|Year : 2013 | Volume
| Issue : 1 | Page : 24-27
Cancer pain and management: Providers' perspective in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
Adekunle O Oguntayo1, Marliyya Zayyan1, Ekundayo S Garba2, Ahmed Mai2, Sunday A Adewuyi3, Elizabeth O Nwasor4
1 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Radiation Oncology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||18-Oct-2013|
Adekunle O Oguntayo
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Pain is a frequent disturbing symptom of cancer, the prevalence and severity of which depend on the primary tumor, its metastatic sites, and the disease stage. The place of pain management in cancer patients cannot be over emphasized. Proper management results in improved quality of life.
Aims: To assess providers' attitude and practice toward cancer pain management in Ahmadu Bello University (ABU) Teaching Hospital, Zaria, Nigeria.
Materials and Methods: This was a cross-sectional descriptive pilot study on provider perspectives on pain management in cancer patients. A structured self-administered questionnaire was completed by 79 medical practitioners of various specialties and ranks.
Results: Seventy-nine clinicians were recruited for the study. The majority of the respondents, 36 (46%), believe that pain was the commonest symptom in cancer patients. Most, 61 (78%), of the doctors assessed pain using subjective methods and only 30 (29%) of the respondents were conversant with other treatment options for pain. Fifty (64.3%) use analgesia, and their choices were guided mainly by the response of the patients. Forty-eight (61.5%) of those who admit to the use of analgesia, were actually limited by the side effects of the drugs. More than half (57.6%) believed that pain management in our settings is suboptimal, and the commonest limitation to optimal pain management in our settings was availability and affordability of drugs.
Conclusion: Professional education needs to focus on the proper assessment of pain, the management of side effects of analgesics, and the use of adjuvant therapies for pain. A better understanding of the pharmacology of opioid analgesics is also needed.
Keywords: Management, pain, perception, providers
|How to cite this article:|
Oguntayo AO, Zayyan M, Garba ES, Mai A, Adewuyi SA, Nwasor EO. Cancer pain and management: Providers' perspective in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Ann Nigerian Med 2013;7:24-7
|How to cite this URL:|
Oguntayo AO, Zayyan M, Garba ES, Mai A, Adewuyi SA, Nwasor EO. Cancer pain and management: Providers' perspective in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Ann Nigerian Med [serial online] 2013 [cited 2020 Feb 27];7:24-7. Available from: http://www.anmjournal.com/text.asp?2013/7/1/24/119983
| Introduction|| |
Pain can be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain is what hurts. 
Pain is one of the most frequent and disturbing symptoms seen in cancer patients. It is considered the single most feared aspect of cancer, and one of the reasons why the terminally ill ask for their doctor's help in dying , Pain can be caused by cancer, cancer treatment, or by the side effects of treatment. At every stage of the cancer management, there is also emotional pain for both patients and the family. ,
It has been estimated that one out of every three patients receiving active treatment for metastatic disease has significant cancer-related pain, with this percentage increasing to between 60% and 90% in patients with advanced disease. ,, The prevalence of pain and inadequate analgesia in patients with cancer is well documented. Experts estimate that 25% of all cancer patients die without adequate pain relief,  despite the fact that the tools for adequate pain control are available.
Pain management is frequently necessary in cancer treatment, making it critical that those treating the cancer patient completely understand how to correctly assess the pain and determine the proper type of treatment.  The problem is enormous as cancer causes one in every 10 deaths worldwide, and it is projected that by year 2015, the estimated figure will rise to over nine million deaths per year globally; 75% of these will be in developing countries. 
The prevalence and severity of pain among cancer patients is a function of the primary, metastatic sites, and the disease stage. , Despite adequate resources in developed countries, pain is still undertreated relative to what obtains in developing nations ,
The failure of pain management in our environment is likely to be related to the nonavailability of resources. Other important factors include lack of knowledge of the physician, patients' fear of addiction, tolerance, and other side effects.  Patients may also think that pain with cancer is inevitable. As a result, they have been reluctant to report pain or the lack of pain relief, as well as to take adequate doses of analgesics.  The World Health Organization (WHO) has, therefore, urged every nation to give a high priority to establishing a cancer pain relief policy. 
