Olaitan Soyannwo

Improving access to analgesic drugs for patients with cancer in sub-Saharan Africa.

WHO expects the burden of cancer in sub-Saharan Africa to grow rapidly in coming years and for incidence to exceed 1 million per year by 2030. As a result of late presentation to health facilities and little access to diagnostic technology, roughly 80% of cases are in terminal stages at the time of diagnosis, and a large proportion of patients have moderate to severe pain that needs treatment with opioid analgesics. However, consumption of opioid analgesics in the region is low and data suggest that at least 88% of cancer deaths with moderate to severe pain are untreated. Access to essential drugs for pain relief is limited by legal and regulatory restrictions, cultural misperceptions about pain, inadequate training of health-care providers, procurement difficulties, weak health systems, and concerns about diversion, addiction, and misuse. However, recent initiatives characterised by cooperation between national governments and local and international non-governmental organisations are improving access to pain relief. Efforts underway in Uganda, Kenya, and Nigeria provide examples of challenges faced and innovative approaches adopted and form the basis of a proposed framework to improve access to pain relief for patients with cancer across the region.

Oral Morphine Effectiveness in Nigerian Patients With Advanced Cancer

ABSTRACT Oral morphine elixir in the immediate release form became available in Nigeria in the year 2006 after decades of use in the treatment of cancer pain in many other countries. In order to determine the effectiveness of oral morphine in Nigerian patients, 182 patients presenting with severe cancer pain at the Radiotherapy Clinic, University College Hospital (UCH), Ibadan, Nigeria, were recruited in a prospective descriptive observational study. Information on patients demography, diagnosis, baseline intensity and character of pain, morphine dosages, and effects were collected using a semistructured questionnaire administered at recruitment and biweekly in the follow-up period. Mean (+ SD) age of the patients was 47 (+ 14.6) years and the most common types of cancer diagnosed in the study participants included cancer of the breast and uterine cervix. The pretreatment pain intensity score mean (+ SD) was 8.09 (+ 1.51). Of the 166 patients whose data were analyzed, 84.3% (95% confidence interval [CI] 77.8–89.5%) achieved a 3-point reduction in pain intensity using the 11-point Numerical Rating Scale at the end of the first week of treatment. Twenty-six patients (15.7%) required adjuvant therapy. The reduction in pain intensity was maintained throughout the 3 months follow-up period, with the mean 24-hour morphine consumption of 55.54 mg in the first month and 61.54 mg in the third month. Oral morphine significantly reduced cancer pain in Nigerian patients (P < .01). Increasing dose as required was found to enhance the effectiveness of oral morphine.

Telemedicine’s Potential to Support Good Dying in Nigeria: A Qualitative Study

Objectives This qualitative study explores Nigerian health care professionals’ concepts of good dying/a good death and how telemedicine technologies and services would fit the current Nigerian palliative care practice. Materials and Methods Supported by the Centre for Palliative Care Nigeria (CPCN) and the University College Hospital (UCH) in Ibadan, Nigeria, the authors organized three focus groups with Nigerian health care professionals interested in palliative care, unstructured interviews with key role players for palliative care and representatives of telecom companies, and field visits to primary, secondary and tertiary healthcare clinics that provided palliative care. Data analysis consisted of open coding, constant comparison, diagramming of categorizations and relations, and extensive member checks. Results The focus group participants classified good dying into 2 domains: a feeling of completion of the individual life and dying within the community. Reported barriers to palliative care provision were socio-economic consequences of being seriously ill, taboos on dying and being ill, restricted access to adequate medical–technical care, equation of religion with medicine, and the faulty implementation of palliative care policy by government. The addition of telemedicine to Nigeria’s palliative care practice appears problematic, due to irregular bandwidth, poor network coverage, and unstable power supply obstructing interactivity and access to information. However, a tele-education ‘lite’ scenario seemed viable in Nigeria, wherein low-tech educational networks are central that build on non-synchronous online communication. Discussion Nigerian health care professionals’ concepts on good dying/a good death and barriers and opportunities for palliative care provision were, for the greater part, similar to prior findings from other studies in Africa. Information for and education of patient, family, and community are essential to further improve palliative care in Africa. Telemedicine can only help if low-tech solutions are applied that work around network coverage problems by focusing on non-synchronous online communication.

Palliative Care in the Global Setting: ASCO Resource-Stratified Practice Guideline

Purpose The purpose of this new resource-stratified guideline is to provide expert guidance to clinicians and policymakers on implementing palliative care of patients with cancer and their caregivers in resource-constrained settings and is intended to complement the Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update of 2016. Methods ASCO convened a multidisciplinary, multinational panel of experts in medical oncology, family medicine, radiation oncology, hematology/oncology, palliative and/or hospice care, pain and/or symptom management, patient advocacy, public health, and health economics. Guideline development involved a systematic literature review, a modified ADAPTE process, and a formal consensus-based process with the Expert Panel and additional experts (consensus ratings group). Results The systematic review included 48 full-text publications regarding palliative care in resource-constrained settings, along with cost-effectiveness analyses; the evidence for many clinical questions was limited. These provided indirect evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% (by consensus ratings group including Expert Panel). Recommendations The recommendations help define the models of care, staffing requirements, and roles and training needs of team members in a variety of resource settings for palliative care. Recommendations also outline the standards for provision of psychosocial support, spiritual care, and opioid analgesics, which can be particularly challenging and often overlooked in resource-constrained settings. Additional information is available at www.asco.org/resource-stratified-guidelines. It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Analgesic Effects of Intrathecally Administered Fentanyl in Spinal Anaesthesia for Lower Limb Surgery

Abstract Background: Intrathecal opioids as adjuvants to local anaesthetics during spinal anaesthesia have been used to augment the analgesia produced by local anaesthetic agents. The aim of this study is to determine the duration of analgesia following addition of fentanyl to 0.5% hyperbaric bupivacaine during open reduction of lower limb fractures. Material and Methods: This prospective randomized study is comparing the effect of addition of 25μg of fentanyl to 10 mg of 0.5% hyperbaric bupivacaine intrathecally on sixty consecutive ASA I and II patients scheduled to undergo elective open reduction and internal fixation of lower limb fractures (ORIF) at the UCH, Ibadan. The patients were randomized into their either bupivacaine saline (SB n=30) 10 mg (2 ml) 0.5% hyperbaric bupivacaine or bupivacaine-fentanyl combination (FB n= 30) through a 25-guage Whitacre spinal needle. Quality and duration of analgesia as well as any sequelae were recorded. Result: Socio-demographic as well as operating data were comparable between the two groups. Fentanyl provided significantly longer duration of complete (239.97 ± 28.58 vs 129.17 ± 11.61), p<0.001 and effective (276.23 ± 26.21 vs 150.80 ± 10.33) analgesia than bupivacaine alone (p<0.001). The pain intensity (visual analog scale [VAS]) at the time to first post-operative analgesic dose in the Fentanyl-Bupivacaine (FB) groups was significantly lower than in the group BS (p<0.001). Eight of the patients in the control group BS (26.67%) group had hypotension whereas six patients (20%) in FB groups had hypotension that required rapid infusion of crystalloid. There was no statistical difference in the level of shivering in the two groups. No patient in either group developed respiratory insufficiency. Conclusion: Addition of 25 μg of fentanyl to 10 mg of 0.5% hyperbaric bupivacaine intrathecally for open reduction and internal fixation of lower limb fractures significantly prolonged the duration of complete analgesia as well as effective analgesia thereby reducing the need for early postoperative analgesic use without increase in severe adverse effect.