Page 284 Guide to Pain Management in Low-Resource Settings

272 Andreas Kopf

intrathecal catheters (for vertebral metastases where Shehu had been instructed carefully, so that he was pa-
pain at rest is well controlled with opioids but pain on tient enough to wait for nausea (and sedation) to wean
weight bearing is unbearable or only bearable with opi- off after a week’s time. In the educational part of the of-
oid doses that cause intolerable side eff ects). fi ce visits, family members were included to discuss the
patient’s wish to stay in Filipoje and his personal attitude
Mr. Shehu’s treatment toward coping with the disease and its symptoms, fi nding
Due to transportation problems and a long waiting list personal strength in the words of his savior at St. Bar-
for treatment in Tirana, Dr. Frasheri decided to treat Mr. tholomew’s church.
Shehu symptomatically at home. In Filipoje, he found
a used walking stick and an elastic bandage, which How did Dr. Frasheri and Mr. Shehu fi nd the
optimum dose of morphine?
helped with ambulation. Diclofenac was available in lo-
cal pharmacies, but Dr. Frasheri decided to advise Mr. Since Mr. Shehu was opioid-naive, meaning he had
Shehu to use paracetamol (acetaminophen) instead, no prior experience with opioids, of advanced age, and
since he was not sure about kidney function and it was with unpredictable cancer pain intensity, the method of
foreseeable that the need for analgesic therapy would be choice is titration by the patient. Th is means that after
long-lasting. When Mr. Shehu received piroxicam from careful explanation of the pros and cons of morphine,
the Catholic mission, he also started taking it orally. It Mr. Shehu was provided with morphine solution (2%),
was pure luck that Dr. Frasheri found out about the pa- which could be locally produced by the pharmacist. Mr.
tient taking piroxicam. He stopped this medication and Shehu was told, with the help of his oldest son Sali, to
explained to Mr. Shehu that the drug had a number of take 10 drops (ca. 10 mg) of morphine as needed, always
negative prognostic factors for renal and gastrointestinal waiting for at least 30 minutes after the previous dose,
side eff ects: old age, prolonged medication, accumula- and was told to always write down the time he took ex-
tion of piroxicam because of a long half-life, among other tra medication. After two days, Mr. Shehu and his son
problems. Mr. Shehu was not satisfi ed with the pain re- were told to come back to Dr. Frasheri, and together
duction from the paracetamol, since he needed to make they looked over the list. It came out that on average ev-
his way to and from the church daily, although when sit- ery second hour a dose was required, more in the day-
ting or lying down the pain intensity was acceptable. So time and less in the night. To accomplish stable—and
he insisted at Dr. Frasheri’s offi ce that he needed some- more tolerable—blood levels of morphine, Dr. Frash-
thing else. eri then advised Mr. Shehu to take 30 mg of morphine
At fi rst, Dr. Frasheri was reluctant to prescribe regularly every 4 hours, since no slow-release version
opioids, because they are not easy available in Albania. of morphine was available. Of course, Dr. Frasheri did
Th e per-capita amount of morphine and pethidine has not forget to allow Mr. Shehu to take—as needed—ex-
been almost unchanged since the time of Enver Hoxha’s tra doses of 10 mg (roughly 10% of the daily cumulative
dictatorship (1970–1980s), and Albania had never dose). If Mr. Shehu did not need extra doses, the basic
signed the Single Convention from 1961. Only recently q.i.d. (four times daily) dose would be slightly reduced,
have prescriptions of fentanyl (mainly for surgery) and e.g., to 20 mg q.i.d.; if he needed 1–4 extra doses the
methadone (mainly for opioid substitution) increased. prescription would stay unchanged; and if the extra dos-
Nevertheless, morphine could be obtained—with dif- es would exceed 4 per day, the basic q.i.d. dose would
fi culty. After a lot of education on the pros and cons of be increased (e.g., with 6 extra doses per day equal to 60
morphine (Mr. Shehu was quite sceptical about taking mg, the regular dose of 30 mg q.i.d. would be increased
it), Mr. Shehu was started on morphine, starting with 10 to 40 mg q.i.d.). Th e same procedure of titration was
mg b.i.d. and gradually increasing the dose over several used for the time so that the balance between analgesia
days. When he found out about the positive eff ects (es- and side eff ects was to the benefi t of Mr. Shehu.
pecially on walking and standing), Mr. Shehu no longer
In conclusion, what should be done?
raised any objections. His steady-state dose was 30 mg
morphine sulfate q.i.d. Activity, drinking an extra liter 1) General:
of water, the healthy Mediterranean diet, and milk sug- i) Patients should not be deprived of the benefi ts
ar helped against constipation, but nausea could not be of analgesia just because they are elderly.
avoided due to the lack of metoclopramide. However, Mr. ii) Include relatives.