PCAZ to ease chronic pain in Zambia with Morphine

One cold night in Lusaka, 12-year-old Lisa Banda struggled desperately to sit up in her bed in University Teaching Hospital (UTH)’s Haematoncology Ward. Frail and thin, the young girl had been roused from a fitful sleep by waves of excruciating pain that washed over her entire body.

She felt so sick, she said: It felt like her muscles were being cut with razor blades and pins were being driven into her flesh.

At Lisa’s bedside, her grandmother, Bernadina Mumba, explained that the girl had been rushed to UTH following a sickle cell crisis that left her whole body motionless from pain.

“My granddaughter’s life is filled with distress and pain each time she suffers an attack. It is a nightmare existence filled with near constant pain,” Mrs Mumba admitted as she helped Lisa sit up to drink from the glass she was holding.

The glass contained a dose of liquid morphine solution, which helped ease Lisa’s pain until the crisis passed.

Although it has long been considered the “gold standard” of pain medications because it is fast-acting, cost-effective, and readily available in most parts of the world, and generally well tolerated by patients, morphine is a drug that is often shrouded in misconceptions fueled by healthcare professionals and the public alike.

The Palliative Care Association of Zambia (PCAZ), a Lusaka-based non-profit organisation, is working to change this, so patients with life-limiting illnesses like sickle cell anaemia, cancer, or HIV/AIDS can better manage the pain that is all too often part of their daily lives.

For people who have never experienced the pain of a life-limiting illness such as Lisa’s sickle cell disease, it can be difficult to fully comprehend the toll it takes on patients and families alike.

This type of on-going pain cannot be treated in isolation because patients often experience it on multiple levels from the physical to social, emotional, and spiritual. Instead, patients need to be treated more holistically.

Effective pain management is a critical element of palliative care; providers work closely with other healthcare professionals to prevent or relieve suffering by identifying, assessing, and treating pain and other problems as quickly as possible.

Since its official registration in 2005, PCAZ has been educating Zambian policy makers, healthcare providers, and the public at large about palliative care, including advocating the use of morphine in pain management.

PCAZ’s small yet dedicated staff has worked tirelessly to engage various stakeholders through workshops and training events that focus on improving care and support available to patients suffering from life-limiting illnesses whether they are in a hospital set up or being cared for at home or in a hospice.

That same year — with support from the American people through the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID) in Zambia — the American International Health Alliance (AIHA) established an HIV/AIDS Twinning Centre partnership linking PCAZ with the Uganda-based African Palliative Care Association (APCA).

APCA and AIHA provided technical assistance to help build PCAZ’s human and organisational capacity; promote best practices in palliative care research and training; and raise awareness by targeted advocacy and information dissemination.

Lisa and other patients like her in the UTH’s Haematoncology Ward now have access to morphine when their pain becomes too strong to bear.

Training Care

PCAZ staff is working to deliver training in pain management and other aspects of palliative care to healthcare providers and allied caregivers throughout Zambia. They identified three medical doctors and two nurses at the UTH, training them on the use of morphine for more effective pain management in August 2010.

According to nurse Mary Kemboi, Acting Sister in Charge of the Haematoncology Ward, the training has had positive impact on her career and — more importantly — on her young patients.

“After the training, I am now much more confident when administering oral morphine in regular doses to our pediatric patients,” Sister Kemboi admits. “I have replicated the training for my fellow nurses and have also taught other caregivers and even parents how to provide the medication to the sick children to help manage their pain.
We mentor these caregivers and monitor how they administer the drug to ensure patients are getting the best care possible,” she explains.

Sister Kemboi has worked in UTH’s Haematoncology Ward for more than a year. She says the changes that PCAZ helped usher in through their training and advocacy campaign has led to a real improvement in the availability of oral morphine for suffering patients.

Old regulations dictated that morphine be stored in locked Dangerous Drug Act (DDA) boxes.

Medical doctors and registered nurses were the only ones authorised to dispense the drug — a procedure that had to be witnessed by two other registered nurses.

These days, Sister Kemboi explains, when doctors prescribe liquid morphine to help manage a patient’s pain, the drug is ordered from the main hospital pharmacy and administered every four hours.

Dr Lwendo Nchimba works in the Haematoncology Ward and also attended the PCAZ training with Sister Kemboi.

Explaining that patients used to be given drugs such as paracetemol, brufen, and diclofenac for pain management, she happily says that this is no longer the case.

“I think this past trend can largely be attributed to misinformation about the use of oral morphine. It was generally believed that morphine should only be administered sparingly due to side effects like respiratory depression,” says Dr Nchimba, who has worked in the ward for the past year.

She says that training of medical staff, coupled with effective patients counselling, has done a lot to convince practitioners and patients alike of the positive aspects of the use of morphine in pain management.

