The International Narcotics Control Board (INCB)32 has published the following figures for the consumption of narcotic drugs in Malaysia during 2005: codeine 123 kg; dihydrocodeine 389 kg; morphine 23 kg; oxycodone 6 kg; pholcodine 78 kg; diphenoxylate 31 kg; methadone 21 kg; pethidine 86 kg; and cocaine 6 kg.
For the years 2003-2005, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)33 in Malaysia was 21. This compares with other countries in the region as follows: Japan 131; Korea 49; Sri Lanka 13; and Nepal 1. No morphine consumption was reported to the INCB by four countries (Table 6).
According to the INCB, 15 kg of morphine were consumed in Thailand in 199834; this increased to 33 kg in 2004 before falling to its 2005 level of 23 kg. This greater consumption is demonstrated at Penang Hospital, where consumption increased from 200 g in 1990 to almost 2 kg in 2001.35
Table 6 Average daily consumption of defined daily doses of morphine per million inhabitants, 2003-2005: countries of Central, South and East Asia
In Sarawak, a state that covers 48,000 square miles, a system of pain control has been devised that links Sarawak General Hospital (SGH), Kuching (the Regional Referral Hospital), with district hospitals throughout the state to facilitate a system of drug delivery to needy patients, even in rural areas (Figure 1). The programme is led by Dr Beena Devi - who obtained a masters degree in palliative medicine from Edith Cowan University (Perth) in 2000 – and is based within the hospital’s department of radiotherapy and oncology (DRO), which has a palliative care unit that caters for cancer patients. When patients are discharged from SGH they are given a one month supply of aqueous morphine and other required drugs. Subsequent supplies are arranged through the patient’s nearest hospital or klinik desa (rural clinic) with the assistance of palliative care trained staff. Drs Beena Devi and Tang Tieng Swee state:
As Sarawak is geographically large and often difficult to access in the rural area, it is acknowledged that one cannot practically provide the type of palliative care service which may be available in a larger city. Hence it was decided that the main emphasis for rural palliative care work is aimed at more effective symptom control and good home-nursing care, both hands on and in an advisory role. As pain is often cited as one of the main and most feared symptoms, good pain control and nursing care are the main objectives of rural palliative care work.36
Figure 1 Flowchart showing the supply procedure for drugs/morphine to patients in rural Sarawak
In 2000, pain began to be monitored as the fifth vital sign for patients admitted to the DRO, a practice that is now being piloted in the home care programme. A poster of this work was presented at the International Network for Cancer Treatment and Research conference in Sao Paulo, Brazil in February 2007. The programme’s morphine consumption rose from less than 200 g in 1993 to 1,400 g in 2006.
Turning to the urban situation the doctor in charge of the palliative care unit at Penang General Hospital, Ong Eng Eng, details opioids that are accessible to the patients in her care:
‘Here we have morphine available to us in liquid form and in slow release tablets. Other opioids are not readily available, although we can get access to durogesic patches.’ 38
In Kota Kinabalu, the relationship between Queen Elizabeth Hospital’s palliative care unit and the Kota Kinabalu Palliative Care Association ensures access to required drugs. Molly Mathew Oommen, a consultant ophthalmologist and volunteer with the Association explains how patients get their medicines:
‘We have twice-a-week clinic in the unit and the nurse co-ordinator, who’s a paid nurse, will see the prescription is delivered directly to the patient’s carer.
We don’t encourage nurses to do the getting of the medication because then it would be too much for them to do. Of course morphine is freely available and
all medication comes through the government – that is, on condition it’s available to all patients. So medications that are available to all patients are also available to our palliative care patients. If other medications are needed - like morphine tablets, which are costly - then the Palliative Care Association buys them for the unit patients.’39
This relationship between the hospital and NGO in Kota Kinabalu – which facilitates the prescribing and dispensing of medicines – is far removed from the situation found during the last decade. In the mid-1990s, Nurse Cheah Hong Chai was working for Hospis Malaysia and vividly recalls the difficulties:
‘In ’96, most of us didn’t stock morphine; the hospice movement didn’t stock it. If you needed morphine you had to get it from general hospitals or from private hospitals. So those were the days when you had to rush round from this hospital to that hospital to get medicine for patients. And these things happened until Ednin Hamzah came, and then our hospice started to get organised and more doctors came.’40
Along with permission for NGOs to prescribe and store morphine came tight security controls. Hospice Malaysia pharmacist Ong Poo Ling explains:
‘We have to follow the Malaysia laws governing narcotic and psychotropic drugs. So I have to follow the rules on how to record all activity. In this book, we record the registration number, the date, the name of the patients, date issued, the quantity, the balance and the signature of who’s taken the drug. Everything must be recorded. Nurses also have some stock for emergency use so I also have to make sure they too have the record books and keep a note when some is issued to patients.’41
Despite the increased availability of morphine, there are still issues about its use, in cases of breathlessness, for example. Lo Ee Chin tells how a fellow doctor criticised her for prescribing morphine to treat such a condition:
‘We know we can use morphine for breathlessness; but the very first case where we used it, the consultant called me up personally and said, “You hospice people, why do you use morphine for everything? This patient is breathless” So then I kind of said to him that I know the patient is breathless. The next day, we printed out five papers from the palliative journal of medicine – evidence of the use of morphine for breathlessness – and I sent them personally to that consultant. The next year he also used morphine for breathlessness. At the beginning, it was difficult, very difficult, but now he’s very supportive.’42
Yip Cheng Har, consultant surgeon in the department of surgery at the University of Malaya Medical Centre, highlights how a combination of factors involving doctors, the hospital organisation and patients themselves, mitigate the effective use of morphine for pain relief.
‘We do know there’s a lot of treatment we can give patients in terms of palliation, symptom relief. But when it comes to pain relief a lot of doctors are not aware of the use of morphine. And even if patients come to the emergency unit in pain, they are sent home without pain killers because you can’t get morphine from the emergency pharmacy; and these are issues that we want to deal with. In Malaysia, pain is a big issue. Our patients all are in pain, because there’s this cultural barrier against using morphine. OK, you can write them painkillers but they won’t use them.'43
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