How to take morphine in rural Guatemala

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Jillian Moore
Jillian Moore is a student at Harvard Medical School. She has worked in rural Mexico and in indigenous communities in Guatemala with Wuqu' Kawoq | Maya Health Alliance. She is currently a Doris Duke International Clinical Research Fellow in Guatemala. Her interests include gender, inequality and marginality, palliative care, and mental health.

Rosa is a 59-year-old woman dying1 of a broken heart: in her heart is a hole that surgeons cannot fix, and the irregular flow of blood across heart chambers congests her lungs so that she feels as if she were drowning, or at least she would if she did not have access to morphine.

While usually used for pain, morphine is also one of the most effective therapies for shortness of breath. But despite how important morphine can be, in Guatemala, beyond the walls of the capital city hospitals, it is exceedingly difficult for a patient to procure. This is not necessarily because there is not enough morphine present. Designated formularies in Guatemala theoretically do stock all essential opioids outlined by the IAHPC.2 But beyond any shortage of medication, people face substantial regulatory obstacles: just four years ago the very-first prescription for oral morphine was written, though last year the Guatemalan government reinforced barriers to access controlled medications, including morphine.

As a result, to acquire and fill a morphine prescription is a weary process. First, a patient must find a physician with morphine prescription pads. To obtain these pads, a physician completes an online form, and then presents herself to a special office in the capital city with her active license to purchase the pads for the equivalent of about five dollars. Each pad contains only twenty-five prescription forms. They do not expire, but when a physician runs out, she must re-apply and travel to the office to obtain a new pad.

Meanwhile, the patient or a family member—whoever will pick up the prescription—applies for a special identification card and registration number. On this application the physician must specify the dose that will be prescribed and the estimated length of time it will be needed. The patient or family member takes this application, during certain business hours, to the Ministry of Health office in the capital city to obtain the card and number. Should the dose she needs change, the physician must complete a brand new application for the patient to present at the office for a new card and number particular for the new dose.

Once the family has a card and a number, the physician writes the prescription being sure to include the patient registration number. The patient or her family member takes this prescription back to the Ministry of Health office in the capital city to have the prescription signed and stamped.

Once signed and stamped, the prescription may be filled at those formularies that carry morphine. Those that regularly stock opioids are attached to national hospitals located in the capital city; pharmacies outside of the capital rarely stock these medications. The patient and her family pay full price for morphine, as no subsidies are offered. After the prescription has been filled, the patient or family member then returns a carbon copy of the prescription to the physician. Should the patient need a refill, she cannot use a previous prescription. She must obtain a brand new prescription and return to the capital city to have it stamped and filled.

In Rosa’s case, her daughter Sara—a single mother who every day sells produce at the roadside—took off multiple days of work to travel from their rural home to the capital city to obtain an identification card and registration number, and then again to have the prescription stamped, signed and filled. While Rosa and her family have support of staff from Wuqu’ Kawoq | Maya Health Alliance (WK) to facilitate transportation and to navigate such bureaucracy, so many others do not have this help, and for patients on their own the system can be nearly inaccessible.

First one must contact a physician willing to prescribe an opioid and with access to the special prescription pads, perhaps more difficult for those without money for a private physician who instead rely on the under-resourced Guatemalan public health system for care, where physicians may be hard to come by, or too overburdened to go through the application process.

If she is able to find a physician willing and able to prescribe morphine, the patient must make it to the capital city to apply for the registration number and card, a long and expensive journey for those living in rural areas. She must find the Ministry of Health Office where all interactions and forms are exclusively in Spanish; as interpreters are not available to help, maneuvering these bureaucratic settings is therefore more difficult for the very many people in Guatemala who speak primarily Maya languages.

If the patient is able to acquire the identification card, registration number, and prescription, she must then return to the capital city to have the prescription stamped and must find a formulary that carries morphine, almost exclusively located in the capital and other large cities. She and her family must be able to pay full price for the medication. Each month Rosa used 60 capsules of morphine, which cost the equivalent of eighty dollars a month. Though WK paid for Rosa’s medication, for other families without support, these prices could be prohibitive.

