Criteria Used to Assess Need for Use of Morphine for Adult Cancer Pain Relief in Kakamega County Referral Hospital, Kenya, Africa


  • Judygrace Monyangi Ombati School of Nursing, Midwifery & Paramedics, Masinde Muliro University, Kakamega, Kenya



Morphine use, cancer pain relief, adult cancer patients


The experience of pain in cancer patients is widely accepted as a major threat to quality of life, and its relief has emerged as a priority in oncology care. Although morphine and other opioids is the mainstay of cancer pain management, patients still suffer from moderate to severe pain. This paper investigated the criteria used to assess need for use of morphine for pain relief in cancer patients in Kakamega county referral hospital. The study used a cross-sectional research design. Target population was 295 which included physicians (medical doctors), nurses and clinical officers working at the Kakamega County General Hospital. The study employed focused group discussion and questionnaires to collect data. The study findings revealed that prescribers of morphine face challenges and FGD indicated that health care providers often create barriers to effective pain management. Time constraints and insufficient knowledge regarding pain management of medical professionals were the most commonly encountered barriers to effective pain management for physicians, clinical officers and nurses. There was a significant relationship between criteria used and morphine use in cancer pain relief (p=0.013) The study concluded that for one to use morphine to control cancer pain amongst adult, they should consider; the dose and length of time allowed by a single prescription, challenges faced when prescribing morphine, that morphine can only be sold to institutions that have at least a medical officer and the actual cost of morphine.


• African Palliative Care Association. Review of the Status of Palliative Care in Ten South African Countries. 2016.

• Agency for Health Care Policy and Research. Clinical Practice Guideline for Cancer Pain Management. Rockville, MD: US Department of Health and Human Services; 2014.

• American Journal of Pathology koodie et al 2010

• Babbie and mouton Reconciling methodological approaches of survey and focus group M Lawal - Nurse Researcher (through 2013), 2009 -… Ashby et al (2005) and Mansell et al (2004) state that the use of focus groups allows group discussion that may lead to in-depth information. while Babbie and Mouton (2001) argue that individual dominance. non-participants and group think can affect the quality of data …

• Bédard, D., Purden, M. A., Sauvé-Larose, N., Certosini, C., & Schein, C. (2006). The pain experience of post surgical patients following the implementation of an evidence-based approach. Pain Management Nursing, 7(3), 80-92.

• Breivik, H., Cherny, N., Collett, B., De Conno, F., Filbet, M., Foubert, A. J., ... & Dow,

• L. (2009). Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Annals of oncology, 20(8), 1420-1433.

• Brescia FJ, Portenoy RK, Ryan M, Krasnoff L, Gray G. Pain, opioid use, and survival in hospitalized patients with advanced cancer. J ClinOncol 1992;10:149-155

• Brahmbhatt, M. M., & Sheth, J. K. (2017). Focused Group Discussion of urban ASHA workers regarding their workrelated issues. Indian Journal of Community Health, 29(2), 187-190.

• Breivik, H. (2001). Opioids in cancer and chronic non‐cancer pain therapy–indications and controversies. Acta Anaesthesiologica Scandinavica, 45(9), 1059-1066.

• Bryman, A. (2015). Social research methods. Oxford university press.

• Caraceni, A., Cherny, N., Fainsinger, R., Kaasa, S., Poulain, P., Radbruch, L., & De Conno, F. (2002). Pain measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care. Journal of pain and symptom management, 23(3), 239-255.

• Caraceni A, Hanks G, Kaasa S, Bennett M, Brunelli C,Cherny N, et al. for the European Palliative ResearchCollaborative (EPCRC), on behalf of the EuropeanAssociation for

• Palliative Care (EAPC). Use of opioidanalgesics in the treatment of cancer pain: evidence-basedrecommendations from the EAPC. Lancet Oncology 2012;13(2):e58–68. [DOI: 10.1016/S1470-2045(12)70040-2]

• Carr and payne (2004) Jacox A, Carr DB, Payne R, et al. Management of cancer pain: clinical practice guideline. No. 9. Rockville, Md.: Agency for Health Care Policy and Research, 1994. (AHCPR publication no. 94-0592.)

