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Striving for Equity in the Treatment of Pain. Access, Training and Negative drug policies-

What are we doing?

Dr Zipporah Ali, MD, MPH, MPC, HonDUnivExecutive Director

Kenya Hospices and Palliative Care Association (KEHPCA)Nairobi, Kenya

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1991: My Brother Harun- Leukemia Patient

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Three County Report (UNICEF/ICPCN) 2014. Reasons for Low Morphine Use

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ADVOCACYMatters!

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Terms of Reference for Legislative Drafting of Bill to Amend the Narcotic Drugs & Psychotropic Substance

Control Act (1994)Overview of policy proposals for the preparation of

Bill to Amend the Act• Provisions for the medical use of opioids, as envisaged by the Kenya National

Drug Policy. Provisions should give recognition that opioids like morphine are indispensable for the relief of pain, promote the availability of opioids for medical purposes, and protect health care professionals from unnecessarily harsh sanctions for inadvertent breach of drug control regulations.

• Provisions for the appropriate use of controlled medicines, including morphine, and the legal requirements for prescribing and dispensing them.

• Review penalties / imprisonment of HCPs •

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Integrating Palliative Care services in Kenya

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Education

An exploration of doctors’ experiences of caring for palliative patients and whether they feel there is a need for further training at undergraduate level (Ali, Z. 2014 –unpublished)

• Pain management was perceived as a challenge by participants in this study. • Respondents were not well informed on pain management. • limited knowledge of the World Health Organization analgesic ladder which

is the standard recommended analgesia for pain management. • The fear of patients’ addiction to morphine also came out• An interesting observation was one of the doctors implied that it was in

order for the patients to be addicted to morphine since they were ‘dying anyway’ (negative attitudes)

• They were afraid of prohibitive regulations /heavy fines

(Pain management was seen as important, although they admitted to not having the necessary knowledge and skills to prescribe & they were afraid of addiction by patients/ and going to prison or paying heavy fines).

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What is the Pain-Free Hospital Initiative?PFHI is a one-year quality improvement initiative to integrate effective pain treatment into hospital-based services

Motivate clinicians to evaluate and treat pain

Supply appropriate drugs to treat pain

Equip clinicians with the skills/tools to effectively treat pain

Measure the impact of the program

Communicate the impact of the program with participants

• Hospital-owned• Low-cost, on-site trainings• Transformative number +

diversity of cadres trained• Measurable results

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One of the participating hospitals: Number of Staff Trained

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Knowledge and Attitudes

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= statistically significant increase (p<0.05)

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Pain Scores

Dental

Medicine

Obstetrics

Orthopedics

Paediatrics

Primecare

Surgery

Radio-oncology

Burns

Comprehensive care centre

Ear,Nose and Throat/Opthalm

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Occupational therapy

Physiotherapy

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Baseline ScoreRecent Score

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Departments*

* A&E, Pharmacy, KMTC do not have pain scores= statistically significant increase (p<0.05)

Overall, pain scores were statistically significantly reduced by

20%

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Morphine Consumption

Base-line

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

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Oral morphine concentration 10mg/ml in 100ml bottles

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Education

In 2002 Fred was to told to go home (and die…he was 32 years old)

“Daktari (doctor), I just want to go..let me go. The pain is too much”

• (GO=DIE!)• Young father with KS and

HIV/AIDS• Was dying in untreated pain • His main distressing symptom

was the unbearable pain • He had given up.. And accepted

his destiny, which was ‘to die in pain’

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Fred’s Journey with appropriate care- Fred is now an advocate …..he did not die of pain, his pain was controlled and he can now live his life…he no longer needs the morphine.

‘This medicine is a miracle medicine. It must have descended from heaven’ says Fred.

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Why do we allow patients to live and die in excruciating pain?

1991-2016:• Stringent (prohibitive) regulations and laws• Attitudes• Lack of knowledge and skills on pain assessment

and treatment among the health care professionals• Unavailability of appropriate pain medications• Culture• Ignorance (Patients, public, policy makers MoH…..)

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Thank you. ‘Put life into their days, and not just day into their lives’

We can do something: We can change the suffering of many through:

Advocacy Education Ensuring

Accessibility,Availabilityaffordability

Developing positive drug Policies(red tape and regulations that are imposed to prescribe/dispense drugs like morphine).