Access to, and the availability of, opioids for pain management has historically been problematic in the southern African country of Mozambique. This is largely attributable to a lack of relevant medical knowledge and skills, minimal evidence regarding existing bottlenecks in the supply-demand chain, and an unguided dialogue between the parties involved.
Ensuring opioids are available and accessible for legal medical use is partly determined by an understanding of the obligations of key stakeholders involved in the medicinal demand-supply chain.
Service providers are required to provide consumption data to in-country regulatory authorities, which use these to report to the International Narcotics Control Board (INCB) and justify the opioid quantities required to meet a country’s demand.
Opioid use for pain management also calls for appropriate knowledge regarding the storage, prescribing and distribution requirements of opioids to inform practices. Country-specific mapping of knowledge, attitudes, practices and estimation procedures, as well as laws and regulations relevant to opioid availability, is therefore critical for scaling up their access for legal use. Lack of access to opioids adversely impacts the significant number of patients needing proper pain management to alleviate unnecessary pain and suffering.
In 2014, the African Palliative Care Association (APCA) and the Mozambique Palliative Care Association (MOPCA), commissioned a survey on national opioids estimation procedures and supply chain mechanisms in Mozambique, with funding from the United States Agency for International Development in the South Africa/Regional HIV/AIDS Program. In late March this year, the Open Society Initiative for Southern Africa made it possible to share the survey findings with the relevant stakeholders.
The cross sectional survey involved interviews with 11 technocrats for the regulatory authority and 26 service providers coupled with a review of the country’s policies, guidelines and narcotic related laws. Findings showed a huge mismatch between opioids available for pain relief and the number of patients with cancer and non-communicable diseases who need pain relief. Other, existing challenges stemmed from poor estimation procedures, gaps in service providers’ knowledge and skills, and restrictive policies.
According to the Chief Inspector of Drugs from the Mozambique Ministry of Health’s (MOH) Pharmaceutical Department, there is further need for collaboration between service providers and his department: “I need to gather information on consumption, number of patients by diagnosis and prescribers from your side as service providers,” he informed an audience at a meeting on the issue in Maputo.
He further stressed this information was critical for planning purposes, including making appropriate consumption estimates; without it, it is very difficult to justify any higher demand for opioids to the INCB. The attending service providers equally acknowledged the need for continued medical education on use of opioids for pain management, especially on issues related to opioids’ storage, prescription and distribution requirements. The stakeholders were pleased to have their discussions centred on country-specific research and noted it was a great opportunity to initiate targeted advocacy and dialogue between partners.
Most rewarding outcomes from the survey included further sensitization of the Chief Inspector on how the INCB operates and on the clause allowing countries to submit supplementary estimates to the organisation if there is need.
“This gives us an opportunity to meet the national demand for opioids,” noted the Chief Inspector of Drugs. “I will take this forward and ensure we request for more morphine because our demand is actually higher”, he noted.
In April 2015, the MOH convened a follow-up meeting on opioids and psychiatric drugs at which all survey recommendations were embraced and which are currently being actioned, to improve the country’s pain management situation. As one participant, a pain management specialist at the Pain Unit of the Mozambique Central Hospital, observed:
“I want to congratulate the team that undertook this important survey. It will help in alleviating unnecessary suffering our patients are going through. The National Pain Unit should have the step-three drugs of the WHO analgesic ladder, otherwise it’s such a pain when patients come to us as a national referral pain unit and we cannot manage their pain effectively because we do not have the appropriate drugs,” he said. “Now we know our problems and where they stem from, so we should now have a dialogue and resolve these issues, with the availability of opioids for pain management prioritised.”
The writer is a Sir Halley Stewart Scholar (MSc Palliative Care), Cicely Saunders Institute, King’s College London, and currently Research Manager at the African Palliative Care Association, Kampala, Uganda.