International Clinical Elective in Palliative Care in Kampala, Uganda Part 1

Kayla Wolofsky, MBBS

Fellow, Palliative Care at Massachusetts General Hospital 

PGY 4

Inequality of access to palliative care is one of the greatest disparities in global health care. In Uganda, the provision of palliative care services started in 1993 with the establishment of Hospice Africa Uganda by Dr. Anne Merriman, who I had the honour of meeting on my second day in Kampala.

A signed copy of Dr. Anne Merriman's novel "Audacity to Love: The Story of Hospice Africa: Bringing Hope and Peace for the Dying." 

Hospice Africa Uganda is licensed by the National Drug Authority to import morphine powder and reconstitute it into liquid form. This is done by Ugandan health workers who are trained to mix the powder with water to create oral morphine ( which is then poured into recycled, clean plastic bottles).  There are two different strengths of oral morphine available, 5mg/5ml and 50mg/5ml. 

Liquid oral morphine in two different strengths.
Green: 5mg/5ml and Red 50mg/5ml.

The International Narcotics Control Board determines how much opioid each country can receive per year. These estimates are based on a country's own prediction of its pain treatment needs for the projected year using data consumed in the previous year. Thus a country that consumed low amounts of opioids the previous year are allocated a low of opioids the following year.

I came to Kampala to learn about symptom management in a resource limited environment. I spent the first two weeks of my elective on the palliative care consult service at Mulago Hospital 

Coming to Uganda, I anticipated medications to manage patient symptoms would only be medications on the essential medication drug list. For pain management this would include: Tramadol, Codeine, Pethidine, and Morphine (oral and IV). I knew pain management would be challenging at times, but had hopes that with access to morphine, a medication we take for granted in North America, pain could be better controlled with the assistance of the palliative care team. However, despite being on the essential medication list, there have been very limited amounts of oral morphine available in the hospital and there is almost no IV/SC morphine.

Mulago National Specialised Hospital

Physicians will write a prescription for morphine and caregivers will have to go to the hospital pharmacy and fill the prescription. There have been times where the hospital has been out of stock and the caregiver will have to search for pharmacies that may carry morphine. Even if the patients are fortunate enough to be able to afford the materials necessary for  IV or subcutaneous morphine it is very unlikely they will be able to find a pharmacy that stocks this form of morphine. It has been very challenging to see patients in extreme pain and not be able to make them more comfortable.

In addition to lack of access to morphine many patients I have managed fear morphine and despite being prescribed may not fill the prescription. This is known as “opioidphobia”. Patients are aware of the opioid addiction crisis in the Western world and fear becoming addicted. They are aso very fearful of the side effects such as constipation. In addition to the patients fear of opioids, physicians and pharmacists are very cautious and also uncomfortable prescribing and distributing higher doses of morphine. Pharmacists despite having a written prescription for morphine by a physician will sometimes not administer what has been prescribed as they fear the dose is unsafe and patients do not get what they were prescribed.

It is clear that there are two significant barriers to access to morphine.  The international drug control system and the propaganda that promotes two myths about opioids: that they are always dangerous and instantly addictive.

Coming to Kampala, I knew there would be challenges with symptom management and access to non-essential medications, what I did not anticipate was the lack of access to medications on the essential medication list and the resistance to prescribing morphine. While enthusiasm for pain education and clinical training in developing countries has grown, restrictions by governments and health administrations have represented a significant barrier to practice changes.