When Anna Moriasi was diagnosed with breast cancer in 2015, she knew that her life would never be the same again.
Doctors at the Kisii Teaching and Referral Hospital (KTRH) recommended that she undergo an operation to remove her right breast in a procedure carried out on June 5, 2015.
After the operation, she recovered from her wounds, but remained in great pain. “I would be in agony most of the time and was unable to stretch my right arm or raise it above my head. Even sleeping became a challenge,” said the 61-year-old.
On follow up visits, medics referred her to the palliative care unit to manage her pain.
Here, clinicians prescribed morphine for Ms Moriasi, which she has been using to date, under the guidance of oncology nurse Felix Omare.
KTRH has a programme to prepare oral morphine solution (OMS) for patients like Ms Moriasi, which enables them access the painkiller at affordable rates.
In the beginning of the Kenyan OMS treatment programme, patients with covered by NHIF were able to access the drugs, but the national health insurer withdrew the medication from the range of medicines and services it covers.
"I have to dedicate part of my business revenue to buy the drug, which I get after every two months. Whenever I am unable to purchase it, my children chip in," said Ms Moriasi.
According to Mr Omare, morphine is an opioid, which is a class of powerful drugs used in medical practice to treat severe pain.
“To ease severe pain, a doctor prescribes it to a patient, and we then dispense it according to the prescription,” said Mr Omare.
Ms Moriasi said it is bitter, and also causes loss of appetite.
“It was very bitter and I would experience nausea and lose appetite after taking it. When I complained about the effects, medics prescribed medication to control the nausea and boost my appetite,” she said.
Ms Moriasi added that her pain is now at manageable levels, enabling her to spend her time at her small clothes business.
According to consultant anaesthesiologist Dr Timothy Muriithi, morphine is essential for cancer or severe pain management.
Dr Muriithi, a lecturer at the University of Nairobi’s School of Pharmacy who also runs the pain services unit at Kenyatta National Hospital (KNH), said pain management involves recognition, measurement and treatment.
“We categorise the pain patients feel into three main types, acute or beneficial pain, chronic pain and cancer or non-cancer pain,” said Dr Muriithi.
“Depending on the grade or level of pain, we use a combination of different types of medication to treat it. When it is very severe, for instance in cases of cancer, we use opioids to manage it, like Fentanyl and morphine,” he added.
Prior to the project, a 2010 Human Rights Watch report showed that morphine was only available in seven of Kenya’s approximately 250 public hospitals, with only medical doctors allowed to administer it.
The report showed that “all the morphine in the country (then) could manage pain in only 1,500 terminal cancer or Aids patients.”
In April 2017, the government begun a local morphine production project, with KNH identified as the chief site.
Pharmacist Dr Josephat Mbuva, who heads Ministry of Health’s committee for access to morphine said the project aims to ensure patients who need the medication could get it locally.
“By locating the project at KNH, we wanted to centralise the preparation process to ensure patients were receiving quality medication. Our plan was to produce enough quantities to supply to facilities for free,” he said.
Dr Mbuva said morphine has a low shelf life of six months, adding that local production would safeguard its quality and guarantee patients affordable access.
“The drug is available in powder form for preparation of OMS. It is very delicate and unlikely to remain stable for safe human use beyond six months. Once it is compounded or prepared below factory standards, its lifespan is very short, which is a tricky prospect because chances of it getting wasted are very high,” he said.
“Producing it locally avoids the stress of importation, and we are able to titrate or prepare it into various formulae as required” he added.
Kenya Hospices and Palliative Care Association (KEHPCA) executive director Zipporah Ali said the association facilitated the manufacturing of morphine at KNH starting from April 19, 2017.
“We begun the first phase of the project with 47 kilogrammes of morphine powder which was to be reconstituted into a solution. The powder was enough to last until the end of 2020,” she said in an earlier interview during its launch.
Through a public-private partnership, the Danish International Development Agency (Danida) procured 47 kilogrammes of the powder at a cost of Sh 185,000 per kilo translating to about Sh8.7 million.
Other partners include the Kenyan government and the America Cancer Society. The Ministry of Health currently provides the bulk of the funding for the programme.
According to Dr Dorothy Aywak, a pharmacist who heads the production team at KNH, a single tin of 100g powder can be used to prepare 100 bottles of 100 ml solution concentrated at 10 milligrams per millilitre (ml).
Initially, the programme produced 1,000 bottles of adult oral morphine and 100 bottles of paediatric oral morphine. The adult OMS dose is 10 mg/ml with the paediatric dose set at 1mg /ml respectively.
Dr Aywak said the drug would cost patients up to 10 times more the price at KNH if bought at chemists. Most do not stock it.
“We are producing medication that is stronger, meaning it requires less doses to manage the extreme levels of pain that patients experience, and at a cheaper cost,” said Dr Aywak.
Dr Ali said KEHPCA had already distributed the drug to 41 hospitals across the country.
“We first distributed the morphine to 11 Level 5 county hospitals. Since then, we have expanded the process to cover 41 hospitals and hospices in total,” she said.
At the beginning, the access committee headed by Dr Mbuva had proposed a price of Sh300 per 100 ml bottle.
However, following the 2019 increase in prices of the powder used to prepare the solution from Sh24,000 per 100-gram tin to Sh38,000, the drug’s price has risen to Sh450 per bottle.
Dr Ali said most of the morphine was prescribed for adults.
“Around 95 percent of the total production was prescribed for adults. This is because adults are the majority of patients at our facilities that require morphine prescriptions. In addition, most medics are reluctant to prescribe it for children for fear it will lead to addiction,” she said.
Ms Ann Mwangi, a palliative nurse at the KNH clarified that OMS is not automatically prescribed for all patients in pain. This, she said, reduces the probability of patients developing addiction to the medicine.
“Not all patients get prescriptions for morphine or other strong opioids. We have less powerful but also effective painkillers like Paracetamol, Brufen and Diclofenac for less severe pain. Depending on the severity of the pain, we can also prescribe weak opioids like Tramadol or Di-hydro Codeine,” she said.
The nurse said the provision of the drug at the facility has been a boon to patients.
“Most of our patients have cancer, with some having high blood pressure and HIV-Aids related complications. The drug’s availability has been a major boost to their pain management programme,” she said.
The Kenya Medical Supply Agency was supposed to distribute the drug to all the public, private and mission hospitals across the country but is yet to start the process.