THE PRICE OF PAIN IN NIGERIA

Two years ago, when I had a tooth extraction due to an impacted third molar that was growing at an abnormal sideways angle instead of obeying the law of gravity and growing downward, I thought my life was going to end. My left jaw became swollen to the size of a large mango, and I could feed on only liquids through a straw for an entire week. Despite Over The Counter (OTC) analgesics, I cried from pain many times and my sleep was interrupted many times from the searing pain shooting from the left side of my face. At night, while nursing my pain, memories of family and patients that had endured the pain of cancer haunted me.

If this is what I was feeling, how did they cope??

In 1811, French writer and courtier Frances Burney underwent a mastectomy for suspected breast cancer without any anaesthesia or analgesia. She documented her ordeal in a very graphic and vivid letter to her sister, thus producing one of the earliest and most detailed, albeit gruesome, accounts of a mastectomy. With centuries of advancement in medicine and cancer care, one would hope that such agonising and torturous pain caused either by disease or therapy would be firmly confined to the coffers of history. This, unfortunately, is not the case. Patients living with cancer all over the world endure immeasurable pain, day in and day out. This pain is brought on either as the direct effect of tumour infiltration, investigational and therapeutic interventions, or noncancer-related comorbidities, all of which the physician has the responsibility to address as part of holistic patient care. Especially in low and middle-income counties like Nigeria, a cancer diagnosis is often unfortunately associated with a sentence of pain, suffering, and death.

The obstacles to proper management of pain in resourceconstrained settings like Nigeria are numerous and inflected by factors peculiar to economically challenged countries. A considerable proportion of patients with cancer in Nigeria present with an advanced and often incurable disease, situations in which pain is almost always present, and pain control becomes a priority. Another complication is the relative inaccessibility or unavailability of essential pain control medications. This combination of high proportions of patients presenting with advanced disease, and the deficiency of crucial pain control measures, culminates in a desperate situation for the patient with cancer in Nigeria. Furthermore, there is a suspected under-exploration of pain control in oncology care, particularly in countries like Nigeria.

The current challenges faced by Nigerian cancer patients in accessing appropriate pain management through narcotics are deeply concerning. Uncontrolled cancer pain not only results in unnecessary suffering but also hampers the ability to cope with illness, disrupts daily activities, and even impacts the efficacy of cancer treatments. The existing barriers to obtaining narcotics have exacerbated this issue, preventing patients from accessing adequate pain relief and undermining their quality of life.

In some instances, premature death has occurred with inadequate pain treatment due to dehydration, anorexia, and infected bed sores. Oncologists, who are well-versed in the treatment of cancer, face limitations in prescribing narcotics due to the lack of available options and the unfounded fear of addiction. The scarcity of palliative care physicians further compounds the problem, as these specialists play a crucial role in managing pain and enhancing the overall well-being of patients with terminal illnesses. The absence of palliative care expertise has left cancer patients without access to knowledgeable professionals who can provide holistic pain management solutions.

The cumbersome process of obtaining morphine in paediatric as well as adult doses, has made it incredibly difficult for patients to access the pain relief they desperately need. The associated paperwork and the lack of morphine-carrying pharmacies in many states have placed undue burdens on patients and their families. Currently 60 pills of morphine 10 mg from Lagos, which is the only source for now is about $90 dollars. Today, 90 pills of morphine 10mg in the US is about 11 US dollars.

Let me paint a picture for easy comprehension.

In the west, a patient with stage four breast cancer with metastasis (spread) to the spine or lungs will be placed long term opioid medication. Patients are prescribed morphine in optimal doses either orally, intravenous infusion, or even suppository tablets. In patients who have had major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral blocks may be continued postoperatively using catheter techniques. In other words, the patient would be pain free while being managed for the cancer.

Fast forward to Nigeria, patients can be heard screaming in the wards (for those opportune to be in the hospital) from the pain in the bodies. I still remember hearing my grandfather’s groans of pain from the kitchen while he was in the bedroom, suffering the end stages of pancreatic cancer. This was twenty-one years ago when we had to source morphine from Lagos every week and even then, the dose was sub-optimal. Many years later, the situation remains the same. My father died of cancer and in pain. So did my cousin. As for my patients, they are too numerous to count. Their tears haunt me to date. So, what is the way forward? The core problems with pain management in cancer treatment are a) Inaccessibility of the drugs b) Fear of addiction and abuse and c) Lack of appropriate pain specialists. To solve these problems, are the following solutions:

Firstly, licensing and distribution of Opioids. Government should license at least one pharmacy location in each state to carry adult dose liquid and oral morphine. The Ministry of health should establish controlled pricing in line with international standards and appoint a single distributor for these medications. Monitor the supply and distribution through an active unit within the Federal Ministry of Health. This active unit will be headed by a director who will approve of prices and check compliance with every distributor in each state.

Secondly, there should be a select group of prescribing physicians to control abuse. The MOH should grant specialized licenses to a select group of about 20 physicians in each state to prescribe narcotics. This group will include oncologists, palliative care specialists, and pain management experts. Additional doctors can be selected by the state Ministry of Health based on geographic considerations.

Thirdly, is the training and monitoring of health workers by providing Continuing Medical Education (CME) training via video sessions to licensed doctors and pharmacists on safe prescribing practices, effects of undertreating pain, and safe drug disposal. This training should be available every two years to ensure up-to-date knowledge.

Additionally, as is already the practice, unique identification and confirmation numbers should be issued to trained doctors, which they must include on narcotic prescriptions. Pharmacists can then use this number to confirm the legitimacy of the prescription by contacting the prescribing physician on a registered cell phone number.

Lastly, is to appeal for additional pain medications. There is a need to advocate for the availability of alternative pain medications, such as Hydromorphone, to address potential tolerance or toxicity issues associated with Morphine. This would provide patients with a viable alternative and enhance their pain management options. Some patients like those with kidney disease cannot take morphine as it would cause toxicity, seizures, and brain damage and so require alternative medication.

You see this song I am singing? It affects all of us. Until there is a more comprehensive and simpler method of curing cancer, we will all continue to suffer. The pain may be directly or indirectly, emotionally or physically, but pain is pain. Watching a loved one suffer or being a primary caregiver is just as distressing.

By addressing issues of licensing, distribution, training, and alternative options, we can ensure that patients receive the pain relief they deserve, enhancing their overall quality of life and improving their ability to cope with their illness. I believe it is our collective responsibility to prioritize the wellbeing of cancer patients and provide them with the care they urgently require.

Because, how do we know, who among us is next?