Exploring Opioid Regulation and Access in Southern Africa: Insights from the Supply Chain Journal Club

Presenter: Khadija Msami

Presented on: 25 May 2024

Namisango, E., Allsop, M. J., Powell, R. A., Friedrichsdorf, S. J., Luyirika, E. B. K., Kiyange, F., Mukooza, E., Ntege, C., Garanganga, E., Ginindza-Mdluli, M. N., Mwangi-Powell, F., Mondlane, L. J., & Harding, R. (2018). Investigation of the Practices, Legislation, Supply Chain, and Regulation of Opioids for Clinical Pain Management in Southern Africa: A Multi-sectoral, Cross-National, Mixed Methods Study. Journal of Pain and Symptom Management, 55(3), 851-863. https://doi.org/10.1016/j.jpainsymman.2017.11.010

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On a recent morning, the Supply Chain Journal Club gathered virtually to delve into a critical issue affecting healthcare in Southern Africa: the regulation and access to opioids for clinical pain management. The discussion was anchored around an insightful article that investigated the practices, legislation, supply chain, and regulation of opioids in Mozambique, Swaziland (Eswatini), and Zimbabwe. Here’s a summary of the key points from the article and the lively discussion that followed.

Overview

The article highlighted the significant burden of pain associated with life-limiting conditions like HIV and cancer in sub-Saharan Africa (SSA). Despite the necessity of effective pain management, access to opioid analgesia remains a challenge due to restrictive laws and administrative hurdles. The study aimed to identify specific barriers and propose actionable recommendations to improve pain management in the region.

Barriers to Opioid Access

During the journal club discussion, participants reflected on the article’s findings that overly restrictive controlled medicines laws and stigmatizing language in key documents significantly hinder opioid access. The article noted that legal texts often use terms like "dangerous drugs," which perpetuate fear and stigma around opioid use. Moreover, the restrictive prescription practices, which limit opioid prescribing to doctors, disproportionately affect rural areas where doctors are scarce.

One participant shared their experience managing opioid stocks in a hospital setting, emphasizing the stringent documentation and regulatory requirements that complicate supply chain management. This reflection underscored the article’s point about challenges, including the critical shortage of prescribers and the high out-of-pocket costs for patients, which further exacerbate access issues.

Estimation Practices and Supply Chain Issues

The article revealed that opioid needs in the studied countries are estimated based on past consumption rather than actual disease burden. This practice often leads to underestimation and frequent stock-outs. The discussion highlighted similar challenges faced in Tanzania, where reliance on historical data for opioid estimation fails to account for the increasing incidence of diseases requiring pain management.

Participants discussed the bureaucratic delays in the tendering process and the scarcity of foreign currency needed for importing opioids, which contribute to frequent stock-outs. One member pointed out that despite orders being placed well in advance, the actual delivery of morphine powder can be delayed for months due to regulatory and supplier issues.

Policy Recommendations

The article and the discussion both emphasized the need for policy updates to balance controlling illicit opioid use with ensuring adequate medical access. Participants agreed that integrating opioids into national pharmaceutical and disease-specific policies is crucial for improving access.

Training and Capacity Building

Expanding the pool of prescribers emerged as a key solution. The article recommended training nurses and other health professionals to prescribe opioids, a point echoed during the discussion. Task-shifting strategies, where specific tasks are transferred to cadres with shorter training, were suggested as a way to address the human resource shortages in the region.

One participant noted that in some parts of Tanzania, entire palliative care teams, not just doctors, are authorized to prescribe opioids. This approach could serve as a model for other countries struggling with similar challenges.

Local Production and Cost Issues

The article proposed local production of basic oral morphine to reduce costs and improve availability. Participants reflected on the high costs associated with importing opioids and the potential benefits of local production. However, they also acknowledged the need for substantial investment in training and infrastructure to make this feasible.

Addressing Knowledge Gaps

Both the article and the discussion highlighted significant knowledge gaps among healthcare providers regarding opioid regulation, distribution, and prescription. Strengthening education and training programs was seen as essential for improving pain management practices.

Conclusion

The journal club discussion reinforced the article’s findings that numerous barriers to effective pain management exist across legislation, supply, and clinical use of opioids in Southern Africa. By advocating for policy changes, revising prescribing restrictions, exploring local production, reducing user fees, and addressing knowledge gaps, significant improvements can be made.

The collaborative spirit and dedication of the supply chain professionals in the journal club underscored the importance of ongoing dialogue and action to address these complex challenges. As the discussion concluded, there was a collective commitment to continue exploring and implementing solutions to improve opioid access and pain management in the region.