Dr. Katherine Irene Pettus Advocacy Officer, International Association for Hospice and Palliative Care, describes her recent visit to Hospice Ethiopia.
“I will assure you 100% we don’t take a single penny. That’s a promise!” This was the commitment given by Dr. Mohammed Nuri, Managing Director and owner of Medtech Ethiopia. This formerly government-owned pharmaceutical company provides free oral morphine solution to the Ethiopian Ministry (FMHACA) that distributes it to public hospitals. Under a recently developed Memorandum of Understanding, government doctors can issue morphine prescriptions for Hospice Ethiopia patients. When Medtech Ethiopia was privatized last year, physicians were worried that prices of essential medicines, such as morphine and phenobarbital, would rise to reflect the new company’s need for profit, but Dr. Nuri, who personally oversees the social responsibility mission of the company, swore he could keep it free of charge. Our visit to Medtech Ethiopia reinforced his commitment to support Hospice Ethiopia, which visits the poorest of the poor suffering from cancer and/or AIDS in their homes.
I was visiting Addis Ababa at the invitation of Dr. Anne Merriman, founder of Hospice Africa Uganda (HAU) and currently Director of International Programs, a role that has her traveling almost non-stop around the world. Still a force to be reckoned with at 80 years of age, Dr. Anne has been coming to Ethiopia since 1975 to plant the seeds of hospice and palliative care. The purpose of this most recent visit was to monitor the progress of the fledgling Hospice Ethiopia (HE), whose medical officers were trained at the HAU ‘mother ship,’ and which is supported by a consortium of largely UK-based charities. Dr. Anne accompanied me on advocacy visits to government ministries with Dr. Yosef Mamo, Technical Advisor Non Communicable Diseases Case Team at the Ministry of Health, and medical consultant to Hospice Ethiopia. In the past week, we have been visiting the various offices responsible for the importation and distribution of controlled medicines, and have had an afternoon of home visits.
One of the main barriers to improving treatment for pain and palliative care in Ethiopia, and in Sub-Saharan Africa generally, is the lack of healthcare providers trained to use morphine. The team visit to Eleni, the young woman in the photo, made clear the need for experienced supervision, as Dr. Anne talked the Health Officer, Dr. Ephram (licensed to prescribe controlled medicines), through the appropriate doses for the management of breakthrough pain, breathlessness, and vomiting. By the end of our visit Eleni was sleeping peacefully, and her family was reassured that the wrap-around care from HE would be available to them should they need it.
One of the many advocacy highlights of the week was meeting with Dr. Abraham Gebregiorgis, Director of the World Health Organization (WHO) Essential Medicines Programme in Ethiopia, to discuss a proposal for a regional meeting of African states to improve access to controlled medicines. We also presented a letter at the African Union (AU) Human Rights Office to request the inclusion of palliative care language in the Draft AU Protocol to protect the rights of older persons. (Download a copy of the letter and read more about the rights of older persons.)
Ethiopia is one of the few countries in the world poised to make palliative care a fifth pillar of national health policy, adding it to the current four: Promotion, Prevention, Treatment, Rehabilitation. The Minister of Health has proposed this policy to the parliament, which is expected to ratify it this year. Currently, the Ministry is sponsoring the participation of nine Addis hospitals in the American Cancer Society’s ‘Pain Free Hospitals’ project, which requires clinician training in pain and symptom management. The Ministry of Health plans to increase capacity by extending training to rural hospitals over the next five years.
As always, however, the challenge is to bring palliative care to the ‘hidden’ patients in rural and urban areas. These patients almost never see a health worker and suffer agonizing pain at home with no strong analgesia. At every one of our meetings, Dr. Anne encouraged the administrators we saw to develop home care services, which are low cost and require task shifting, for example licensing appropriately trained nurses to prescribe controlled substances such as morphine. Despite the huge need, she says: “We don’t want to let it – morphine – loose on people who are not trained.” My role was to explain the international law that allows countries to use controlled substances for medical and scientific purposes, to remind government officials that access to pain treatment is a human right, as it says on the wall of Hospice Ethiopia, and to encourage them to integrate palliative care into their healthcare systems as per World Health Assembly resolution 67/19.
To read Katherine’s full article in ehospice, and for more information on global civil society organizations’ activities to protect the rights of older persons, click here.
Willem Scholten, PharmD MPA, Consultant – Medicines and Controlled Substances, Willem Scholten Consultancy, Lopik, the Netherlands.
In a letter-to-the-editor in PAIN (the official journal of the International Association for the Study of Pain), Jack Henningfield and I argued that the outcomes of a systematic review on “misuse, abuse and addiction” by Vowles et al. are invalid because of the low quality and heterogeneity of the studies included.1,2 Vowles et al. included 38 studies and many of these had been rejected in a Cochrane study by Minozzi et al. on their determination that the studies were not adequate for the purposes of a meta-analysis.2,3
Amazingly, the authors’ definition of misuse is identical to what is generally called patient non-compliance, a common problem in patients to whom medicines are prescribed. Therefore, putting a figure on non-compliance among patients using opioid analgesics only makes sense if comparing to non-compliance rates for all medicines, which is 25 %,4 while Vowles et al. found that among patients using opioid analgesics it is “between 21% and 28 %”. So, non-compliance (‘misuse’) in these patients is not any different from the general population of patients who use medicines.
Also the analysis of addiction rates is not a reliable outcome and contrary to what Vowles et al. suggest, according to the Cochrane study by Minozzi et al., there is not any reason to withhold opioid analgesics to pain patients in need.
Moreover, in a Special Commentary in PAIN, Dr. Jane Ballantine commends the authors by saying that they “tackle the debatably impossible task of estimating the prevalence of opioid misuse, abuse, and addiction in chronic pain”, but simultaneously, she admits that “it is hard to understand what addiction actually is when it arises during pain treatment with opioids.” 5 So they tackle the issue without a good understanding?
In the USA unfortunately, the press and the politicians have been distorting the image of pain patients and their use of analgesics for a number of years now, but it is amazing that Vowles et al. and Ballantyne, being medical professionals, lend themselves to enforce these mechanisms which lead to patients having problems of accessing adequate pain management. We consider this health abuse.
1. Vowles KE, Mindy L, McEntee ML, Peter Siyahhan Julnes PS, Frohe T, Ney JP, Van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. PAIN, April 2015; Vol 15(4): 569-576.
2. Scholten W, Henningfield JE. A meta-analysis based on diffuse definitions and low quality literature is not a good fundament for decisions on treatment of chronic pain patients. PAIN, August 2015; 156(8): 1576-1578.
3. Minozzi S, Amato L, Davoli M. Development of dependence following treatment with opioid analgesics for pain relief: a systematic review. Addiction. 2013 Apr;108 (4):688-98.
4. DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–209.
5. Ballantyne JC. Assessing the prevalence of opioid misuse, abuse, and addiction in chronic pain. PAIN, April 2015; Vol 15(4): 567-568.