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Balance: maximizing access to opioids for medical use/
minimizing risk of diversion and illicit use
 
Although ensuring access to morphine for anyone in need is imperative, it also is necessary to take reasonable 
precautions to prevent diversion and non-medical use. Model guidelines for this purpose are available 
(46). 
Hospitals, CHCs and pharmacies should store morphine in a sturdy, locked and well-anchored box or 
cupboard at all times, keep records of the remaining supply, and record the amount dispensed for a patient 
and the amount wasted or returned by a patient’s family. All personnel at these sites who handle controlled 
medicines such as opioids should be trained in safe storage and recordkeeping. Doctors should be trained 
to assess and minimize risk of opioid dependence and opioid diversion for non-medical uses. In keeping 
with the principle of balancing maximum accessibility of opioids for medical uses with minimum risk of 
opioid diversion, additional precautions might be necessary in areas with high rates of crime or violence. 
For example, it might not be possible to make morphine safely accessible at the community level in areas 
with high crime rates. In these places, accessibility must be ensured at higher levels in ways that do not 
unduly increase the travel burden for patients and their families. Where home or clinic supplies of morphine 
are frequently stolen, or patients and their families are put at risk by carrying or storing morphine, patients 
needing morphine might require admission to a hospital or inpatient hospice.
Other medicines
Among the other essential palliative medicines are oral and injectable haloperidol and oral fluoxetine or 
another selective serotonin reuptake inhibitor (SSRI). Although these medicines are considered psychiatric 
or psychotropic medicines, they have multiple essential uses in palliative care and are safe and easy to 
prescribe. For example, haloperidol is the first-line medicine in many cases for relief of nausea, vomiting, 
agitation, delirium and anxiety. An SSRI, such as fluoxetine, is the first-line pharmacotherapy for depressed 
mood or persistent anxiety, both of which are common among people affected by humanitarian emergencies 
and crises (HECs). Any doctor who provides primary care should be prepared and permitted to prescribe 
these medicines – not solely psychiatrists or neurologists. Patients with more severe psychiatric illnesses, 
such as psychotic or bipolar disorders, should be referred for specialist psychiatric care whenever possible. 

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23
A WHO guide for planners, implementers and managers
Petroleum jelly is essential for dressing non-healable wounds. Wet-to-dry dressings typically cause pain 
or bleeding when changed and can be avoided by applying petroleum jelly to dressings. Metronidazole 
powder, made by crushing metronidazole pills, is essential to reduce or eliminate the odor of any wound 
infected with anaerobic bacteria. The powder can be sprinkled on the wound or mixed with petroleum jelly 
or hydrogel dressings.