The International Narcotics Control Board¹¹ has published the following figures for the consumption of narcotic drugs in Tanzania: Morphine 1 kg; Pethidine 27 kg.

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)¹² in Tanzania was 1. This compares with other African countries as follows: Swaziland 1; Egypt 2; Uganda 4; Zimbabwe 13; Namibia 73; South Africa 103. Twenty nine countries reported no morphine consumption during 2000-2002 (Table 4).

Table 4 Average daily consumption of defined daily doses (for statistical purposes) of morphine per million inhabitants, 2000-2002: countries of Africa

Source: International Narcotics Control Board Narcotic Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations, 2004.

Morphine is procured and supervised from government stores via Ocean Road Cancer Institute in Dar es Salaam. The pharmacist at the Institute advises that 100mg of morphine powder is dispensed each month, making 10 litres strong solution of morphine. This is then diluted as required.

Selian Lutheran Hospital

The hospice at Selian Lutheran Hospital receives 10 litres of diluted morphine every three months from ORCI. Morphine is prescribed by the medical team but administered by volunteers and family in the home. The volunteers alert the medical team when there is a change in the status of a patient. Patients or their family members source drugs directly from Selian Lutheran Hospital. The step 2 drugs on the WHO analgesic ladder are often used successfully to manage pain.

Muheza Hospice Care

This service receives five litres of concentrated strong solution every three months from ORCI and is the largest user of morphine in Tanzania outside of ORCI.

PASADA

PASADA has authorisation from the Ministry of Health as the only non-hospital organisation in Tanzania to use oral morphine for the control of pain. The morphine report for 2004 describes the history and development of opioid use at PASADA. It indicates that the first patient was given oral morphine on 27 May 2002, and from then until the end of 2003, 14 patients with severe pain were treated with morphine with good results. In 2004 this number increased to 30 patients and included patients with severe diarrhoea and dyspnoea when other treatments had failed. No side effects have been reported from the use of oral morphine.

The low numbers of patients receiving morphine at PASADA is attributed to the fact that pain in HIV/AIDS patients is largely due to infection. When infection is treated, pain recedes and morphine is not required. However, the report acknowledges there may be additional reasons:¹³

• Lack of knowledge regarding pain assessment
• Patients do not report pain
• Reluctance to prescribe morphine
• Regulations regarding opioids prescription.
• Fear of addiction

Other drugs include other analgesics on the WHO analgesic ladder; non-steroidal anti-inflammatory drugs (NSAIDs); oral antifungals (ketaconazole, fluconazole, clotrimazole, miconazole oral gel, nystatin suspension), skin preparations; clotrimazole cream; steroids, and locally made preparations. These include a steroidal acqueous cream and a mixture of 15 mls of nystatin suspension, 400mg of acyclovir and 400mg metronidazole/flagyl (NAF). Basic medications for opportunistic infections, TB treatments and antiretroviral therapies (ARVs) are all provided by this service. Lessons have been learned from the antiretroviral pilot project undertaken in 2003. Ongoing negotiations surrounding funding and logistics for distribution of ARVs are taking place with the Clinton Foundation, Catholic Relief Services USA and the PEPFAR programme.

Ocean Road Cancer Institute

All morphine in Tanzania is distributed by ORCI after the regulatory pharmaceutical board approved it as the sole distributor in the country in 2001. The Medical Stores Department is responsible for importing the raw powder, mixing it into an oral solution and distributing the different strength solutions to other health care providers throughout Tanzania. There is continuing resistance to morphine among hospital doctors who fear its addictive qualities. However, in recent years the palliative care team has been using the drug with great success, and has led training sessions for doctors. Outside of the hospital however, resistance continues.

They still think that they prefer pethidine than morphine, and pethidine is not very good for chronic pain. Sometimes they go for Tramadol, this is an expensive drug and mostly they get it injected.¹⁴