The international Association for the Study of Pain (ISAP) defines Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Dame Cecily Sauders, a founder of the modern hospice movement, defined pain as “what the patient says it is”.
The Pain & Policy Studies Group (PPSG) and the African Palliative Care Association (APCA) worked collaboratively to organize a 3 days of workshop “Availability of Opioid Analgesics for Pain Management” for the first Africans Pain Policy Fellows (APPF) and each of their global experts in palliative care.
This workshop was the first of its kind in Africa. The programme, selected 5 fellows from across Africa including: Ghana, Sudan, Ethiopia, Rwanda & Zambia. The fellows each demonstrated a strong leadership among peers to improve management of pain to patients with cancers and HIV/AIDS. The aim of the workshop was to share with fellows the opportunities through this program to improve the accessibility and availability of opioids analgesic in their respective countries.
In low and middle-income countries, pain itself among is often neglected by health professionals and ignored by the population themselves. Over 75% of advanced cancer and AIDS patients have pain. Recent data shows that pain prevalence is the same in patients with end-stage renal disease and patients with cancer.
The World Health Organization considers morphine an essential medicine for the treatment of pain, but access of the drug depends largely on where you live.
High-income countries (HICs) consume 93% of the world’s morphine supply, yet 70% of deaths from cancer occur in low- and middle-income nations (LMICs). In 2010, people living in HIC consumed 90% of Morphine. Put another way, people from LMICs consumed only 10% of the morphine.
Put simply, there is big disparity of consumption between HICs & LMICs.
Why Pain is often undertreated
The need of pain relief from patients is huge from simple, moderate and severe pain. There are so many barriers to treat pain and make patients comfortable but 4 are the most:
a) Lack of access to and knowledge about opioids not only among health providers but also the population who considers strong opioids like morphine as “passive euthanasia” treatment. This is a myth. Morphine is essential for cancer & HIV/AIDS patients who experienced moderate and severe pain. The side effects of morphine should be well controlled, as should the fear of using it.
b) Healthcare providers who are not trained in pain assessment and management often underestimate the patient pain a patient experiences. When a patient is not free from pain, the situation puts his/her family under a stressful circumstance, which will reduce their quality of life. There is an imperative to educate healthcare providers. This will improve the quality of life of patients and families.
c) Healthcare providers doubt the patient’s report of pain. They believe pain it is not a subjective reflection of the patients but something that only they can judge as a professional. This attitude creates a gap between patients and their caregivers.
d) Patients underreport their pain because they feel there is little to be done or they fear taking medications. In Rwanda the word “Kwihangane” (Stoicism) is an important cultural value where expressing feelings & emotions could be interpreted as weakness.
Most Africans have no access to effective screening, early diagnosis and treatment. Patients with cancer and other life-threatening illnesses often experience a painful and distressing death.
The single convention on narcotic drugs (1961) as amended by the 1972 Protocol, establishes a dual drug control obligation “to ensure adequate availability of narcotic drugs, including opiates, for medical and scientific purposes, while at the same time & preventing illicit production of, trafficking in and use of such drugs.” (www. incb.org)
This document specifies a necessity of governments, civil societies, opinion leaders & communities to be involved to release pain among patients using opioids for medical and scientific purposes. That means freedom from pain is not a privilege for a group of patients but a necessity as a moral, legal, political and public health imperative.
Releasing pain could be well addressed in Africa among cancer and HIV/AIDS patients. Even if there are many challenges, there are also many opportunities to improve our public health systems. We must continue to advocate for effective strategies that address the multiple challenges to opioid availability in Africa.
“Balance….maximize the availability & accessibility of opioids for medical purpose and minimize risk of diversion, this is your key word from this workshop to take to your respective countries” said Jim Cleary, the Director of the University of Wisconsin Carbone Cancer Center’s Pain and Policy Studies Group the end of workshop.
A message many could learn from.