses, just like the doctors, are insufficiently trained in pain management and therefore fear the use of morphine. ‘If their skills are sharpened up, the problem will be solved. Solved 100%.’

Once the new legislation comes into effect, nurses will have to undergo training and be licensed to prescribe opioids and other medicines. ‘Currently this will be an additional qualification for nurses,’ says Gwyther. ‘It puts the safety net in place, and as nurses are more empowered, there will be more effective pain control for our patients.’

There is a problem, however. The Pharmacy Council’s current regulations specify that pharmacists can only dispense on a doctor or dentist’s prescription, and not on that of a nurse. A request has been sent to the Minister of Health, Dr Aaron Motsoaledi, to direct the Pharmacy Council to revise their regulations to allow pharmacists to dispense from nurses’ prescriptions. ‘In South Africa we need to loosen these regulations so that nurses can prescribe,’ says Gwyther. ‘The whole task-shifting concept is blocked because of an arcane law.’