• Carr and cousins (2012) Brennan F, Carr DB, Cousins M. (2014). Pain management: a fundamental human right. Anesth Analg. 2014;105:205–221.

• Carr and cousins (2012) Brennan F, Carr DB, Cousins M. (2014). Pain management: a fundamental human right. Anesth Analg. 2014;105:205–221.

• Chapman CR, Foley KM. Changing concepts of tolerance to opioids: what the cancer patient has taught us. In: Chapman CR, Foley KM, eds. Current and emerging issues in cancer pain: research and practice. New York: Raven Press, 1993:331-50.

• Cherny, N., Ripamonti, C., Pereira, J., Davis, C., Fallon, M., McQuay, H., ... & Expert Working Group of the European Association of Palliative Care Network. (2001). Strategies to manage the adverse effects of oral morphine: an evidence-based report. Journal of Clinical Oncology, 19(9), 2542-2554.Coughlan, M., Cronin, P., & Ryan, F. (2009). Survey research: Process and limitations. International Journal of Therapy and Rehabilitation, 16(1), 9-15.

• Cleeland CS. The impact of pain on the patient with cancer. Cancer.2004; 54( 11 suppl): 2635-2641.

• Clarke, V., & Braun, V. (2014). Thematic analysis. In Encyclopedia of quality of life and well-being research (pp. 6626-6628). Springer, Dordrecht.

• Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.

• De Lima, L. (2015). Palliative care and pain treatment in the global health agenda. Pain, 156, S115-S118.

• Dechartres, A., Altman, D. G., Trinquart, L., Boutron, I., & Ravaud, P. (2014). Association between analytic strategy and estimates of treatment outcomes in meta-analyses. Jama, 312(6), 623-630.

• Deng, D., Fu, L., Zhao, Y. X., Wu, X., Zhang, G., Liang, C., ... & Zhou, Y. F. (2012). The relationship between cancer pain and quality of life in patients newly admitted to Wuhan Hospice Center of China. American Journal of Hospice and Palliative Medicine®, 29(1), 53-59.

• Dreidi MM, Hamdan-Mansour AM. (2016). Pain, sleepdisturbance, and quality of life among Palestinian patientsdiagnosed with cancer. Journal of Cancer Education 2016;31(4):796–803. [DOI: 10.1007/s13187-015-0946-5]

• Duggleby W. (2000). Enduring suffering: a grounded theory analysis of the pain experience of elderly hospice patients with cancer. Oncol Nurs Forum.2000; 27: 825-831.

• ESMO 2012 Management of cancer pain: ESMO Clinical Practice Guidelines C. I. Ripamonti1, E. Bandieri2 & F. Roila3 Annals of Oncology 22 (Supplement 6): vi69–vi77, 2011clinical practice guidelines doi:10.1093/annonc/mdr390

• Faith Mwangi-powell,OSF, Stephen Connor, WPCA and Mary Callaway. (2013).Making oral opiods available in eastern Europe and central asia: the industry speaks out., OSF918 March 2013 News/Policy

• Farrant, L., Gwyther, L., Dinat, N., Mmoledi, K., Hatta, N., & Harding, R. (2012). The prevalence and burden of pain and other symptoms among South Africans attending HAART clinics. SAMJ: South African Medical Journal, 102(6), 499-500.

• Ferreira-Valente, M. A., Pais-Ribeiro, J. L., & Jensen, M. P. (2011). Validity of four pain intensity rating scales. Pain®, 152(10), 2399-2404.

• Ferrell BR, Grant M, Ritchey KJ, Ropchan R, Rivera LM. The pain resource nurse training program: a unique approach to pain management. J Pain Symptom Manage.2003; 8: 549-556.

