Short Wave - Uganda's Solution For Treating Extreme Pain

Episode Date: November 25, 2019

Uganda has come up with a low-tech solution to treat patients in a lot of pain: drinkable liquid morphine. Nurith Aizenman tell us how this model works and how other African countries are taking inspiration. Follow host Maddie Sofia on Twitter @maddie_sofia. Email the show at [e-mail]. See pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences.NPR Privacy Policy

You're listening to Shortwave from NPR. Maddie Safaya here with NPR Global Health and International Development Correspondent, Narit Eisenman. Hi, Noreen. Hi, Maddie. So you were in Uganda recently, reporting on a story about how health care workers treat patients in extreme physical pain. Right. They've turned to a creative solution, a drug that might surprise some people in the U.S. Yeah. So in the U.S., drug makers have flooded the country with these powerful, sophisticated opioids that are at the center of the opioid epidemic.

That's the U.S. opioid crisis. Right. But in Uganda, and in fact in a lot of African countries, for years, they've been dealing with their own opioid crisis, which is the opposite issue. Patients there don't have enough access to major painkillers. Why is that? It's a combination of governments not spending on it, not making it a priority, which, when it comes to an internationally controlled narcotic substance, there's a lot of red tape.

So there's not many options beyond simple painkillers like ibuprofen, acetaminophen, what a lot of us know is Tylenol. That's not usually enough for people in extreme pain, like from cancer. It can feel so, so, so horrible. You just, sometimes it can even just end up crying and you're like, God, please get me through this. Please get me through this. Justine Naka has breast cancer that's metastasic.

I met her at a hospice center in Kampala. A tumor had reached her spinal cord. Justine's 30 years old, but she's lost so much weight. She looks like she could be 12. That's rough. Yeah, really awful pain. But then a nurse gave Justine a dose of Uganda's go-to solution, drinkable liquid morphine. She says the pain was gone in a matter of hours.

I went and laid down. Oh, my God. The sleep came, and I just drifted the way. till morning, I'm like, wow, extract is lift till morning. Okay, so liquid morphine. That's, I mean, that's an opioid that can be addictive, right? Yes, but in Uganda, health officials say they've figured out a system for how to use it effectively,

cheaply, and safely to treat pain. So today on Shortwave, managing pain in Uganda, we'll hear about this simple solution that they've come up with, drinkable liquid morphine. It's been life-changing for patients in terrible pain. And not just in Uganda. It's a model that a lot of countries throughout Africa are looking to as a way to bring pain relief. Okay, Nareet, we're talking about how Uganda uses drinkable liquid morphine to treat serious pain. Where do we start?

I wanted to see how this whole model works. So I went along with the Ugandan nurse, Josephine Nabitaka, around Kampala. She's with a nonprofit called Hospice Africa. Josephine's delivering liquid morphine to patients who were too sick to come into the clinic. So this is the home. The first stop is at the house of an 81-year-old woman with advanced colorectal cancer. She's curled up in bed, a mosquito net hanging over her. And Josephine checks in with the caregivers there to make sure the morphine's helping with her pain.

Now, I wanted to know when she takes the morphine. Does the pain reduce? Is she sleeping? And is she able to sleep at night? Is she eating? And then after looking at a card where doses are logged, she gives them a couple more bottles of morphine. It's filled with this green-colored liquid. Every four hours.

Then at night, they give a double dose. So we're talking like bottles of liquid morphine. Right. The size of an ordinary water bottle. It's powdered morphine mixed with water at a government-funded facility. And it's a two-weeks. supply for patients to drink. Okay, drinkable liquid morphine. Not the type of pain killer we widely prescribe here in the U.S. for extreme pain. Right. Here in the U.S. we use morphine and painkillers

related to it, but those tend to be amped up formulations that are many times as powerful, or they've got fancy delivery systems like patches, time release capsules, pumps that give you the right dose with a push of a button. Oh, like when you're in the hospital and you push that little red button to ask it for more morphine or whatever? Exactly. But, Advocates in Uganda say, in almost all cases, they don't need that. Morphine is fine. And this low-tech drinkable formula is very doable. Here's how Dr. Anne Merriman, who actually helped set up Uganda's liquid morphine system back in the late 1990s, describes this solution.