“We talk to the patients about the proper administration of oral morphine and tell them that once this is done properly, addiction or withdrawal symptoms cannot be experienced by the user,” Dr Nchimba says. “So far, we have not had any report concerning the mismanagement of oral morphine by our patients.”

Although Nurse Anna Chiteya did not participate in the PCAZ training, she too has benefitted from it.

An 8-year veteran of the Haematoncology Ward, Sister Chiteya says she has noticed dramatic changes since her colleagues attended the event and shared what they learned with other staff and families of patients.

“Previously, we had no knowledge about pain management. We just used to dispense drugs such as paracetemol and diclofenac, which did not adequately manage excruciating pain in most of our patients,” Sister Chiteya explains.

“Now we are containing the situation and able to provide more holistic care. Our children cry less, their rate of recovery is faster, and they are able to regain their normal strength in a shorter period of time. We are able to discharge them as soon as they have responded to treatment,” she reports.

Despite these successes, however, many of the negative attitudes and beliefs about morphine persist — even among healthcare workers.

“Some of my peers who do not work in this ward still have misconceptions about morphine use,” Sister Chiteya says, “but a number are coming to appreciate that it is safe and effective for pain management.”

Sister Kemboi has worked in UTH’s Haematoncology Ward for more than a year. She says the changes that PCAZ helped usher in through their training and advocacy campaign has led to a real improvement in the availability of oralmorphine for suffering patients.

Old regulations dictated that morphine be stored in locked Dangerous Drug Act (DDA) boxes. Medical doctors and registered nurses were the only ones authorised to dispense the drug — a procedure that had to be witnessed by two other registered nurses.

These days, Sister Kemboi explains, when doctors prescribe liquid morphine to help manage a patient’s pain, the drug is ordered from the main hospital pharmacy and administered every four hours

Dr Lwendo Nchimba works in the Haematoncology Ward and also attended the PCAZ training with Sister Kemboi.

Explaining that patients used to be given drugs such as paracetemol, brufen, and diclofenac for pain management, she happily reports that this is no longer the case.

“I think this past trend can largely be attributed to misinformation about the use of oral morphine. It was generally believed that morphine should only be administered sparingly due to side effects like respiratory depression,” says Dr Nchimba, who has worked in the Ward for the past year. She says that training of medical staff, coupled with effective patients counselling, has done a lot to convince practitioners and patients alike of the positive aspects of the use of morphine in pain management.

“We talk to the patients about the proper administration of oral morphine and tell them that once this is done properly, addiction or withdrawal symptoms cannot be experienced by the user,” Dr Nchimba says. “So far, we have not had any report concerning the mismanagement of oral morphine by our patients.”

Advocacy and Outreach

Zambia is a signatory to international conventions on psychotropic substances and narcotic drugs signed under the United Nations. These conventions serve as the basis for the country’s current laws that regulate the use of such drugs, including morphine.

The Pharmaceutical Regulatory Authority (PRA) has the responsibility of administering the Dangerous Drugs Act on behalf of the Ministry of Health.

Although the country’s laws do not prohibit medical practitioners from using morphine in pain management, lack of accurate information and prevailing misconceptions about the drug do, according to PRA Pharmaceutical Inspector, Makomani Sianga.

According to Mr Sianga, many of the existing misconceptions surrounding morphine use are due to the fact that medical personnel do not fully understand the provisions of the law.

Recently, however, PRA and PACZ launched a Morphine Pilot Project to assess current morphine use at selected hospitals throughout the country and educate health practitioners on proper usage of the drug — all with the goal of improving access to morphine as an effective pain management medication for all those who need it.

According to Choolwe Kaliba, a chemical analyst with the Zambian Drug Enforcement Commission (DEC), the Narcotic Drugs and Psychotropic Substances Act provides for the lawful possession and use of morphine and even includes provisions that protect doctors who unknowingly prescribe the drug to a patient who has not disclosed that another doctor has already prescribed morphine for them (double prescription).

Mr Kaliba describes seeing expired bottles of morphine lining the shelves of health institutions he has visited.“There are patients who needed this drug, but health practitioners did not prescribe it,” he says sadly.

The training and sensitisation work PCAZ has been doing has helped dispel some the myths and misconceptions that have long been attached to morphine usage, Mr Kaliba points out. “There is evidence to show that the demand for morphine has gone up and that more health facilities are ordering it and using it for the right reasons,” he continues.

“That’s good,” he acknowledges, “because when administered properly, addiction levels are very minimal and we have received very isolated reports of morphine abuse and trafficking.”

PCAZ National Coordinator Njekwa Lumbwe recognises that the organisation has accomplished a lot over the past six years since it was founded, but more work lies ahead.

“We are grateful to the American government because they continue to support us through funding for operational costs while other donors have only concentrated on funding for specific activities,” Mrs Lumbwe says.

PCAZ and all other organisations concerned with palliative care must focus on expanding our efforts in advocacy and sensitisation.

[Times of Zambia]