Partnership with the Federal Ministry of Health to improve access to morphine for pain treatment
Start of Project: February 2012
Length of Project: Three years
Objective: Improve access to oral morphine for Nigerians with moderate or severe pain
Accurate data on the number of people with moderate or severe pain in Nigeria do not exist, but a minimum number can be estimated. The World Health Organization (WHO) estimated that 192,000 people died from HIV and 107,000 people died from cancer in 2010. Assuming that 50% of those who died from HIV and 80% of those who died from cancer experienced moderate or severe pain, 182,000 of those deaths required treatment with opioid analgesics, according to the WHO pain treatment guidelines. This number reflects a minimum need, since it does not include people who died of other conditions with pain, such as trauma or myocardial infarction, and people who suffered with painful conditions but did not die.
The government of Nigeria reports opioid consumption to the International Narcotics Control Board on an annual basis. The average reported consumption of opioids from 2009-2011, standardized as morphine-equivalents, was 2.3 kg. Assuming that patients, on average, are treated for the last 3 months of their life with 67.5 mg of morphine per day, 2.3 kg would have provided a full treatment for 371 people. The amount of opioids required to treat 182,000 people is 1,122 kg. Please see our fact sheet on access to pain relief in Nigeria for more data.
TABLE 1. SNAPSHOT OF ACCESS TO PAIN RELIEF IN NIGERIA
In February, 2012, Treat the Pain established a 3-year partnership with the Federal Ministry of Health (FMOH) to improve access to oral morphine for the treatment of moderate or severe pain. At the time of the agreement, Nigeria had been without oral morphine since the last order expired in May 2010.
As part of the agreement, we agreed to hire a consultant to serve as a Special Assistant to the Director of Food and Drug Services, leading the following efforts:
- Development of a strategic plan for improving access to pain relief: The Consultant works with FMOH and the National Agency for Food and Drug Administration and Control (NAFDAC) to create a strategic plan for improving access to essential pain medicines in Nigeria. This forms the guidance for improving the quality of pain treatment and incorporates the other elements in this list.
- Drug forecasting: The Consultant works with the FMOH, other partners identified by the FMOH, and the Treat the Pain Headquarters team to develop a methodology and tools to do regular drug forecasts for opioid analgesics. These forecasts are designed to estimate the demand for opioids (as opposed to forecasting the need) to ensure that procured drugs will be consumed before expiration.
- Stock monitoring: The Consultant is assisting the FMOH to design a system for monitoring stock in key facilities in Nigeria to ensure that stock levels are maintained and that central stocks are replenished before facilities exhaust their stocks. Tracking of consumption rates will also be used to refine the forecasting models.
- Supplier identification and negotiation: The Consultant is working with the FMOH, NAFDAC, and the Treat the Pain Headquarters team to identify potential suppliers and to assist with negotiation between the supplier and the FMOH to obtain the best terms for procurement.
- Procurement: The Consultant assists the FMOH with all aspects of procurement of opioid analgesics, including drafting documents, following up correspondence, forecasting and quantification, and communication.
- Communication of availability: Once opioids are available at the Central Medical Stores, the Consultant assists the FMOH with communicating their availability to end-users, such as pharmacists and hospital administrators. The Consultant serves as a central point of communication between end users and the FMOH and NAFDAC, answering questions, responding to problems, and communicating information.
- Facilitation of approvals: The Consultant assists the FMOH with streamlining the internal approvals required for a facility to procure opioids from the Central Medical Stores, while ensuring that products are not diverted.
- Stock tracking: The Consultant works with the FMOH, NAFDAC, and end users to create a simple and inexpensive system to track stock levels of opioid analgesics. The system can be used to inform drug demand forecasts and to detect aberrations in use that may be suggestive of diversion and require investigation.
- HIV/Cancer guidelines: The Consultant works with the Cancer Control Program and the Nigeria Agency for the Control of AIDS (NACA) and their partners to integrate effective pain control into national cancer and HIV clinical guidelines.
- Medical training: The Consultant coordinates with the Ministry of Education, university officials, and other local partners to integrate state-of-the-art training on pain relief into medical training programs, including nursing and medical school in-service training programs as well as continuing medical education programs. The Consultant is also seeking funding to support clinical training on state of the art pain treatment.
- Coordination with NGOs: The Consultant works with local non-governmental organizations (NGOs) that provide clinical services to increase and improve access to pain relief in their service delivery.
- Coordination with PEPFAR and NACA: The Consultant will work with the US Government’s President’s Emergency Plan for AIDS Relief (PEPFAR) and NACA to ensure that pain relief is integrated into all aspects of HIV service delivery including quantification and procurement, training, medical charting and data collection, and patient education and advocacy.
- Supporting Infrastructure Upgrades: The Consultant works with the FMOH to upgrade the infrastructure for reconstituting morphine. This entails planning for the refurbishment of a production facility, raising funds for the refurbishment, and implementing the refurbishment.
Update on activities, as of February 2013
The FMOH procured 19 kgs of morphine sulphate powder, which arrived into the country in December 2012 and is now available for pick-up by accredited public hospitals. To learn more about accessing and using morphine, and to download SOPs for collection and reconstitution of powder into oral solution and stock tracking tools, please visit our FAQ page.
Treat the Pain has donated 5 kgs of bronopol preservative to the FMOH, which can be picked up at Federal Medical Stores, free of charge, by hospitals that purchase morphine powder. The use of preservative in the preparation of oral morphine solution will extend the shelf life to 6 months. The shelf life without preservative is just 4 weeks.
The FMOH has provided funds to renovate the manufacturing laboratory at Yaba, Lagos to allow for FMOH-produced oral morphine solution. Renovation is underway and is expected to be completed this year. Once production has begun, hospitals may buy finished oral morphine solution directly from Federal Medical Stores.
Treat the Pain has established an SMS batch notification system that includes the phone numbers of 120 healthcare providers who have been trained in pain treatment or are interested in pain treatment. We used the system to notify the group about the availability of morphine in Federal Medical Stores and will continue to use it to pass on new information. To be added to the SMS list, please email us at firstname.lastname@example.org and include your mobile number in your request.
Treat the Pain has been working extensively with palliative care organizations in Nigeria, including the Hospice and Palliative Care Association of Nigeria (HPCAN), the Centre for Palliative Care Nigeria (CPCN), and the Society for the Study of Pain Nigeria (SSPN), the FMOH Cancer Control Program, the HIV/AIDS Division of the FMOH, and PEPFAR implementing partners to incorporate state-of-the-art guidance on pain treatment into existing clinical guidelines and to expand clinical training for pain treatment.
Priority objectives for the partnership in 2013 include:
- Completing renovation of the FMOH manufacturing lab at Yaba, Lagos and start-up of national production of oral morphine solution
- Establishment of a second distribution point at the Federal Capital Territory Medical Stores in Abuja
- Updates to the curricula in medical and nursing schools to include state-of-the-art pain treatment
- Expansion of clinical training on pain treatment for physicians and nurses already in practice