This study was designed to assess the attitude and practice of cancer pain management among the health care providers in the hospital and to make recommendations in the areas where there is need for improvement.
| Materials and Methods|| |
This is a cross-sectional descriptive pilot study, using structured self-administered questionnaires properly completed by 79 medical practitioners of various specialties and ranks. The study period was between January and April 2010, and the study was carried out in A.B.U Teaching Hospital, Zaria, Nigeria. Approval for the study was obtained from the Ethical and Scientific Committee of the Teaching Hospital.
Data generated were analyzed using Excel statistical package (Microsoft office, 2007). Descriptive statistics using mean, median, mode, standard deviation, ratios and percentages were used to analyze and summerise the data. Demographic representations were also applied.
| Results|| |
Seventy-nine medical practitioners of various specialties and cadre were enrolled into the study. Fifty four (68.3%) were males. The registrar cadre constituted the majority of the respondents accounting for 37 (46.8%) [Figure 1]. The majority, 47 (59.4%), of the respondents were within the age group 31-40 years. The study cut across a wide range of specialties, which included the following, surgery, obstetrics and gynecology, pediatrics, and internal medicine. The majority of the respondents, 36 (46%), believe that pain was the commonest symptom in cancer patients [Table 1].
There was no uniform method of assessment of pain among the health care providers. The majority, 61 (78%), of the doctors used the subjective method for assessment of pain. Sixty-six (84.5%) of the respondents qualified cancer pain as severe and, only 30 (29%) of the respondents were conversant with other treatment options for pain. Sixty five (64.4%) use analgesia and their choices were guided mainly by the response of the patients [Table 2].
In practice, 95% of the medical practitioners use oral and parenteral routes to administer analgesia. Only 5% use other routes of administration. Sixty-four (84.2%) considered side effects before they use narcotics, and 61.5% will not use these drugs at all or are limited by the side effects of the drug. Forty-eight (61.5%) of those who admitted to the use of analgesia were actually limited by the side effects of these drugs. More than half (57.6%) believed that pain management in our settings is suboptimal. The commonest limitation to pain management in our settings is non-availability and non-affordability of drugs. Poverty ranked topmost among the limitations to optimal cancer pain management. Non-availability of drugs was also identified as a major challenge.
Some of the respondents suggested free treatment for all histologically diagnosed cancer and that the respective bodies or agencies should ensure that these drugs are made available and delivered to the end users. Most of the respondents also advised on creating a pain management team in the hospital while others suggested that there is a need for training and re-training of all health care providers.
| Discussion|| |
Pain is a major health care problem for patients with cancer and despite the existence of guidelines for cancer pain management, undertreatment is a widespread problem.  Pain management indexes (PMIs) evaluate the congruence between the patient's reported level of pain and the intensity/strength of the analgesic therapy. Negative scores indicate inadequate prescriptions. ,,
The study revealed that the attitude and practice of our medical practitioners is suboptimal at all levels irrespective of the rank. The findings are similar to a report from Italy where nearly one of two patients with cancer pain is undertreated. The percentage is high, but consists of a large variability of under treatment across studies and settings. 
The suboptimal care of pain in patients with cancer is as a result of many factors.
First is the knowledge of the medical practitioners who may not be aware of current concepts concerning the mechanisms of pain, the modalities available for its control, and their availability.  There was no uniform method of assessment of pain among the health care providers. Also only 30, (29%), of the respondents are conversant with other treatment options for pain. Sixty five (64.4%) use analgesia and their choices were guided mainly by the response of the patients. These were some of the effects of poor knowledge of pain management, as there are various standardized methods of pain assessment and management. The providers themselves admit that there is a need for training and re-training in the management of pain.
Second is the socioeconomic status of the patients. The dimension of these problems is worse in developing countries, especially countries in Africa, where there is a lot of ignorance about cancer, negative cultural beliefs about causes of illness, and poverty.  Poverty is a common factor in the health situation of low resource countries, and it is the main determinant of diseases, since most of the patients earn less than a dollar per day (below the breadline), and as such cannot afford to cater for their health. Over 70% present late to the hospitals with pain. Denial, anxiety about the future, fear of loss of income, and fear of dying contribute to these late hospital presentation when the option of cure becomes impossible. 
