Challenges around opioid availability for children in sub Saharan Africa

In sub-Saharan Africa the majority of countries are low and middle income countries where health care is not adequately funded, and both children and adults die of illnesses which could have been prevented or cured if they lived in high income countries.

In 2016, 2.1 million children worldwide had HIV and 90% of them lived in sub Saharan Africa. 120 000 of those under 15 years of age in sub Saharan Africa died of AIDS. Many children also die of cancer and other life threatening illnesses, most of them dying in unnecessary pain and agony because opioids, which are effective in treating moderate to severe pain are not available. The reasons why opioids are not available are varied including:   restrictive laws; a lack of prescribing knowledge; and a lack of education for health professionals. Not having funds to purchase opioids is also a challenge in some countries, such as Tanzania.  Legislation and rigid rules also create barriers to opioid accessibility. For example out of 50 countries, only 4 allow prescription by clinical practitioners other than doctors, such as nurses and clinical officers, which is essential in order to ensure opioids are available to those in need, due to the acute shortage of physicians in these countries. South Sudan also restricts importation of narcotics to prevent their illicit use, completely disregarding their need for medicinal use. Prescribing procedures can also be difficult, for example in Sudan three signatures are needed for each prescription. Thus, sending the patient to and from the pharmacy to obtain special forms and the required signatures. Stock outs of medication are also a common feature, either in the country depot or facility’s pharmacies often due to negligence.  In one of the South African provinces, morphine is often not available because the pharmacist manager does not order enough stock.

Availability of opioids for children is compounded by many factors:

• Firstly, they are often not available in paediatric formulations which makes it difficult to administer to children. Breaking tablets for children either results in over or underdosing.
• Secondly, health professionals have misconceptions about giving opioids in children. For example, a study in Sudan revealed that physicians thought that opioids are contra-indicated in children and the elderly.
• Thirdly, many health professionals have no knowledge of how to prescribe opioids for children. For example, in Khartoum, a child was left to roll on the floor with pain because physicians would not increase her 3mg morphine dose because they considered it was dangerous.

Pain relief is a human right, thus recommendations to improve access to opioids for children in sub Saharan Africa include:-

• Firstly, Unduly restrictive laws and procedures should be removed to allow adequate importation, easy prescribing and dispensing for medicinal use of opioids as per the WHO document on. Ensuring Balance in National Policies on Controlled Substances: Guidance for Availability and Accessibility of Controlled Medicines.
• Secondly, national supply management systems need to be developed that include selection, quantification, procurement, storage and distribution to adequately estimate and assess the need for controlled opioids using the Guide on Estimating Requirements for Substances under International Control and improve data-collection mechanisms. This will enable countries to present reasonable consumption estimates to the INCB and ensure opioid availability according to domestic need.
• Thirdly, increasing the number of prescribers through policy change/development. We have learned from countries such as Uganda that allowing and training nurses and clinical officers to prescribe opioids, makes them available to all those who need them, and that are able to prescribe effectively and safely. It is also important that training should include pharmacists.
• Fourthly, paediatric formulations need to be developed in order to increase availability for children.
• Fifthly, it is important to consider financial assistance including private sector engagement to those countries with limited financial capability.
• And finally there needs to be regular updating of the WHO essential medicine lists.