Essential Yet Scarce: Rational use of medical morphine for home hospice

By Katherine Pettus, PhD
IAHPC Senior Director of Advocacy and Partnerships

My sister's home death from glioblastoma last month would have been much more distressing without the "just in case" kit (that included a bottle of oral morphine) supplied by Hospice of the North Coast in San Diego. Lisa died peacefully thanks to nurse Alma’s expert guidance on safe dosing during the last hours and days. To avoid possible diversion, she told us to dispose of the bottle once Lisa died. I was struck by the trust the hospice put in us as caregiver stewards of this essential controlled medicine, which was in contrast to the discourse focused on abuse and diversion that dominates the mainstream media and policy debates.

Our family caregiver team that included sister Josie, Lisa’s son Sam, and me, initiated oral morphine when Lisa complained consistently of pain on being moved to prevent bedsores or for personal care. Morphine was also a blessing when delirium arose toward the end. The hospice team gave us the green light to gradually increase the dosage to reduce her agitation. 

Chronic lack of availability elsewhere

Despite its having been included for more than half a century in the WHO Model List of Essential Medicines, morphine is chronically unavailable for medical purposes in more than 80% of the world (mostly lower- and middle-income countries). [See the WHO Left Behind in Pain report, and Modules 2 and 3 of IAHPC's Advocacy Course for more information.] The IAHPC and its partners have been addressing this public health challenge for decades through international and regional advocacy. We also support clinical and advocacy training for national associations and health leaders to ensure that trained professionals and closely supervised lay caregivers like me can use it safely and effectively. Unlike illicit fentanyl and oxycodone, oral morphine does not produce the effects necessary to make it lucrative on the street. The 2024 World Drug Report does not even include morphine in its section on seizures of opioids. 

Clinicians agree on morphine's efficacy

Senior clinicians’ lectures for the seven-module, online IAHPC/International Neuropalliative Care Society course on Palliative Care in Neurological Conditions have all mentioned the efficacy of morphine and other internationally controlled essential medicines—including benzodiazepines for seizure—in treating children and adults with brain tumors, ALS, multiple sclerosis, and other serious conditions. 

Our IAHPC advocacy team continues to raise awareness and promote policy change at sessions of the Commission on Narcotic Drugs in Vienna and the UN Human Rights Council in Geneva. Please contact me if you would like to join us. 

UN Human Rights Council on Board!

The Special Rapporteur on the Right to Health, Dr. Tlalang Mofokeng, issued a recent thematic report to the Human Rights Council in Geneva stating that: 

"All people rely on essential controlled medicines for pain, opioid dependence, palliative care and other health conditions. The right to health includes a core, minimum obligation to provide access to essential medicines, which, under the WHO Model List of Essential Medicines, include morphine, methadone and buprenorphine. [italics added]"

Newsflash: National palliative care associations can help! Your professional associations can educate and inform yourselves and your governments —the gatekeepers of controlled medicines—of the guidelines, model laws, policies, and best practices available. [See the box below; Modules 2 and 3 of IAHPC's Advocacy Course cover this topic.]

UN also discusses care & support!

As someone who has just come off an intense stint of family caregiving, I was very interested in an “informal intergovernmental interactive dialogue” in July hosted by the UN Economic and Social Council (ECOSOC). The televised event focused on the cross-cutting nature of care in the 2030 Agenda for Sustainable Development Goals (SDGs), and the economic value of caregiving as part of a country's gross national product. This care is largely provided by women, many of whom are older. 

The workshop—chaired by ECOSOC's president Her Excellency Paula Narváez, Ambassador for Chile—brought together experts, member state representatives, civil society, and the private sector. [Read the Concept Note here.]

Panels focused on how to envision, promote, and support an equitable, sustainable care economy based on human rights principles. Latin American and African women from ECOSOC, UN Women, the UN Economic Commission for Latin America and the Caribbean, and the UN International Labour Organization led the panels, which focused on the value of women’s paid and unpaid labor, workforce training, and sustainable development. 

Palliative care advocates who get little policy traction in health and medical systems are discussing shifting focus on ensuring availability of palliative care to this global movement for a care economy. After all, serious illness is a growing global health issue, particularly for older persons who need care and support in the form of a workforce trained in primary palliative care. IAHPC Research Advisor Tania Pastrana and Professor Emeritus Scott Murray et al. make the fiscal case for upstream investment in palliative care in an excellent commentary titled "The Value and Economic Benefits of Palliative Care in Primary Care: An international perspective."

Does your country protect the right to care?

What policies and practices in your country already (or could) protect the rights of people giving and receiving care? Folks living in the Americas are fortunate to be able to refer to the Inter-American Convention on the Human Rights of Older Persons, which explicitly stipulates rights to care and support that includes provision of palliative care services. 

Is your country aligning its national policies with regional and international law? How can IAHPC help you ensure compliance? 

IAHPC webinar on caregiving in October

IAHPC is organizing an October webinar on care and support, continuing a tradition we began on October 29, 2023, to coincide with the first International Day of Care and Support proclaimed by the UN. The event will feature researchers, informal caregivers, and care providers (members of the care workforce) as well as patients and families. The discussion will focus on caregiver needs and how health systems can better support them. 

If you would like to participate in planning and executing this webinar, please contact me. 

Prison hospice

On July 18, Nelson Mandela International Day, the UN Office of Drugs and Crime highlights the UN Standard Minimum Rules for the Treatment of Prisoners, known as the Nelson Mandela Rules. These provide the blueprint for 21st century prison management that preserves the safety, rights and human dignity of all. The rules include a right to standard health care, which includes palliative care. For more information, see End-of-Life Care Behind Bars, Barry Ashpole's periodic literature review. 

Reference

1. UNODC. The United Nations Standar Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), 2015. https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf

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