Improving Morphine Availability in Resource Limited Settings

1. Improving Morphine Availability in Resource Limited Settings Uganda’s Experience

3. Uganda at a Glance… A former British Colony Independence – October 9th 1962 1971-79 – dictatorial regime of Idi AMIN 1980-1985 – guerrilla war & human rights abuses; many lives were lost. Relative stability and economic growth since 1986 High burden of life-threatening illnesses – HIV and Cancer

4. Uncontrolled pain

5. The Beginning Very high disease burden associated with severe pain Absence of opioids to control pain Worked closely with MoH and Drug Regulatory Authority Many barriers identified

6. Barriers to opioids availability • Severe Opiophobia and Morphinephobia; • Inadequate knowledge about morphine; • Overly restrictive laws governing use of narcotics; • Anti-Narcotic Enforcement fear of diversion; • Problems of distribution of Opioids to remote rural areas; • Shortage of prescribers and dispensers due to a poor doctor to population ratio;

7. Finding solutions to the barriers Education, Sensitization, Advocacy Facilitating distribution to remote rural areas; Revisiting and amending restrictive and outmoded laws on narcotics Expanding the prescribers of opioids Demystifying concerns about Addiction

8. Guideline on Handling Opioids • Proper Guidelines – by MoH on how to handle Narcotics including morphine for medical use while preventing illicit use – the fundamental principle of Balance

9. Dispensing Morphine as per Guidelines A Morphine Prescription Measuring and Labeling

10. Dispensing of Morphine Details are recorded in specific book and signed for by person collecting the medicine Detailed instructions for taking the drug are given Signing for Medicine Clear Instructions on Usage

11. Clear Instructions This medicine is not to be shared Patient should take it as instructed and you can call this number in case of questions Return all unused medicines to Hospice pharmacy For patients from upcountry return to clinic with remaining medicines (if at all) When a patient dies remaining medicines should be brought back and if not possible to be poured in a pit latrine

12. Finding solutions to barriers through clinical education Doctors and students on a Ward Round Learn about use of morphine • Palliative care in medical training curriculum • Encouraging use of affordable but effective oral morphine solution • Educating the public about opioids • The media – TV and Radio

13. Improving accessibility through task shifting – nurse prescribing 2004 – Government amended the law on narcotics to authorize specially trained nurses and clinical officers with a certificate to prescribe and dispense oral morphine.

14. MINISTRY OF HEALTH STATUTORY INSTRUMENTS SUPPLEMENT No. 13 23rd April, 2004 STATUTORY INSTRUMENTS SUPPLEMENT to The Uganda Gazette No. 18 Volume XCVII dated 23rdApril, 2004 Printed by UPPC, Entebbe, by Order of the Government. STATUTORY INSTRUMENTS 2004 No. 24. PART II - PRESCRIPTION AND SUPPLY OF CERTAIN NARCOTIC ANALGESIC DRUGS 4. Subject to regulations 5,6 and 7 a Clinical Officer or a Nurse with a certificate in specialist palliative care shall be authorised to prescribe and supply the narcotic analgesic Drugs specified in the Schedule. 5. A Clinical Officer or a Nurse authorised to prescribe drugs under regulation 4 may only prescribe drugs for the management of pain and as part of the palliative care of patients suffering from severe pain and similar symptoms. 6. The narcotic analgesic drugs to be prescribed under regulation 4 shall be only those products and in the form described in the Schedule. 7. The requirements for prescribing narcotic analgesic drugs referred to in regulation 6 shall be those in para­graph 3 of the Ministry of Health Guidelines for Handling of Class A Drugs, March 2001 or any revisions to those guidelines. SCHEDULE NARCOTIC ANALGESICS WHICH MAY BE PRESCRIBED AND SUPPLIED BY CLINICAL OFFICERS AND NURSES 1. Morphine oral solution 1 mg/1mL (or 5 mg/5mL) 2. Morphine oral solution 50mg/5mL 3. Morphine tablets SR 10 mg 4. Morphine tablets SR 30 mg 5. Morphine tablets SR 60 mg BRIG JIM MUHWEZI, Minister of Health.

15. Successes Health Sector Strategic Plan – PC included in the Basic Package under MOH Essential Clinical Care; Government committed to availability of Opioids to all patients who need it since 2003; Government distribution system to rural areas – NMS Circulars from MOH to all directors of health institutions to ensure availability of opioids for medical use at all times

16. Challenges • PC still looks strange to some clinicians and policy makers • Slow policy changes and implementation • Resistance from among health workers • Capacity to reconstitute Oral Morphine Solution is still limited • Getting reliable suppliers of Oral Morphine • Difficulty accessing patients in remotely placed areas.

17. What is making it possible? • Working closely with government and partners in development • Creating awareness within the Drug Enforcement Commission about the medical and scientific roles of opioids • Involving the nursing profession – the backbone of palliative care • Continued education: • Health workers • Allied health workers • Patients, family and general public