Intended for healthcare professionals

Feature Pain control

The politics of pain

BMJ 2010; 341 doi: (Published 11 August 2010) Cite this as: BMJ 2010;341:c3800
  1. Tatum Anderson, freelance journalist
  1. 1London
  1. tatumnanderson{at}

    Pain relief is often taken for granted in the Western world, but in about 150 countries the use of morphine is severely restricted. Tatum Anderson investigates how this has come about, and what steps are being taken to stop patients living and dying in extreme pain.

    Dozens of recycled plastic mineral water bottles are filled with brightly coloured solutions. The bottles are full of oral morphine, colour coded for different strengths—green for the weakest, then pink, and blue for the strongest. Every day, teams of nurses take them to paediatric and cancer wards and patients living at home near Kampala, Uganda.

    In a country where fewer than 5% of cancer patients ever receive radiotherapy or chemotherapy, and with a high HIV/AIDS prevalence, the need for pain relief is crucial, says Anne Merriman, an Irish palliative care specialist who set up Hospice Africa there in 1993.

    She agreed to establish the service on condition the government changed its rules on morphine provision. Previously only doctors, dentists, and vets were allowed to prescribe opioids—although midwives could prescribe pethidine. In the early 1990s oral morphine was used only rarely, and with a shortage of doctors, few patients ever met a health worker allowed to prescribe it. In 1992 the government agreed to allow nurses and clinical officers trained in palliative care at Hospice Uganda to prescribe oral morphine. “The government had seen so much suffering with the AIDS epidemic. Everyone had a family member who had died in agony,” says Dr Merriman.

    Lack of oral morphine

    Today, despite Hospice Africa’s attempts to export the model, widely available oral morphine remains an exception rather than the rule. In about 150 countries,1 including Indonesia and India, severe restrictions on the use of morphine for pain relief means patients are still living and dying in severe pain.

    Although WHO …

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