• Ferrell BR, Rhiner M, Ferrell BA. Development and implementation of a pain education program. Cancer.2013; 72(11 suppl): 3426-3432.

• Foley KM. Changing concepts of tolerance to opioids: what the cancer patient has taught us. In: Chapman CR, Foley KM, eds. Current and emerging issues in cancer pain: research and practice. New York: Raven Press, 1993:331-50.


• Goldberg, D. S., & McGee, S. J. (2011). Pain as a global public health priority. BMC public health, 11(1), 770.

• Hanna, T. P. and A. C. T. Kangolle (2010). Cancer control in developing countries: using health data and health services research to measure and improve access, quality and efficiency. BMC international health and human rights 10(1): 24.

• Hanks GW, de Conno F, Cherny N, et al. Expert Working Group of the Research Network of the European Association for Palliative Care. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer. 2001;84:587–593

• Hastie, B. A., Gilson, A. M., Maurer, M. A., & Cleary, J. F. (2014). An examination of global and regional opioid consumption trends 1980–2011. Journal of pain & palliative care pharmacotherapy, 28(3), 259-275.

• Human Rights Watch (HRW). Needless Pain: Government Failure to Provide Palliative Care for Children in Kenya. 2010. [Last accessed on 2016 Oct 04]. Available from: .

• Jagwe J, Merriman A. Delivering analgesia in rural Africa opioid availability and Nurse prescribing. 2007. J Symptom Management, Volume 33, (Issue 5), p 547-551

• Kenya Hospices and Palliative Care Association (KEHPCA). Hospices. 2016. [Last accessed on 2016 Oct 04]. Available from:

• Kopf, A. (2010). Pain in Old Age and Dementia. Guide to Pain Management in Low-Resource Settings: 269.

• Kombo, D. K., & Tromp, D. L. (2006). Proposal and thesis writing: An introduction. Nairobi: Paulines Publications Africa, 5, 814-30.

• Korir, G. K., Wambani, J. S., Korir, I. K., Tries, M., & Kidali, M. M. (2013). Frequency and collective dose of medical procedures in Kenya. Health physics, 105(6), 522-533

• Kothari, C. R. (2004). Research methodology: Methods and techniques. New Age International.Levy B, Paulozzi L, Mack KA, Jones CM. Trends in morphine analgesic-prescribing rates by specialty, U.S., 2014–2012. Am J Prev Med 2015;49:409–13.

• Lynch, T., Connor, S., & Clark, D. (2013). Mapping levels of palliative care development: a global update. Journal of pain and symptom management, 45(6), 1094-1106.

• Lohman D, Amon JJ. Evaluating a Human Rights-Based Advocacy Approach to Expanding Access to Pain Medicines and Palliative Care: Global Advocacy and Case Studies from India, Kenya, and Ukraine. Health Hum Rights. 2015;17:149–65. [PubMed]

• Malloy P, Paice JA, Ferrell BR, Ali Z, Munyoro E, Coyne P, et al. Advancing palliative care in Kenya. Cancer Nurs. 2011;34:E10–3. [PubMed]

• McCaffery M, Ferrell B, O'Neil-Page E, Lester M, Ferrell B. Nurses' knowledge of opioid analgesic drugs and psychological dependence. Cancer Nurs.1990; 13: 21-27.

• McCaffery M, Ferrell BR, Pasero C. Nurses' personal opinions about patients' pain and their effect on recorded assessments and titration of opioid doses. Pain Manag Nurs.2000; 1: 79-87.

• McQuay 2011 Wiffen PJ, McQuay HJ. Oral morphine for cancer pain. Cochrane Database of Systematic Reviews 2007 Oct 17;(4):CD003868.

• Miaskowski, C., Dodd, M., West, C., Schumacher, K., Paul, S. M., Tripathy, D., & Koo, P. (2004). Randomized clinical trial of the effectiveness of a self-care intervention to improve cancer pain management. Journal of Clinical Oncology, 22(9), 1713-1720.

