Morphine shortage leaves cancer patients needlessly suffering from pain

Unable to get morphine, Hoang Thuy Linh, 27, has been taking painkillers by the dozen to soothe the pain caused by her cancer.

Sometimes she takes 63 pills a day.

« Mom, it hurts so badly, » Linh said one day on a 2 a.m. phone call with her mother. She sat on the bed, head leaning on the wall, one hand pulling her hair and the other touching the lymph node on the left side of her neck, a sign of her stage-three nasopharyngeal cancer.

The lymph node has distorted her face and given her a droopy right eye.

Every time the pain becomes intolerable, she calls her mother, her « mental painkiller. »

She says: « Sometimes it hurts so badly that I smash my head against the wall to distract myself. I feel helpless. »

At these times she needs morphine, but cannot find it after returning from Hanoi to a hospital in her hometown in Lang Son, a mountainous rural province.

Morphine, the opioid painkiller prescribed when all other pain-relief medicines became ineffective or unusable, is the best treatment for pain-racked cancer patients like Linh.

According to the Ministry of Health’s Decree 52/2017, all healthcare facilities with beds, regardless of level, can prescribe painkillers like morphine for outpatients. Morphine is cheap at just VND6,000 (24 cents) a dose, but many healthcare facilities do not stock it.

To lay their hands on it, patients need to find hospitals with palliative care departments or major oncology centers. But a prescription is only valid for 10 days, meaning they need to return again and again.

Linh has returned home since the Lang Son hospital has been unable to do anything to relieve her pain. She vomits blood often and has lost a lot of weight, only weighing 35 kg now.

She is exhausted after countless and prolonged bouts of pain that have kept her sleepless for days at a time. On the World Health Organization pain scale, she rates hers as a nine out of 10, unbearable and intense.

Like almost 70% of cancer patients in Vietnam, Linh discovered her condition too late and at an inoperable stage. Her chances of survival are slim, but her final days on earth are a living nightmare.

Her financial status does not allow her to stay in a hospital in Hanoi, a costly city, or travel over 200km to the city three times a month to receive her morphine. This means she must find a way to survive without morphine.

She used to search online for pain relief medicines, but with most listings being fake, she has decided against them. She has tried her luck with home remedies but in vain.

She ended up using some over-the-counter drugs like paracetamol, which barely ease her pain.

Her mother also tried every way she could to find painkillers for her. Through an acquaintance, she ordered some from a person in Hanoi. Since then Linh has taken two doses a day of 21 pills each. This is three times the dose she took a year ago.

The lymph node on her neck makes swallowing difficult, and so she needs to ground the pills into powder.

On some bad days, when the pain becomes insufferable, she takes three doses, or 63 pills a day.

« I feel like God is punishing me. »

She does not know what medicines she is taking or care much either; she only looks to suffer a bit less.

Dr Lam Trung Hieu, head of the palliative care department at the Center of Oncology and Nucleology, Military Hospital 175, HCMC, says: « Patients have difficulty getting morphine prescriptions through official means. The access to morphine in Vietnam is quite low, and its use is frowned upon. »

The issue is that medical personnel do not know how to properly use morphine, he says. They consider it addictive and so tend to prescribe common pain relief medicines instead, he explains.

The situation is not limited to local healthcare facilities, but also occurs at national-level hospitals, he adds.

Linh’s case is testimony to this, and the consequence is that patients suffer from an unnecessary degree of pain.

Doctors « scared » of morphine

Ho Thi Quynh Duong, head nurse at the HCMC University of Medicine Hospital’s palliative care department, who has worked for over six years, says ensuring morphine supply for discharged patients is a very difficult task.

When they are sent back to hospitals in their rural hometowns, she asks them about the morphine options for the patients, but the reply is usually in the negative.

« Morphine is accessible to everyone, pricewise. But patients typically cannot get it. »

Pain relief medicines like morphine are categorized as part of palliative care for chronic patients, according to both WHO and Vietnam’s Ministry of Health. The purpose of such treatment is not only to extend the life of patients but also to reduce pain, both physical and mental, and improve well-being at all stages, especially of terminal patients.

Dr Truong Nguyen Xuan Quynh from the College of Health Sciences of VinUniversity says: « While theoretically morphine is financially affordable, in reality, only the more affluent patients can afford it. »

While its price is low and subsidized by health insurance, patients must bear the cost of traveling to or living in major cities that have hospitals offering palliative care.

After long periods of treatment, which deplete their savings, many can no longer afford it and return home to wait to die in agony.

Every year Vietnam has 180,000 new cancer patients, 70% of whom require palliative care.

Dr Nguyen Thi Huong, deputy director K of Hospital Hanoi’s palliative care department, says 70% of patients in her department need type II (weak opioids) and type III (strong opioids, including morphine) painkillers.

Half of them need morphine, but many doctors are reluctant to prescribe it due to its addictive nature and strict regulations regarding its prescription, she says.

Even at the most specialized cancer hospitals, morphine is only used in palliative care departments and most other departments refrain from it, she points out.

« Patients could try to sell [the morphine] illegally, which will have consequences, maybe even legal, for doctors. »

She reveals the instance of a patient’s family who concealed their death for three months to obtain opioid-based pain relief drugs, most likely to sell in the black market.

