Cancer pain remains inadequately treated despite internationally accepted pain management guidelines and a myriad of treatment options.
According to a World Cancer Report, over 12 million people in developing countries are diagnosed with cancer and the number is expected to hit 15 million by the year 2020 with anticipation of the figure doubling by the year 2030. Two-thirds of these patients are likely to experience moderate to severe pain. It is essential that clinicians are skilled in management of pain and that opioid medication is available on country Essential Medicines Lists.
Dr Joe Kanja of Meru Level 5 Hospital says there is an exaggerated fear of addiction yet research shows that psychological dependence occurs in less than 1% of hospitalized patients taking opioids for pain relief.
“All we need is a change of attitude to make better use of opioids as lack of conviction is the reason why patients have little or no access to morphine.” Dr Kanja says.
He says this fact needs to be discussed with patients, families and physicians if they seem hesitant to use pain medication.
The World Health Organization (WHO) guidelines for the management of cancer pain published in 1990 are still valid and palliative care providers recognise the efficacy of the WHO three-step ladder for cancer pain relief. According to the WHO: if pain occurs, there should be prompt oral administration of drugs in the following order:
- Non-opioids (aspirin and paracetamol) for mild pain
- Mild opioids (codeine) for moderate pain
- Strong opioids (morphine) for severe pain
WHO recommends following these guidelines until the patient is free of pain, if the pain is difficult to control, additional drugs may be added depending on the clinician’s assessment of the cause of pain.
To maintain freedom from pain, WHO advises giving of drugs by the clock, that is, every 4 hours for short-acting medication rather than on demand. If the patient waits until the pain returns, he will experience pain each time the medication wears off instead of being pain-free.
Dr Kanja says if palliative care providers follow the 3-step model; it is a guarantee that we will achieve 90% of pain control.
He recommends prescription of morphine syrup as injections are not advisable in chronic pain management. Opioid tablets are not currently available in Kenya.
This, he says, enables patients to be close to relatives at home enabling them to live longer and cut expenses of travelling to hospices and palliative care units for injections.
“Prescription of a syrup will also ease congestion at hospices and palliative care units as it can easily be administered at home.” Dr Kanja says.
Dr Esther Muinga of Kenya Hospices and Palliative Care (KEHPCA) says it is appropriate to ask patients what they are feeling, as they should be the final decision makers in palliative care.
Dr Muinga says this will go a long way in the holistic approach of the concept of pain management in palliative care.