Failing a Nation in Pain

There is a famous joke that emanated during the early days of PMB’s second tenure in 2019. You remember those days, don’t you? When inflation was gradually creeping in, and insecurity was gradually becoming the order of the day. The joke was that if you saw a person sitting quietly by himself, with his hand […]

There is a famous joke that emanated during the early days of PMB’s second tenure in 2019. You remember those days, don’t you? When inflation was gradually creeping in, and insecurity was gradually becoming the order of the day. The joke was that if you saw a person sitting quietly by himself, with his hand supporting his chin, looking thoroughly morose and lost in thought, you would ask: ‘Jikin ko garin?’

‘Jikin’ meaning physical pain, while ‘Garin’ meant environment or more sincerely, financial factors. The joke is meant to tease Nigerians going through monetary issues, and I myself used to through it around casually until I heard a colleague ask a well-dressed man sitting under a tree in the hospital a similar question to which the man replied sadly: ‘Jikin’.

The man was in severe pain. So severe was the pain that he could only mumble a few words. He ached all over his body and he described it a raging fire consuming his entire being. The pain was labile, mild on some days and severe on other days. He had been living with the pain for three years. The pain was driving him mad, he lamented. He had undergone all manner of tests including a full body scan, electromyography and serologies for all types of autoimmune diseases. His hospital file was as thick as the famous Grey’s Anatomy textbook. The poor chap had even seen the psychiatrist a few times after he was told the pain could be in his head. 

Yet, nothing.

The conclusion on his case was that he suffered from Fibromyalgia. Fibromyalgia, also called fibromyalgia syndrome (FMS), is a long-term condition that causes pain all over the body. It is characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and sometimes mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain and spinal cord process painful and nonpainful signals. Unfortunately, there is no real test to confirm this diagnosis, meaning it is a diagnosis of exclusion. Also, pain killers do not eliminate the pain totally. A combination of antidepressants, exercise, psychotherapy, and alternative therapy including acupuncture are frequently used to manage the condition. There’s little or no evidence to show that other types of medicine help reduce long-term pain.

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Whenever I meet people who suffer from chronic pain conditions like sickle cell disease, cancers, arthritis, slipped disc and many more, my heart goes out to them. My sympathy is not only to their diagnosis, but to the lack of adequate pain management methods in Nigeria, as well.

Pain is the leading clinical complaint all over the world. In the US, it has become the 5th vital sign in addition to blood pressure, heart rate, temperature, and respiratory rate. The history of pain in human affliction is a long and dreadful one. The word “pain” itself originated from the Latin word “Poine”, meaning penalty. It was believed that the Greek goddess of revenge, Poine, was sent to punish the mortals who had angered the gods. From the dawn of the ages, many cultures have viewed pain as punishment for wrongdoing. This attitude persists in our societal subconscious to this day. When pain persists, we start to ourselves- What did I do wrong?

Who did I offend? 

Is my knee pain due to something I did in my past?

Is God punishing me?

Even worse, pain is subconsciously accepted as an unavoidable aspect of any illness, especially one as ‘serious’ as cancer or sickle cell disease. We are expected to adapt to the pain and suffer in silence. Or like my professor used to say ‘Living under wayyo Allah’

Unfortunately, this should not always be the case.

In Nigeria, like many African countries, there are shortcomings in the management of pain, especially chronic pain. The obstacles to proper management of pain in resource-constrained settings like Nigeria are numerous and inflected by factors peculiar to economically challenged countries. It may seem to the casual observer that pain would be an expected and unavoidable part of chronic illness. However, it is crucial for the doctor to understand that pain is a complex symptom that affects most aspects of the patient’s life, from physical functioning to daily living; as well as psychological, emotional and social status; and if properly managed, can be avoided or at least controlled. 

The simple truth is, in Nigeria, we under-treat pain and this has profound and varied effects on the patient, family and society at large. Although significant milestones have been made in understanding the physiology of pain, there remains a deficiency in the complete control of pain; due to a dynamic combination of socio-cultural, educational, economic, religious, legal, and political factors. 

Years ago, the American Cancer Society, in partnership with Low- and Middle-Income Countries (LMICs) gave a training on pain management titled ‘Treat the Pain’. During the module on management of pain in labour, I felt tears sting the back of my eyes. For the first time in my life, people were explaining the pain women suffered in labour without the usual whitewash of: ‘Oh! Its not really pain, it’s just discomfort or pressure you are feeling’. Or the doctor that was quoting scripture when I was screaming of pain while delivering my son: ‘…and in pain you shall bring forth children….’

I have since cursed him acute urinary retention in his old age. Wherever he maybe.

Anyway, I digress. 

The training addressed many painful conditions in our environment. When the discussion turned to the management of sickle cell crisis among children, we all had to bow our heads in collective shame. Because how could we justify giving ordinary paracetamol, ibuprofen or even codeine to a child with severe vaso-occlusive crisis?? These drugs just scratch the surface of the pain and are nowhere near as potent enough to delete it completely. These kids writhe and scream in painful distress, yet we only address 30% of their pain and tell them to be patient. The drug of choice according to the WHO pain ladder, in this group of children, should be opioids which Nigerian many clinicians are wary of for fear of causing dependence.

Yet, we must use these narcotics.

As more and more people are ageing and  living longer with painful conditions, it is becoming imperative that physicians arm themselves with the knowledge of pain management and techniques so that we can help these group of patients. Opioids can be part of an effective pain management plan, but to help avoid side effects and risk of addiction, it should be used under strict physician’s supervision.

Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication globally. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly. Conversely, sales of opioid pain medication while having increased in parallel with opioid-related overdose deaths, has significantly reduced the prevalence of pain among patients taking them.

A friend of mine told me about the time she travelled to Cairo for a surgical procedure. Till date, she does not remember feeling any pain post-surgery because of the analgesic infusion that was constantly in her blood stream until after she was discharged home, pain free.

Another friend had to move her child with sickle cell disease to the US for adequate management of her pain and for the future possibility of a marrow transplant.

There are many of these examples. Through the ‘Treat the pain’ training across Nigeria, many hospitals have adopted for adequate many management methods. Currently, no woman is allowed to have a natural delivery without any form of analgesia in tertiary centres across the country. Morphine syrups are prescribed more often to children with sickle cell disease, while those with cancer pain are given a large choice of analgesia from which to choose from.

We are on the way, but still nowhere near where we ought to be.

Living with pain in this country is a nightmare. Since we can’t do anything about ‘Garin’, we should hasten to help those with real physical pain, Jikin.