The Sierra Leone team was elated to receive the raw morphine sulfate powder that they processed to relieve the suffering of palliative care patients, both adults and children. The team members pictured are (L-R): Dr. Mary Bunn, pharmacist Ishmael Ivan Jalloh, Dr. Melvina Thompson, Dr. Mark Kapuwa, and nurse Fatmata Jalloh. Photo used with permission.
Sierra Leone On Its Way to Reliable Access to Medical Morphine
On October 2, 2024, the first bottles of oral morphine solution for palliative care patients in the government sector in Sierra Leone were released for use. Our story of the long, complex journey to reach this point is shared to help others striving for access to this essential medicine.
For the past six years, due to multiple barriers to procurement, we functioned on small donations of Oramorph and morphine sulfate tablets from various agencies as well as government purchases via Unicef, but availability was unpredictable. We were also permitted to make up oral liquid morphine from injectables when other forms were unavailable.
But our goal was to procure morphine powder in order to make oral morphine solution that would be both cost effective and allow better control of availability.
1 kilo of morphine powder received
In 2023, Palliative Care Sierra Leone, a United Kingdom-based charity, agreed to fund procurement of the powder. Despite bureaucratic delays, the necessary licence was finally acquired, then dispatched to a pharmacy in Kenya.
Payment was made, and we received one kilogram of morphine powder on January 20, 2024.
Compounding: a costly challenge
Finding a suitable lab for newly trained pharmacy interns to compound the morphine was one of many obstacles overcome. Photo used with permission.
The next obstacle was to make up the powder into a solution, a process called compounding. This required a suitable laboratory and equipment: precision scales, stainless steel buckets, stirrer, pestle and mortar, measuring cylinders, pH and conductivity meters, dispensing bottles and labels, as well as preservative, pure mineral water, and food colouring.
Initial budget estimates, to compound the entire amount all at once, were prohibitive, so the plan was revised to make smaller amounts of 20 liters at a time, which was funded by Palliative Care Sierra Leone. The first 20 liters cost around £400, a price that included one-off purchases (such as scales, pH meter, etc.) as well as recurrent costs (such as water, preservative, and labour). The cost of compounding each additional 20 liters is expected to be between £70-£100.
The equipment was bought and the location for production was finally agreed upon. Our pharmacist recruited and trained six pharmacy students and apprentices to help with the compounding. The date for the first compounding was settled: June 18, 2024.
Bottles in hand, but new obstacles
All went well; 100 bottles of 200 ml of 5 mg/5 ml oral morphine solution were produced with great rejoicing. It was stored in a cool, locked cupboard with the expectation that it would be dispensed to patients in the next few days.
However, two new obstacles arose. Unfortunately, the pharmacist immediately went on a six-week annual leave. In the interim, the National Narcotics Board added new stipulations:
- confirm that the products were not available from any importer;
- make certain that processes are in place to mitigate against risk of miscalculation or any other errors or health and safety issues;
- perform a quality control test, and in-house stability and visual inspection before use or supply to a patient; and
- prepare a method for good record keeping.
More meetings were held, and three months later, the solution was finally released for use. We are still waiting for a properly printed controlled drug prescribing book, but are currently using a handwritten ledger.
Thirty bottles were dispensed in the first month, so we are planning the next compounding in December.
Training in progress
The morphine produced supplies patients at the Connaught Palliative Care Unit, which provides services at no cost for those in need of palliative care at both Connaught and Ola During Children's Hospital. We are also training palliative care teams in the districts, so that patients who come to the capital for treatment can continue to receive care after they return home.
Lessons learned
Recruiting a committed palliative care pharmacist is key, as is gaining support and trust from senior staff by offering a good clinical service and delivering training in safe use of morphine. We also needed donor support—and perseverance!
Future challenges
Our concerns are for sustainability, and preventing mission drift with deviation to chronic pain management that can lead to opioid abuse. Ongoing training and advocacy for palliative care and morphine use are essential.
Our vision for a sustainable, nationwide, integrated palliative care service in the government sector in Sierra Leone continues.