You know, they say it's easier to make than a cup of coffee, and you can make it at the kitchen sink. And we did for 17 years. Yeah, in the early days, they were using a kitchen sink, observing basic protocols, but still pretty simple to make. So if it's that easy to make, it must keep the cost of liquid morphine down. Exactly. This treatment is cheap, like $2.50 for a one-week supply. But for our cancer patient and anyone else who gets it in Uganda, absolutely no cost. Because for some years now, Uganda has been providing the liquid morphine for free.

Oh, wow. Yeah, in a country where more than 40% of the population lives on less than $2 a day, that's huge. So this all sounds good, but like we said, opioids, it's a huge issue in the United States. My reaction immediately is like, oh, this is addictive. Has this led to any problems like that in Uganda? Yeah. From a chemical standpoint, morphine has potential for addiction. So I put this question to Anne. And she says, this setup that they're using for giving out the drinkable morphine, remember, they give it to patients in a very controlled way, isn't likely to foster misuse. It's so dilute. It's so dilute. It's not going to get. you high. They have to take an over lot to get any form of a high. So that's her theory. But whatever the reason, after all these years, it does not seem to be producing an addiction problem in Uganda. So Anne Merriman was the driving force behind all this?

Yeah. She was the founder of Hospice Africa, and she proposed this idea of using this drinkable morphine to treat pain in Uganda. And then what really made the difference was that it was embraced by some key Ugandan officials. They ran with it. The head of surgical training, at the Premier Medical School, started training surgeons on prescribing liquid morphine. And then the country passed a law allowing nurses to prescribe the mixture. I'm sure that helped to make a difference. Yeah, it was huge because there are way more nurses than doctors there. So now around 11% of patients who need liquid morphine in Uganda are getting it. But it's been stuck at that level. And that's still pretty low. Right. So what's the challenge? Why is it stuck there?

Liquid morphine might be relatively inexpensive to make, but... Funding is a major issue. Even where you have access to oral liquid morphine, you need personnel who will be able to go to the home of the patient. Dr. Immanuel Lurika heads the African Palliative Care Association, a nonprofit that promotes this model. Emanuel says Uganda spends very little of its national budget on health care. So there's not enough money being spent to train and then deploy nurses to prescribe the liquid morphine. And he says also compared to health programs that save lives, efforts to reduce patients' pain are just a much lower priority for African governments and also for international donors, which is maddening for Emmanuel, because of how cheap pain management through liquid morphine is. We don't need a lot of money. It's not billions of dollars that we need. We need little money to make sure that all the patients who need to access the oral liquid morphine get them as an integral part of the health system.

He's like, this is an effective way to spend the money if we had it. Yeah. And this lack of funding is also why other African countries have been slow to get liquid morphine to their patients, even though they've shown a lot of interest in replicating Uganda's model. And there's been a stream of visitors from more than a dozen African countries who've come to Uganda to learn how Uganda's system works and bring that information back. In fact, when I was in Kampala on the home visit with Josephine, there was actually a doctor from Malawi who was shadowing her. So Malawi is trying to copy Uganda's liquid morphine system. Yeah, Malawi is one of several countries that have taken inspiration. They've now legalized the importation of liquid morphine too.

And Botswana, Rwanda, and Swaziland, have gone even further. They've taken up Uganda's idea of covering the cost for patients. But again, when it comes to the actual getting of the morphine to patients, that's been progressing at a glacial pace. So you've got this very promising model for helping. A lot of countries interested in it. And yet the vast majority of patients who need it are yet to be helped by it. Right.

And I want to leave you with this moment that just crystallized it. It was so poignant. You know, I'm watching this, the head chemist of the government-funded facility where Uganda's liquid morphine solution is made. His name is Chris Nettege, and he's scooping the morphine powder from a bag onto a scale. Every time I weigh out the powder, I'm imagining that patient in the day. village who could be in pain and you have here a powder that can take away all that pain. And like even after the bag is empty, he just keeps scraping. I don't want to leave even a small gram inside there because I know it's, it will be helpful

to every patient out there in pain. He says, you know, until Uganda starts producing enough, every wasted gram means a patient who's going to be left in pain. Global Health and International Development correspondent, Noreet Eisenman. Thank you, Noreet. Glad to do it. Today's episode was produced by Rebecca Ramirez and edited by Viet Le. I'm Maddie Safaya, and this is Shortwave from NPR.

We'll see you tomorrow.