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.

Label of the morphine solution that was part of Lisa's "just in case" kit.

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
INCB Annual Report 2023, p. 25. Used with permission.

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]"

Our family’s end-of-life experience with home hospice and morphine should be the global norm, not the exception. Lisa’s death, supported by the blessing of sufficient morphine, has only deepened my decades-long commitment to advocate for equitable global availability. All UN organizations are now on record supporting safe and affordable use of morphine. Their member states need to walk the talk!

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
Steps Your National Association Can Take to Advocate for 
Improved Availability of Morphine & Other Essential Palliative Care Medicines

If your national association wants to begin advocating for improved availability of these medicines, the first step is to designate at least one member of your national association, or a small team, to take leadership. They can then embark on the following activities and deliverables:

  1. Prepare a short policy brief on availability of essential palliative care medicines in your country. (Members, watch IAHPC's Advocacy Course Module 6: How to Write a Simple Policy Brief.) Begin by taking the following steps and contact me if you need technical help. 
    1. Review the palliative care medicines listed in Section 2 of the WHO Essential Medicines List (EML). 
    2. Compare those medicines with your national medicines list (see https://global.essentialmeds.org/dashboard/countries).
    3. Using INCB's Narcotic Drugs 2023 report, identify the quantities of EML medicines imported annually by your country. If you can’t find your country’s imports and estimates in the report, then it is not doing the reporting required. This is important information for advocacy. 
    4. Describe the landscape of morphine availability in your country (i.e., pharmacies, hospitals, electronic prescriptions, special prescription pads, restrictive time limits, dose limits, etc.) and other access challenges (i.e., transportation, inappropriate formulations, affordability, etc.) that increase patient suffering. Include anecdotes from association members.
    5. Study the UN's Special Rapporteur for health’s recommendations in the latest report to the Human Rights Council and cite them in the policy brief. Dr. Mofokeng called on member states:
      "[...] to ensure that drug control policies do not impede access to essential medicines, including but not limited to those required for palliative care and pain management (including for children) and harm reduction (e.g., methadone and buprenorphine).1 [italics added]"
  2. To make your case, review your national drug control policies, laws, frameworks, and practices. For instance, do you know:
    1. How the laws that govern controlled medicines are enforced (i.e., electronic prescribing, controls on diversion, pharmaceutical industry regulations)?
    2. Are doctors, nurses, or patients ever prosecuted for legitimate medical use? Are they afraid of prosecution? Do health care professionals face criminal penalties for honest prescription errors? 
    3. Do pharmacies routinely stock and dispense controlled medicines in your country? Is there a rural/urban divide? 
  3. Background resources include the 2023 WHO report on access to morphine, "Left Behind in Pain;" the United Nations' Office on Drugs and Crime (UNODC) World Drug Report 2024; and the 2023 INCB report mentioned in point #1c.
  4. Identify and contact your national drug control authority. Invite it to review your report on availability and challenges in your country. Follow up in person if possible.
  5. Schedule a preliminary roundtable/hearing to explore the possibility of a national consultation for improved availability. Invite:
    1. Public officials and policymakers from relevant departments
    2. Your WHO country officer
    3. Head of UNODC field office in your country. (See the list of field offices.)
    4. Medical professionals (including surgeons, psychiatrists, OB/GYNs, anesthesiologists, substance use disorder treatment clinicians, and others who prescribe controlled medicines) 
    5. Communications professionals (traditional and social media)
    6. Patients and caregivers (people with lived experience) 
    7. Deans and professors of pharmacy, medical, and nursing schools 
    8. an INCB member (to do a video presentation)
  6. Form an implementation team and follow up with key stakeholders.

Read more of this week's issue of Pallinews

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