Third, cancer pain management is not a health priority in developing countries, including Africa as addressed in the United Nations Millennium Development Goals (MDGs). Listed priorities include eradication of poverty and hunger, universal primary education, gender equality, reduction of child mortality, improvement of maternal health, combating HIV/AIDS, malaria and other major diseases, environmental sustainability, and global partnership for development.  This has also contributed to the neglect of cancer care in general and pain in particular.
Fourth, suboptimal pain management may also be as a result of health care professionals being overly concerned about addiction. The providers also consider in addition to development of tolerance, side effect management, and regulatory scrutiny of physicians who prescribe narcotics. ,
Lastly, suboptimal pain management may also be as a result of lack of drugs and equipment. For many countries in Africa, availability of opioid analgesics is a major challenge for effective cancer pain treatment. The most common narcotic analgesic available for use in Nigeria now is pentazocine whose potency is not comparable to the other strong opioids. The mean consumption of morphine in the African region was the lowest of all the WHO regions of the world, at 0.7 mg per capita; while South Africa ranked highest at 3.4 mg per capita.  If the drugs are available, cost is a major constraint,  as is lack of knowledge on their use.
These myriad of problems accounts for the lack of adequate cancer pain management, and thus pain management has had a low priority in cancer care in our environment. This problem is compounded by patients concern about addiction, drug side effects, and development of tolerance to analgesics. ,,, Some patients may even prefer to die than to subject themselves to care and therapy.
| Conclusion|| |
We believe the way forward for Africa will be to advocate actively for inclusion of cancer among the priority diseases within the MDGs and explore the area of global partnership for effective cancer control and treatment, including the multidimensional problem of cancer pain management. Medical education and continued medical education for health care providers need to focus on the proper assessment of pain, the management of its drug side effects, and also the use of adjuvant medications. A better understanding of the pharmacology of opioid analgesics cannot be overemphasized. With appropriate education and availability of essential drugs, adequate pain relief can be achieved in more than 75% of cancer patients using simple techniques such as opioids, non-opioid analgesics, and adjuvant medications. ,
| References|| |
|1.||Managing cancer pain: Bedside approach. Ann Berger in Continue Medical Education under Education for Todays Improvement Focused Health Care Professional. Available from: http://www.cmell.com. [Last accessed on 2009 Jan 10]. |
|2.||The management of cancer pain. In: Ogunyemi O, editor. Archives of Ibadan Medicine. Vol. 1. 2000. p. 34-5. |
|3.||Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Ann Oncol 2008;19:1985-91. |
|4.||Soyannwo O. Cancer pain - progress and ongoing issues in Africa. Pain Res Manag 2009;14:349. |
|5.||United Nations Millennium Development Goals. Available from: http://www.un.org/millenniumgoals/. [Last accessed on 2009 Mar 23]. |
|6.||World Health Organization. Cancer Pain Relief. With a guide to opioid availability. 2 nd ed. Geneva: World Health Organization; 1996. |
|7.||Joranson DE. Unavailability of opioid analgesics for relief of pain in Africa. Available from: http://www.medisch.wisc.edu?painpolicy/publical/monograp/unavailability_africa.htm. [Last accessed on 2009 Mar 18]. |
|8.||De Lima L, Sweeney C, Palmer JL, Bruera E. Potent analgesics are more expensive for patients in developing countries: A comparative study. J Pain Palliat Care Pharmacother 2004;18:59-70. |
|9.||Twycross R. Incidence of pain. Clin Oncol 1984;3:5-15. |
|10.||Foley KM. The treatment of cancer pain. N Engl J Med 1985;313:84-95. |
|11.||Saunders C. Current views of pain relief and terminal care. In: Swerdlow M, editor. The therapy of pain. Lancaster: MTP Press; 1981. p. 215. |
|12.||Melzack R, Ofiesh JG, Mount BM. The Brompton mixture. Effects on pain in cancer patients. Can Med Assoc J 1976;115:125-9. |
|13.||Bonica JJ. Treatment in cancer pain. Current status and future needs. In: Fields HL, Dubnev R, Cervero F, editors. Advances in pain research and therapy. New York: Raven Press; 1985. p. 589-616. |
|14.||Bonica JJ. Cancer pain. In: Bonica JJ, editor. Pain. New York: Raven Press; 1980. p. 335-62. |
[Table 1], [Table 2]