Calling for advocacy, education and public policy actions on pain control for patients with cancer in Africa.

It is of serious concern that there is a lack of focus on pain management in patients with cancer in Africa. Most patients with cancer present with advanced disease on diagnosis, experiencing moderate to severe pain and in need of palliative care. Integration of palliative and oncology care is recommended by European Society of Medical Oncology (ESMO) and by the World Health Assembly resolution WHA67.19.

At the recent ESMO Summit Africa 2020, a Pain Workshop was attended by representatives from across Africa. A consensus was reached to escalate concerns about lack of pain management in patients with cancer in Africa and to call on ESMO to make universal cancer pain control, and int egrated oncology and palliative care as an immediate priority area. Many developed countries are concerned about the overuse of opioids. However, in Africa, opioid consumption has decreased during the last decade from a low level below the global average to a totally inadequate level.1 This problem is confounded by an increase in the incidence of cancer, the advanced stage presentation of patients with cancer, few radiotherapy machines for cancer treatment and the quadruple burden of disease in Africa.2 The group agreed that pain management and palliative care are closely related and that the integration of universal access to pain control requires universal access to palliative care.

The ESMO pain guidelines and the African Palliative Care Association’s recommendation state that oral morphine remains the opioid of choice for patients with cancer with moderate to severe pain.3 4 Addressing barriers to implementing these guidelines require a strong advocacy and strong partnerships. Identified barriers are the inability of healthcare workers to assess, prescribe and communicate pain management details to patients and families. There are still many oncologists across Africa who have received little or no training in palliative care although this training for oncologists is advised by the WHA67.19 resolution on palliative care.5 Misconceptions regarding palliative care and morphine use are still very common in African society. This may be driven by western propaganda around opioid phobia where there is a focus on stricter control measures due to opioid abuse.6

Afrocentric education on pain and palliative care and communication skills among healthcare providers can overcome these misconceptions. There are also misconceptions among policymakers which feed into regulatory obstacles in the procurement and distribution of opioids; thus, resulting in minimal prescribing of opioids. These regulations include limitations on who can prescribe, where the morphine is available, and the time interval that it can be administered. We are aware that opioids are mainly being prescribed in cancer centres only, by oncologists, for short periods of time, making access to opioids at primary care and in remote areas impossible. In order to get opioids at the right level of care, being dispensed in a safe and effective manner requires integrated and aligned policies, laws, education and advocacy. Uganda overcame these obstacles by importing morphine powder for local reconstitution and enabling nurse prescribing. Universal access to opioids is recommended strongly by the WHO, the United Nations, the European Association of Palliative Care and the International Association of Hospice and Palliative Care among others and this workshop calls for action to be taken to realise improved access.5 7 8

Training of healthcare workers in pain management and palliative care should be mandatory for all healthcare professionals in Africa, caring for patients with cancer across the continuum of care. In order to reach these goals, palliative care education needs to be monitored and evaluated at a national level and become a health indicator.

Morphine is an effective, inexpensive medication recognised as the gold standard for control of severe pain.3 The cost of a morphine should be regulated; thus, not leaving patients nor their families impoverished to obtain pain control nor palliative care.

A pan-African public health initiative is needed. ESMO has committed to assist in achieving better care for patients with cancer in Africa through the ESMO Designated Centre of Integrated Oncology and Palliative.9 We also ask for high-level advocacy to enforce regulations that monitor and evaluate morphine availability and palliative care training. These are simple, achievable, low cost and high benefit interventions which will benefit patients with cancer and their families.