Data from the International Narcotics Control Board¹⁴ shows the following figures for narcotic consumption in Zambia, 2002 unless stated: codeine 17 kg (2000); morphine 2 kg (2000); dihydrocodeine 4 kg (2000); pholcodine 9 kg (2000); dextropropoxyphene 25 kg; tilidine 2 kg (2000); pethidine 2 kg; diphenoxylate 2 kg.

For the years 2000-2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)¹⁵ in Zambia was 3. This compares with other African countries as follows: Swaziland 1; Egypt 2; Zimbabwe 13; Botswana 53; Namibia 73; South Africa 103. Twenty nine countries reported no morphine consumption during 2000-2002 (Table 2).

Table 2 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

Zambia has strict importation rules pertaining to medication. Jon Hospice has taken the lead in lobbying the Medical Council of Zambia for the import of morphine and relaxing the restrictive legislation of the Narcotics Control Board of Zambia. While progress has been made research may yet be needed to convince the state of the need for easily accessible morphine. There is little understanding amongst health professionals as to the benefits of morphine and myths surrounding its effects persist. Consequently, assessment and management of pain is underdeveloped.

Mother of Mercy Hospice uses the basic analgesics, non-steroidals and lower opiates (pethidine). Injectable morphine is inexpensive and available through UTH although oral morphine is extremely difficult to obtain. The hospice nurses and clinical officer assess pain and are able to recommend morphine use. The prescription is signed by the hospice doctor and the drug administered by the nurse. Home based patients requiring morphine are visited daily by a nurse although logistically it is simpler for such patients to be admitted to the hospice. No syringe drivers are available.

Jon Hospice continues to actively campaign for easy access to morphine for palliative care. Only injectable morphine is easily accessed and there are legislative obstacles to providing a range of pain medications. Morphine is under-prescribed and this hospice acknowledges that many patients die in pain. Cromwell Shalunga: ‘Sometimes we have no option but to use pethidine’.¹⁶ Jon Hospice uses the WHO pain ladder and most drugs are available but expensive.

Ranchhod House nurses administer pain medications as necessary. These include paracetamol, analgesics and ibuprofen, diazepam and septrin when necessary. As there is no doctor attached to the hospice injectable morphine is not used although it is easily accessed. Morphine tablets are donated occasionally by a US-based donor and these are used when required. Mary Chidgey:

I think we are controlling pain. The Zambians are not used to taking medications at every turn. I think their pain tolerance is quite high, so they respond quite well to what we give.¹⁷

Our Lady’s Hospice does not utilise the injectable morphine available in Zambia as they do not have a doctor on site to source it. They receive donated morphine (oral and tablets) from external donors but this is used sparingly due to erratic supply, preferring not to start it if they cannot continue. Sr. Crucis:

The concept of pain is different here too. Pain is something to be endured. Most people have only had access to simple remedies like aspirin, so their belief is that pain just happens and is part of the illness and part of suffering.¹⁸

Cicetekelo Hospice ( Ndola Hospice).Accessing morphine is extremely difficult and palliative care in this setting is often challenged to achieve pain control without either Step 2 or Step 3 of the WHO analgesic ladder. Morphine is rarely available at Ndola Central Hospital.¹⁹