A recent article in Time magazine presented a gloomy picture of the repercussions of a high demand for pain medication among the US population; it stated that about 1/3 of the population suffers from chronic pain, and the quest for relief has resulted in the progressive increase in the consumption of opioid analgesics and a subsequent increase in abuse of these medicines.
The problem is quite different In Ghana and most other developing nations. Our problem is an inadequacy of effective pain relief. Recent figures from the WHO reveal that global morphine consumption – an indicator of access to pain treatment- is skewed in the direction of developed countries. In 2003, six developed countries accounted for 79% of global morphine consumption. Developing countries, which represent about 80% of the world’s population, accounted for only about 6% of global morphine consumption.
This inadequacy is felt most by individuals with chronic debilitating illnesses like terminal cancer and AIDS. In Ghana, more than 80% of patients with moderate to severe pain from terminal cancer and AIDS die without adequate pain management. This statistic from the International Narcotics Control Board (INCB) means that these patients and their families suffer through the agony of pain- which can be excruciating- before they die. This is inhuman. Apart from these individuals, there are millions more who suffer acute and/or chronic pain without adequate pain relief, from patients with fractures or recovering after surgery, to those with recurrent sickle cell crises or degenerative conditions of the spine.
The drugs that are readily available- paracetamol, ibuprofen, aspirin, diclofenac and the like- only work for mild to moderate pain. For patients with severe pain, strong pain medicines, mainly of the opioid family- like morphine, pethidine and fentanyl, are needed for relief. These medicines, however, hardly find their way to the patient’s medicine bag.
The causes
The primary deterrent to the use of opioid analgesia emanates from healthcare professionals. Most healthcare professionals are worried that patients given opioid analgesics will become addicted to them. For this reason, either the prescriber would not prescribe it or the nurse would decidedly withhold the medicine from the patient. But this fear is largely unfounded.
According to the WHO, “in practice, most patients, who are appropriately prescribed controlled medicines, do not become dependent from rational use of these medicines”; the patient suffering from the chronic pain of cancer, or who has just come out of surgery is not a typical candidate for addiction. Even in areas where there is widespread use of opioid analgesics some studies have found that only about 3% of people with chronic non-cancer pain using opioid drugs abused them or became addicted.
The risk was even less than 1% in people who had never abused drugs or been addicted. So the risk of addiction for our patients is very low. Interestingly, it is widely known in the medical fraternity that a good number of people addicted to or dependent on prescription opioids are healthcare professionals- nurses, doctors, pharmacists. Statistics are lacking, but it would be a revealing one if it were available.
Probably related to this fear of addiction is a lack of knowledge in the use of opioid analgesics. The WHO in its 2011 World Medicines Situation report states that “the curricula of medical doctors, nurses and other health professionals in many parts of the world fail to include the rational use of opioids.” As such, practitioners come out of training with little to no knowledge about the complexity- or rather, simplicity- involved with using opioid medication. This concern is echoed by Anaesthesiologist and Lecturer at the Kwame Nkrumah University of Science and Technology (KNUST) School of Medical Sciences, Dr. Akwasi Antwi-Kusi as he bemoans the paucity of pain management education in our health-training institutions. Dr. Antwi-Kusi, who is also the current President of the Ghana Chapter of the International Association for the Study of Pain (IASP), contends that if a medical student gets only 1 hour of lectures dedicated to pain management in all 6 years of medical school, “do you expect that that person will be competent in the management of pain?” This lack of knowledge is not even apparent to some, since they assume that with practice, you should become familiar with these medications and how to use them; the 80% of patients dying in pain from cancer will definitely disagree.
But the health professionals’ fears and lack of knowledge are not always to blame. The medicines are sometimes just not available. Dr. Antwi-Kusi ascribes this lack to poor record-keeping. Because opioid analgesics are controlled medicines, their use is highly regulated- by no less an organization than the International Narcotics Control Board (INCB). The supply is tightly linked to demand, and demand is determined by records of consumption supplied to the INCB; unfortunately record- taking and keeping is not the Ghanaian’s strongest attribute; medicines are dispensed without enough information recorded about the transaction, which means we cannot account to the INCB about those transactions. The outcome is a demand-supply imbalance. With this situation prevailing, even the few prescriptions that are written are unlikely to be served, because the medicines are unavailable.
The process of making amends
IASP, since its inauguration in Ghana in 2009 has been spearheading a revolution in pain management in the country. Every year, over 400 health professionals receive some training in pain management. However, these health personnel have not been able to exert their new knowledge on the health system enough to change the statistics.
To be able to speed up the revolution, many other organizations and institutions would need to make pain management a priority. The Medical and Dental Council (MDC), whose mandate is to protect the public and guide the profession of medicine is one such body. Just as the MDC expects every medical practitioner to take at least one seminar in ethics each year, it could also ask every practitioner, or at least those in relevant fields, to take a course in pain management every 3 years or so. This would make a big difference in the way pain is managed in Ghana.
Another way to make amends is to make assessment of pain severity part of the regular (objective) vital signs- of temperature, pulse, respiratory rate and blood pressure- checked at every visit to the hospital. Proponents of this paradigm shift argue that most prescribers arbitrarily decide which pain medication to give patients, without any appreciation of how severe the patient’s pain is. The main concern raised by those who oppose this proposal is that pain is subjective, but advocates like Dr. Antwi-Kusi would retort that pain is what the patient says it is. Moreover there are many pain assessment tools that can give a fairly accurate idea of the patient’s level of discomfort. This 5th vital sign may be a long distance from being incorporated into standard practice, but at least, all patients with chronic pain should have the severity of their pain assessed and documented, and this assessment should guide treatment.
Setting up pain clinics will also help improve pain management in Ghana. In 2009, at the launch of the Ghana chapter of IASP, Professor Nii Otu Nartey, then CEO of the Korle-Bu Teaching Hospital supported calls for the establishment of a pain clinic at Korle-Bu. Six years on though, there is still yet to be a pain clinic in Ghana. Such pain clinics would use a multidisciplinary approach to deliver pain relief to patients with chronic pain. These clinics would also make non-pharmacological methods of pain relief like nerve stimulation, massage and heat therapy available to the patient at one spot. Were we to have such clinics in every region in Ghana, our problem would be half-solved.
A foot note
Pain relief is considered by some as a treatment bonus, but this couldn’t be more false. Pain can significantly alter the outcome of a patient’s condition, e.g. pain in the post-operative period is known to increase the risk for infections or dangerous blood clots and can lead to a precipitous rise in the blood pressure. These factors can cause a bad outcome for such patients. Apart from the physical consequences, pain exerts an emotional toll on the patient, and their family, a toll that can drive some to commit suicide. Pain has to be managed actively if maximum benefit is to be obtained.
With all said, let’s not forget that pain relief is a matter of human right. In denying a patient access to adequate analgesia, we are denying the person the highest attainable standard of health, and the right not to be subject to torture or to cruel, inhuman or degrading treatment or punishment. Pain is unpleasant, and no one needs to suffer through it when it is so easily remediable.
By: K.T. Nimako (MB ChB)
Dr. Kojo Nimako is a private medical practitioner with an interest in public health and Citi FM’s Chief Medical Correspondent. He is also the Executive Director of Helping Hand Medical Outreach, an NGO focused on health education.
E-mail: [email protected]
Twitter: @KTNimako