In this way, poor and indigenous patients from rural areas face nearly insurmountable obstacles to obtain morphine. Indeed, Anita Chary has described how institutional bureaucracies in Guatemala reinforce health disparities along lines of structural inequalities and marginalization, and in similar settings, others have similarly described how through bureaucratic processes, social welfare and development programs can limit the poor from accessing the resources and services they need.

Just as the struggle to breathe is a symptom of a sick heart, this impenetrable bureaucratic red tape limiting access to essential medicines in Guatemala is a local manifestation of a grander problem, namely a militarized ‘war on drugs’ born in the United States that targets those who use and possess certain substances as bodies to be hunted, monitored, and imprisoned. This fearful prohibitionist orthodoxy has since spread around the world, infiltrating international drug regulatory policies, medical education, and the public image of these substances.

Responding to the well-publicized epidemic of opioid addiction in the United States, the United Nations Office on Drugs and Crime and the International Narcotics Control Board (INCB) have kept tight control over opioids. Countries must report the quantities of opioids required annually so that these amounts may be approved by the INCB for importation or licensed manufacture. While some counties have the infrastructure to comply with this required monitoring and reporting, for low and middle-income countries such demands can create incredible obstacles. Furthermore, in these countries the prices of medications may be inflated due to high costs of regulation, importation, and licensing.

However, many regulations limiting morphine access in Guatemala are actually not required by the INCB, and could be changed: for instance the patient identification cards, the special multiple-copy prescription forms and restricted access to prescription forms. Furthermore, while the media and public consciousness promoting instances of overdose or addiction may perpetuate in providers a fear of opioid prescribing, this fear could be lessened through palliative care and pain management training programs. Unfortunately, in Guatemala only one of nine schools includes palliative care training in its curriculum, and there are no specialized post-graduate training programs in palliative care or pain management. Amidst such professionalized silence, providers may feel uncomfortable prescribing opioids and could be hesitant to do so, even for patients who need them.

Consequently, opioid consumption in Guatemala, and in other low and middle-income countries, remains frightfully low, even while consumption elsewhere continues to rise. The International Narcotics Control Board (INCB) estimates that 17% of the world population—living in America, Canada, New Zealand, and parts of Western Europe—consumes 92% of all morphine. This means that 83% of the world population, including Rosa, consumes only 8% of the morphine, some in this sub-population almost certainly unnecessarily enduring suffering that could be relieved.

This ‘war on drugs’ apparatus3 reaches across borders, intimately intertwining the suffering of seemingly anonymous actors. That Rosa and her family must struggle to acquire her morphine, and that others like her without institutional support endure pain and dyspnea without relief, these experiences are not apart from those of rural Mexican farmers whose livelihoods now depend on cultivating opium poppy destined for the US heroin market; not apart from those of Guatemalan farmers whose tomato and corn fields have been destroyed by the aerial spraying of herbicides as a part of the US antinarcotic program; not apart from those of black and Ladino men in the United States criminalized and incarcerated for substance possession as a part of system of racialized social control; not apart from those of pregnant women with drug addictions in the United States who, rather than being provided proper treatment and prenatal care, have been criminalized by their society.

On the ground, this ‘war on drugs’ is hardly that, for those who endure the consequences of these policies and discourses are exclusively poor and minority communities already marginalized by their societies. A militarized, prohibitionist approach to substance use in the United States—and a gross neglect of public mental health—so intimately affects the lives of people like Rosa, hundreds of miles away, who must resolutely struggle and strive against bureaucratic barriers to obtain those essential medicines that should be available to all.4

1 Rosa died at home with her family from complications of Eisenmenger syndrome just weeks after I wrote this essay. Her name is a pseudonym.

2 The IAHPC is the International Association for Hospice and Palliative Care.

3 Foucault uses the term apparatus to describe “a resolutely heterogeneous grouping composing discourses institutions, architectural arrangements, policy decisions, laws, administrative measures, scientific statements, philosophic, moral and philanthropic propositions; in sum, the said and the not-said…”

4 Others have thoughtfully and eloquently described the global disparities in opioid consumption and palliative care, and have proposed approaches to address these injustices, neatly reviewed in a table here, including local community engagement, international pain fellowships, nurse prescribing privileges, national opioid policy reform, and incorporation of palliative care into the international human rights discourse and global health agenda.