Pain workshop ESMO: Africa (response).

The COVID-19 pandemic is shining a light onto a tragic paradox. Pain, and the suffering people experience as a result of pain, is one of the greatest neglected global health challenges we face while the means to alleviate pain are some of the least costly and most cost effective global health interventions.1

We live in a world where the strategies to manage pain have become more significant than the pain itself, and a world where privilege and postcode is more likely to determine when and how pain is alleviated. The opioid epidemic in the USA has put off kilter a decade of work to establish essential medicines for palliative care.2

European Society for Medical Oncology (ESMO) pain guidelines, developed by an expert working group for non-experts, are relevant in each African country.3

However, these guidelines are only as effective as the capacity within each country for implementation. We will review the barriers and strategies for addressing challenges which are even more pertinent as we reflect on the impact on the COVID-19 pandemic on already stretched health systems.

Much is already known and widely acknowledged about the barriers. Myths, misconceptions and fears about opioids such as morphine remain prevalent among policy makers, healthcare workers and the community. This opiophobia includes beliefs that all morphine use is addictive, that side effects will be dangerous, or that it should only be used for dying patients with cancer. Most healthcare workers are not trained in the safe use of opioids in their basic or in-service training.

Regulatory frameworks and policies for protection and procurement of medicines while offering important systems and protections have created a number of unintended consequences which restrict access to those most in need of pain relief. Limitations on who can prescribe morphine, how many cosignatures are required even when death is close and time-limited, add to lack of robust procurement, insufficient stock, suboptimal storage and absence of any buffer. In many African countries, morphine is only available in major city centre hospitals, or national cancer centres, and not in health centres in rural regions. Patients in severe pain due to illnesses such as cancer may struggle to afford their medications alongside other out of pocket health and travel costs, thus pushing them further into a spiral of debt and poverty.

Strategies

The paper by Krause et al4 puts forward a number of important strategies, including: developing Afrocentric education tools around pain and palliative care; improving communication skills among health care providers, so that essential pain relief can be dispensed accurately and adequately; tackling the misconceptions and misinformation about opioids, through a concerted campaign for improvement in health literacy and essential health information for all.

We suggest that there are additional practical strategies that could be developed. Economies of scale through regional procurement, as has been developed for other medications, could create a pan-Africa platform for investing in palliative care and pain relief. This may allow a range of affordable formulations that allow for cost-effective procurement and distribution, as well as flexibility, for patient use. Rigorous, protective yet flexible systems for monitoring opioid distribution, such as using mobile phone technology, could create linkages which can support procurement and match supply and prescriber availability to patients.

Although there remain many challenges, much has been accomplished across the African continent by palliative care and hospice services supported by many pioneering national palliative care associations. The works of the pan-African Palliative Care Association (APCA), the International Association for Hospice and Palliative Care (IAHPC) and the International Children’s Palliative Care Network (ICPCN), have drawn together excellent resources to support services and build adequate pain relief at national levels. The WHO Planning and Implementing Palliative Care services published research conducted by the University of Edinburgh and Makerere University in their Integrate project (funded by a Tropical Health Education Trust and the UK’s Department of International Development), which set out templates to show how these implementation strategies can be integrated into health systems.5 6

Renee and colleagues note that ESMO is committed to assisting in achieving better care for patients with cancer in Africa, through the ESMO Designated Centre of Integrated Oncology and Palliative Care, and they ask for high-level advocacy to enforce regulations that monitor and evaluate morphine availability and palliative care training. With this vital ‘pan-African public healthcare initiative’, we would also suggest that a monitoring consortium to track and analyse policy, health system, socioeconomic and political responses to access and delivery of the guidelines through the journal is established.

Palliative care and pain management is being redefined in the current era taking account of global developments.7 Coming back to the current challenges of COVID-19, it is even more poignant to note the role opioids, such as morphine, have in the management of refractory breathlessness and the implications of the current challenges in access, ‘In this most challenging time, health responders can take advantage of palliative care know-how to focus on compassionate care and dignity, provide rational access to essential opioid medicines, and mitigate social isolation at the end of life and caregiver distress’.8

However, the global supply chains are being disrupted further, and it is conceivable that the existing procurement processes for opioids may become unaffordable or even, unavailable. If ever there was a time for global solidarity and for ensuring palliative care is integrated into health and education systems alongside community empowerment and compassionate, holistic, dignified care for those in pain and at the end of life, that time has come.

Suffering and our response to suffering is a fundamental part of our humanity. We lose a part of ourselves when we fail to respond to suffering, and even more so when relatively cheap but highly effective solutions exist. We need to understand the granular detail of the barriers in each African country, which prevent access to opioids. Using evidence along with local knowledge and cooperation, we should together build a system which will not fail those who are suffering from pain.