To reduce the risk, doctors tend to prescribe lighter doses than needed, which causes patients to supplement them with other painkillers, she says.

For instance, K Hospital, one of the country’s leading cancer treatment centers, might prescribe 10 doses of morphine a day for a patient, whereas hospitals at lower levels would only prescribe five, she says.

Patients have to sign an agreement saying they will only use morphine for personal purposes.

Huong warns that since many patients in non-metropolitan areas have difficulty accessing morphine, they have to supplement it with less effective pain relief medications or buy it on the black market.

They are violating the law with such purchases and could also overdose, which might prove lethal, she says.

They also end up buying fake medicines, which carry inherent risks, she points out.

The reluctance to use morphine is not limited to doctors, and many patients and their families also refuse to use morphine, concerned about possible addiction.

But this concern is not fact-based, Huong says. « Even though morphine is an addictive drug, the risk is very low if patients follow doctors’ instructions. »

Dr Nguyen Manh Duy, deputy head of palliative care at the HCMC Oncology Hospital, says the reluctance against morphine also stems from an incorrect belief that it could cause hypoventilation and worsen patients’ existing health problems.

« All drugs might carry side effects. In the case of morphine, the side effects tend to be temporary and go away after a while.

« If patients take morphine according to prescribed dosage, it is safe. »

Research by Trang Nguyen et al (HCMC University of Medicine) published in 2024 collating results from 207 healthcare personnel and 15 policymakers shows that 63.3% of healthcare professionals and 80% of policymakers do not sufficiently understand opioids in healthcare.

Some 64.7% of healthcare professionals and 80% of policymakers harbor negative attitudes towards the usage of opioids to reduce cancer-induced pain.

Both have been factors in causing a shortage of opioids for patients, especially the oral variety.

Easing the pain

According to the Vietnam Association of Palliative Care Medicine, every year at least 271,800 adults and 15,000 children need palliative care, a majority of them late-stage cancer patients and the rest with organ failure, stillborn and elderly patients.

Though palliative care has been a stand-alone medical branch since 2003, it remains in a fledgling state and mostly limited to major cities.

Despite rising demand, according to Dr Dang Huy Quoc Thinh, chairman of the Vietnam Palliative Care Association, 80% of the treatments now focus on mitigating pain through medicines like morphine, while other methods to relieve pain are underused.

According to WHO, the four pillars of a national palliative care programme are policymaking, availability of pain relief drugs like morphine, education, and execution.

This model is compared to an umbrella, in which policymaking plays the role of the handle, providing grounds for other pillars to thrive.

« Vietnam can be compared to an incomplete umbrella, with its handle, policymaking, remaining inadequate, » Thinh says.

The Ministry of Health has issued a Guideline for Palliative Care (2022, second edition), which focuses primarily on healthcare expertise, but without regulations on mandated supplies of morphine across the country.

Without such a mandate, healthcare facilities have « little incentive to implement it, » Thinh says.

According to Dr Le Dai Duong, head of the HCMC University of Medicine’s palliative care department, there are three levels of palliative care: basic, intermediate and specialized.

At the specialized level, patients have complicated medical needs, which only palliative care departments at top-level hospitals and oncology centers can provide.

At the intermediate level, doctors and nurses of other specialties can monitor palliative care treatments.

At the basic level, local clinics and district-level hospitals can prescribe medicines and monitor some treatments for patients transferred from higher-level hospitals.

For patients from rural areas like Linh, the basic-level palliative care is the most appropriate.

In Vietnam, however, palliative care has been mostly limited to the specialized levels in metropolises.

Dr Duy of the HCMC Oncology Hospital says the medical sector needs to change its attitude towards morphine and palliative care. Doctors should balance between drug management and patient care, and not let legal concerns dictate their patients’ access to necessary care, he says.

There are many ways to manage morphine prescription, such as mandating the return of drug packaging to ensure that the drugs are not being sold illegally.

To promote palliative care at a public health scale, Assoc Prof Eric Lewis Krakauer, director of the Global Palliative Care Programme, Massachusetts General Hospital (U.S.) says palliative care at home is vital as patients typically wish to spend time with their family at home during the last moments of their life.

However, this service is very limited and expensive in Vietnam as it is not covered by health insurance.

The HCMC Oncology Hospital is the first healthcare institution to offer this service. However, due to its small number of staff, prohibitive costs for patients and lack of insurance coverage, the hospital can only support five or six patients a week, all in central HCMC.

« Health insurance should include palliative care treatment at home to make these services more widely available, » Krakauer says.

« Patients should not suffer from pain in their last moments in life at home. »

Linh has found some relief in the love her 7-year-old son shows. He has begun to understand Linh’s health issues since last year after seeing her in pain.

Once in a while he would come, gently touch Linh’s head, kiss her on her cheeks, and ask « how are you mummy? »

Looking at him, Linh wishes her pain lessens so that she could can spend most of her little remaining time with him.

Her lymph node has doubled in size since she was first diagnosed.

The pain has intensified as the unlabeled pills are starting to be less effective.

Her health has declined rapidly, and there are tremors in her hands and feet.

She knows what is coming. She does not hope for a miracle.

The only thing she prays for is a good night’s sleep, undisturbed by pain.

By May Trinh & Le Phuong & Le Nga – VnExpress.net – August 18, 2024