• Miaskowski, C., Dodd, M. J., West, C., Paul, S. M., Tripathy, D., Koo, P., & Schumacher, K. (2001). Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. Journal of clinical oncology, 19(23), 4275-4279.

• Morris C. Palliative Care and Access to Medications for Pain Treatment. Cancer Control. 2013.Union for International Cancer Control. Palliative Care Backgrounder. The Global Opioid Policy Initiative (GOPI) Survey. 2013

• Morgan, D. L. (1996). Focus groups as qualitative research (Vol. 16). Sage publications.Berg, B. L., & Lune, H. (2014). Pearson New International Edition: Qualitative Research Methods for the Social Sciences. Pearson.

• Mwangi-Powell FN, Downing J, Powell RA, Kiyange F, Ddungu H. Palliative care in Africa. In: Ferrell BF, Coyle N, Paice JA, editors. Oxford Textbook of Palliative Nursing. 4th ed. New York: Oxford University Press; 2015. pp. 1118–29.

• Nabal, M., Librada, S., Redondo, M. J., Pigni, A., Brunelli, C., & Caraceni, A. (2012). The role of paracetamol and nonsteroidal anti-inflammatory drugs in addition to WHO Step III opioids in the control of pain in advanced cancer. A systematic review of the literature. Palliative medicine, 26(4), 305-312.

• Neo SH, Loh EC, Koo WH. An audit of morphine prescribing in a hospice. Singapore Med J. 2011;42:418. [PubMed]

• Neo, S. H., Loh, E. C., & Koo, W. H. (2011). An audit of morphine prescribing in a hospice. Singapore medical journal, 42(9), 417-419.

• Nyakundi 2013 AcquinasNyakundi (2013). A nurse’s role in palliative care: News and insipiration around the world. Ehospice palliative care; Edition Kenya

• O'Brien, M., Mwangi-Powell, F., Adewole, I. F., Soyannwo, O., Amandua, J., Ogaja, E., ... & Merriman, A. (2013). Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa. The Lancet Oncology, 14(4), e176-e182.

• Patton, M. Q. (1997), Utilization focused evaluation: The new century text. Sage Publications, Thousand Oaks, CA.

• Pargeon KL, Hailey BJ. (1999).Barriers to effective cancer pain management: a review of the literature. J Pain Symptom Manage.1999; 18: 358-368.

• Potter VT, Wiseman CE, Dunn SM, Boyle FM. (2003). Patient barriers to optimal cancer pain control. Psychooncology.2003; 12: 153-160.

• Paul, J., & Ribeiro, M. D. (2003). Analgesic efficacy of morphine applied topically to painful ulcers. Journal of pain and symptom management, 25(6), 555-558.

• Paul D., Standifer K. M., Inturrisi C. E. and Pasternak G. W. (1989) Pharmacological characterization of morphine‐6 beta‐glucuronide, a very potent morphine metabolite. J. Pharmacol. Exp. Ther. 251, 477–483.

• Ripamonti C, Brunelli C. (2012). Randomized Clinical Trial of an Implantable Drug Delivery System compared with comprehensive Medical management for refractory cancer pain: impact on Pain, Drug-Related Toxicity, and survival. J Clin Oncol 2012; 21(14): 2801–2802.

• Schug SA, Zech D, Dorr U. Cancer pain management according to WHO analgesic guidelines. J Pain Symptom Manage 2010;5:27-32

• Seidman, G. W. (1999). Gendered citizenship: South Africa's democratic transition and the construction of a gendered state. Gender & Society, 13(3), 287-307.

• Sepúlveda, C., Marlin, A., Yoshida, T., & Ullrich, A. (2002). Palliative care: the World Health Organization's global perspective. Journal of pain and symptom management, 24(2), 91-96.

