Africans die in pain because of fears of opiate addiction

Attempts to improve palliative care services in Africa are being hampered by the fear that many African professionals have of using morphine therapeutically and by poor access to the drug, a conference was told last month.⇓

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Many countries in Africa have no access to morphine so that palliative care is reduced to the level of supportive care without pain relief, delegates from 35 countries heard. They were attending the second palliative care conference for Africa, in Nairobi.

While the world's 20 richest countries consume 86% of global therapeutic morphine, countries such as Rwanda use just 0.039 mg per capita, one of three lowest users in the world.

Opiophobia—the fear of using morphine therapeutically—is a big obstacle facing palliative care services in the continent, the conference heard.

Fear of addiction, excessive bureaucracy, inadequate requisitioning, and a reluctance to use oral morphine outside hospital are widespread throughout Africa. In addition, the lack of doctors, especially in rural areas, makes nurse led prescribing essential, but there is an unwillingness to encourage nurses to take on the prescribing of morphine. At the same time the need for palliative care services is growing.

Cecelia Sepulveda, head of the cancer control programme at the World Health Organization, said that palliative care is only now being introduced to HIV/AIDS programmes in some African countries while cancer is generally a neglected area of health care in resource poor countries.

“Worldwide there are 11 million new cases of cancer each year, with a forecast of 90 million by 2030, due to tobacco, dietary factors, and HIV/AIDS,” she told the conference. “Seventy per cent of these are in the developing world, where 0.5% of the population may require palliative care at any one time. But few can access it.”

Those trying to establish palliative services in Africa also face the challenges of staff shortages because of migration of trained health workers, health systems that focus mainly on infectious diseases, meagre health funding, huge distances and travel costs, and indifference to the dying by policy makers and senior medical staff. There is the added problem of social and cultural barriers to discussing death.

Successes are encouraging, and Uganda is held up as an example of what can be achieved. Uganda, the home of the African Palliative Care Association, which organised the conference, has done more than any other country to make cheap oral morphine widely available through trained nurse prescribing. It has also included palliative care in its national health plan. Many other countries, including Zambia, Tanzania, Malawi, and Nigeria, are following.

The association is supporting advocacy for access to oral morphine throughout the continent, and delegates expressed strong commitment to the idea.

“Pain relief should be a basic human right,” said Liz Gwyther, from Cape Town, and the Worldwide Palliative Care Alliance. “This is a challenge that the whole medical profession should address urgently: to eliminate the regulatory and legal barriers in the way of achieving relief for the millions living and dying in unnecessary pain.”