Pain-racked Jordanians struggle to obtain relief

Drug laws severely restrict the distribution of prescription analgaesics to people who desperately need them.

AMMAN // Every two weeks, Afaf Saeed goes to the pain clinic at the King Hussein Cancer Centre in Amman to get morphine tablets for her husband Adel. Three years ago, he was diagnosed with vasculitis, a disorder that is characterised by inflammation in the blood vessels. "He suffers from chronic abdominal pain, severe pain in his lower limbs and skin ulcers," said Mrs Saeed, 53, a nurse and mother-of-four. "He is tired most of the time. Morphine tablets are helping easing his pain but it is extremely difficult to get them from any other place."

Like other patients suffering from debilitating illnesses in Jordan, getting morphine to ease his chronic pain has been a constant struggle for Mr Saeed and his family. Though it is legal to prescribe opiates in the kingdom, physicans are reluctant to prescribe them for patients with chronic pain and many pharmacies do not have them. They are mostly available just for cancer patients at the KHCC.

The risk of drug abuse and regulatory sanctions mean they are strictly controlled and penalties for misuse include a minimum of one year in prison and a fine of up to 3,000 Jordanian dinars (Dh16,000). "This spooks many physicians and pharmacists and makes it hard for patients with chronic pain to get them," said Hussein Abu Khudair, head of the department of Anesthesiology and Pain Management at the King Hussein Cancer Centre.

For a medical worker to prescribe opiates, and for a pharmacist to obtain them, a permit is needed from the Jordanian Food and Drug Administration, forms have to be filled in, signatures given and an annual report must be submitted with details of the amounts used. Mrs Saeed said before she got the tablets from KHCC, it was a hassle to get treatment for her 57-year-old husband, who has suffered several strokes and haemorrhaging in both his legs and heart.

"Because he was on pethidine [a painkilling drug], a couple of hospitals refused to treat him, while his health insurance was revoked because he was perceived as an addict. Trying to get a prescription for morphine was impossible," she said. Last week, Dr Abu Khudar and 10 other physicians, anaesthesiologists, nurses and a psychologist all working at the KHCC launched the Jordanian Pain Society (JPS), an NGO that seeks to improve access to opiates to treat chronic pain in all patients, not just those suffering from cancer.

Through raising public awareness, it seeks to change common perceptions among health-care providers regarding the use and prescription of morphine. "We want to evaluate the current laws and regulations and see if they impede access to morphines for patients with chronic pain. There are laws in place that allow even the veterinarian to possess them. But it seems there are many restrictions as well as confusion about the role of morphine in pain treatment," said Dr Abu Khudair, who heads the JPS. "Pharmacists say it is dangerous and doctors are concerned about getting into trouble. It is always the same scenario."

Dr Abu Khudair said there are misconceptions among health workers regarding addiction and morphine. "We need to educate people at all levels about the use of morphine. When used for pain, it is not addictive," he said. "We deal with pain through a multidisciplinary approach, one that includes drugs, physiotherapy and psychology, and if these methods don't work we prescribe morphine in low dosages to alleviate the suffering of patients with chronic pain."

According to international human-rights law, countries have to provide medications for pain treatment as part of their core obligations under the right to health. Failure to take reasonable steps to ensure patients have access to adequate pain treatment may result in the violation of the obligation to protect against cruel, inhuman and degrading treatment, Human Rights Watch said in a report last year.

In the past decade Jordan has taken strides to improve the quality of pain treatment. Morphine became available in tablet form in 2003, and the prescription of morphine was increased to last the patient needs for ten days instead of three. In 2005, the morphine consumption for Jordan stood at 1.1021mg per capita while in Austria it was 121.4477mg, the highest in the world. In the same year, in a list of 156 countries indicating the capability of a nation to treat moderate to severe pain, Jordan was placed at 60. In 2007, it had moved up to 44 out of 160 countries.

In one instance, Dr Abu Khudair recalled how one of his patients, a 26-year-old vegetable seller, who was treated at KHCC for colon cancer this year, resorted to buying cannabis from a refugee camp to ease his pain. "For some reason, he was not referred to the pain clinic, but three months ago he came to us," Dr Abu Khudair. "He told us, 'I pray and I have a family, I do not want to resort to drugs.' We gave him morphine and his pain eased," he said. Pain impairs people's lives. It is a human-rights issue."