• Sylla, B. S. and C. P. Wild (2012). A million africans a year dying from cancer by 2030: what can cancer research and control offer to the continent? International Journal of Cancer 130(2): 245-250.

• Thiadens, T., Vervat, E., Albertyn, R., van Dijk, M., & Van As, A. B. (2011). Evaluation of pain incidence and pain management in a South African paediatric trauma unit. SAMJ: South African Medical Journal, 101(8), 533-536.

• Trollor J. Cancer inpatients and morphine usage: A New England area survey. Aust J Rural Health. 2013;1:163–8. [PubMed]

• Twycross, A. (2002). "Educating nurses about pain management: the way forward." Journal of Clinical Nursing11(6): 705-714.

• Vainio, A., & Tigerstedt, I. (1988). Opioid treatment for radiating cancer pain: oral administration vs. epidural techniques. Acta anaesthesiologica scandinavica, 32(3), 179-185.

• Vervat 2011 Thiadens T. Vervat E. Albertyn R, et al. Evaluation of pain incidence and pain management in a South African paediatric trauma unit. S Afr Med J. 2011;101:533–536b. [PubMed]

• Vissers, K. C., Besse, K., Wagemans, M., Zuurmond, W., Giezeman, M. J., Lataster, A., ... & Huygen, F. (2011). 23. Pain in patients with cancer. Pain Practice, 11(5), 453-475.

• Ward S, Donovan HS, Owen B, Grosen E, Serlin R. An individualized intervention to overcome patient-related barriers to pain management in women with gynecologic cancers. Res Nurs Health.2000; 23: 393-405.

• Ward S, Hughes S, Donovan H, Serlin RC. Patient education in pain control. Support Care Cancer.2001; 9: 148-155.

• Ward SE, Carlson-Dakes K, Hughes SH, Kwekkeboom KL, Donovan HS. The impact on quality of life of patient-related barriers to pain management. Res Nurs Health.1998; 21: 405-413.

• Ward, S. E., Goldberg, N., Miller-McCauley, V., Mueller, C., Nolan, A., Pawlik-Plank, D., ... & Weissman, D. E. (1993). Patient-related barriers to management of cancer pain. Pain, 52(3), 319-324.

• West, C. M., Dodd, M. J., Paul, S. M., Schumacher, K., Tripathy, D., Koo, P., & Miaskowski, C. (2003, January). The PRO-SELF©: Pain Control Program--An Effective Approach for Cancer Pain Management. In Oncology nursing forum (Vol. 30, No. 1).

• WH0 (2011). Cancer pain relief: with a guide to opioid availability, World Health Organization.

• World Health Organization. Access to Controlled Medications Programme: Framework. Geneva, Switzerland: World Health Organization; 2007. Available at: Accessed November 2, 2010. World Health Organization (WHO).

• WHO, 2014 ;WPCA 2014 World Health Organization (WHO) and Worldwide Palliative Care Alliance (WPCA). Global Atlas of Palliative Care at the End of Life. 2014. [Last accessed on 2016 Oct 04]. Available from: .

• WHO Definition of Palliative Care; 2016. Available from: cancer/palliative/definition/en/. [Last accessed on 2016 Oct 04].

• World Health Organization. Palliative Care Factsheet No.402. 2015. Available: Accessed: 15 September 2016.

• Wittwer, J. D. (1973). Liquid chromatographic determination of morphine in opium. Journal of Forensic Science, 18(2), 138-142. Breivik, H. (2001). Opioids in cancer and chronic non‐cancer pain therapy–indications and controversies. Acta Anaesthesiologica Scandinavica, 45(9), 1059-1066.




How to Cite

Ombati, J. M. (2020). Criteria Used to Assess Need for Use of Morphine for Adult Cancer Pain Relief in Kakamega County Referral Hospital, Kenya, Africa. Asian Journal of Pharmacy, Nursing and Medical Sciences, 8(6).