Liquid Morphine: Rwanda’s Answer to Addressing Global Pain Inequity

By: Julian Mok

Lexington — Rwanda is steadily becoming a model in providing free and effective pain management through the production and controlled distribution of liquid morphine. Since 2014, Rwanda has set out to make liquid morphine available to all patients who need palliative care by 2020. Palliative care, “the treatment of the discomfort, symptoms and stress of serious illness,” is a necessity for patients with chronic diseases particularly as they near their end-of-life, but only 14% of people worldwide who need it receive it.

In the US, the quantity of opioids is three times more than what patients need, leading to thousands of deaths associated to the flagrant over-prescription of painkillers. 90% of opioids are consumed in the richest countries where only 17% of people live. In low-income countries, these drugs are typically inaccessible and rarely prescribed.

“Opioid use disorders” per 100k people. Addiction is significantly more prevalent in wealthier countries. Source — *“Opioid use disorders” per 100k people. Addiction is significantly more prevalent in wealthier countries.* *Source*

Expensive painkillers like oxycodone, tramadol and fentanyl are unaffordable in countries like Rwanda. Many pharmaceutical companies; however, are not interested in producing cheaper and more accessible painkillers like morphine. In 2013, Stephen Connor, executive director of Worldwide Hospice Palliative Care Alliance, called on 100 pharmaceutical companies to convene and discuss possible solutions to the pain inequity – only five attended and none were American.

Liquid morphine is the one of the world’s oldest painkillers, cheap and highly addictive. Morphine has similar side effects to more modern opioids, however pharmaceutical companies choose to develop and produce new varieties of opioids as it is more profitable, largely through patenting their products.

As there is only a small market in developing countries for these opiates of the more expensive variety, many poorer nations face this palliative inequity.

Therefore, government-regulated and locally-produced liquid morphine has become an answer to the problem of pain in low-income countries like Rwanda.

High costs are not the only barrier to palliative care in Rwanda. Pain relief is not a public policy priority. Many Rwandans believe that pain is inevitable, a punishment from God for their wrongdoings and sins and, therefore, do not seek painkillers. There is also widespread distrust of opioids, with many citizens associating it with addiction and crime. This belief led to an extremely restrictive protocol, requiring opioid prescriptions to be written in red pen and signed by three to four different individuals.

Dr. Christian Ntizimira, the executive secretary of the Rwanda Palliative Care and Hospice Organization and practicing doctor at Kibagabaga Hospital in Kigali, recalls how he was unable to ease the agonizing pain of a 24-year old patient dying of liver cancer due to the limiting protocol. This inspired him to help change the narrative surrounding painkillers and make morphine more accessible to patients needing palliative care. By 2009, Dr. Ntizimira transformed Kibagabaga Hospital into the first pediatric palliative care program in the country.

Other hospitals began to follow suit, training their staff to provide better palliative care to patients in need. Just two years later, Rwanda brought palliative care to the forefront of public policy, launching a national plan that would ensure that all Rwandans in need of end-of-life care could have access to high quality and affordable treatment by 2020.

One thing stood in the way. Rwanda’s supply of morphine did not meet the demand. Since 2014, however, Rwanda has strived to change this. Morphine powder is imported three times a week, and mixed with liquid in a single room, which produces 200 bottles per batch. These batches are transported to hospitals and pharmacies and kept under lock and key until community workers pick them up and carry them to the homes of the suffering. Production and distribution are kept under strict government supervision and only prescribed to patients near the end of their life to prevent drug abuse.

As Rwandan patients become more able to choose a dignified and comfortable end-of-life, other African countries are aspiring to do the same for their citizens. Homemade morphine to ease suffering is spreading slowly and steadily across Africa. As of today, 22 of the 54 African countries have now made affordable liquid morphine publicly available, although use is still limited. This is set to change as Rwanda continues to make pain relief a priority and unnecessary suffering a relic of the past.