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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 29  |  Issue : 2  |  Page : 197-202

Analgesia Self-Medication practice and pentazocine dependency in adult sickle cell patients in Southeast Nigeria


1 Department of Haematology and Immunology, UNTH/Departmant of Haematoogy, AEFUTHA, Abakaliki, Nigeria
2 Department of Community Medicine, College of Medicine, Enugu Campus, Enugu State, Nigeria

Date of Submission01-Feb-2020
Date of Decision09-Feb-2020
Date of Acceptance16-Feb-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Omotowo Ishola Babatunde
Department of Community Medicine, College of Medicine, University of Nigeria, Enugu Campus, Enugu State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_1_20

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  Abstract 


Background: Painful crisis is a debilitating hallmark characteristic feature of sickle cell disease (SCD). Analgesia medication is the standard of care. Self-medication is becoming a quick fix for pain resolution for persons living with SCD. The aim of this study was to evaluate analgesia self-medication practice and pentazocine dependency among adult sickle cell patients. Methods: A descriptive cross-sectional study was conducted among 111 adults with SCD attending sickle cell clinic at the University of Nigeria Teaching Hospital (UNTH) Ituku Ozalla Enugu and Alex Ekwueme Federal University Teaching Hospital Abakiliki (AEFUTHA) Ebonyi. Data were analyzed using SPSS version 22. A P < 0.05 was considered statistically significant. Results: The proportion of adults SCD participants in the study was 45.4% from UNTH Enugu and 54.6% from AEFUTHA Ebonyi. The proportion of male and female who self-medicated was 61.5% and 38.5%, respectively. The prevalence of analgesic self-medication was found to be 28.8%. Analgesics most and least frequently self-administered were paracetamol 50.5% and morphine 0.9% most reported reason for self-medication was “treatment delays in hospital” 73%. Dependency to pentazocine was 22.5%. Age was a significant predictor of self-medication among adult SCD patients. Conclusion: This study shows high prevalence of self-medication and dependency to pentazocine. There should be strict regulation on the use of pentazocine.

Keywords: Analgesia, pentazocine dependency, self-medication, sickle cell disease


How to cite this article:
Nwagha T, Babatunde OI. Analgesia Self-Medication practice and pentazocine dependency in adult sickle cell patients in Southeast Nigeria. Niger J Med 2020;29:197-202

How to cite this URL:
Nwagha T, Babatunde OI. Analgesia Self-Medication practice and pentazocine dependency in adult sickle cell patients in Southeast Nigeria. Niger J Med [serial online] 2020 [cited 2020 Oct 1];29:197-202. Available from: http://www.njmonline.org/text.asp?2020/29/2/197/287915




  Introduction Top


Sickle cell disease (SCD) is a chronic multisystem disorder characterized by episodic acute painful crisis, an insignia of SCD. Urgent resolution of painful episodes is critical to prevent frequent hospital admission, school, work absenteeism, and reduction in the quality of life of persons with SCD. Pain medications like opioids are commonly prescribed, especially for severe pain.[1] According to an American “survey” painful crisis in SCD was the highest indication of hospital readmission with a significant contribution to overall cost of hospital stay.[2] Opioids analgesia is the mainstay in pain management in SCD,[3],[4] and in Nigeria, pentazocine is the main opioids prescribed for the treatment of painful crisis in sickle cell painful crises.[4],[5] Its limited dysphoric and euphoric effect makes it a favorite among clinicians.[6] The downside of prescribing pentazocine is the side effects of opioids; dependency and addiction. The burden of opioid dependency and addiction is increasing among adult sickle cell patient population. It negatively impacts on overall pain management in SCD.

Self-medication, which is the use of nonprescription medications under an individual's own initiative is exceedingly common in persons with chronic disease like SCD.[7],[8] Studies show that adults with SCD often lack self-efficacy, positive coping responses, self-care management skills, and the ability to adhere to treatment regimen, or skills required for independent and/or supportive living related to such neurocognitive deficiencies possibly due to brain necrosis[9],[10],[11] These may encourage self-medicating practice in persons with SCD and in resource-limited settings, out of pocket expenses which is the major source of health care funding is also contributory.

There have been numerous case reports of analgesia self-medication pentazocine dependency and addiction among Nigerians living with SCD[5],[12],[13],[14] In this era of the global opioid crisis,[15] there are growing concerns of the vulnerability of the SCD population to this opioid abuse, especially in resource-limited settings like Nigeria. This will certainly set back the advances made in pain management of SCD and create additional burden to a disease already characterized by reduced health-related quality of life, substantial morbidity, and mortality. With growing reports of pentazocine abuse, findings from a recent study are questioning the continual use of pentazocine and its efficacy in pain management in SCD as patients who were treated with pentazocine fared worse than other who received other treatments.[16]

This study aimed to assess the self-medication practice and prevalence of pentazocine dependency in Nigerian adult sickle cell patients. This would contribute data to the extent of the crisis within the sickle cell population as well as for the special attention of policymakers and health-care professionals to protect the sickle cell population from the opioid addiction crisis in our settings.


  Methods Top


Study area

This study was conducted between November 2017 and August 2018. Adult sickle cell patients attending sickle cell clinic at outpatient sickle cell clinics of Sickle cell center Alex Ekwueme Federal University Teaching Hospital (AEFUTH) Abakiliki and University of Nigeria Teaching Hospital (UNTH) Ituku-Ozalla, Enugu were recruited for this study. Both were tertiary health facilities with patients referred from other health-care facilities in southeast Nigeria.

Study design and patients selection

This was a cross-sectional study of 111 adults with SCD. These cohort of patients were approached by their hematologist during the consultation in hematology outpatient sickle cell clinics of both centers. Inclusion criteria: (1) SCD patients; (2) age ≥18 years at the time of the interview. Exclusion criteria: (1) patients without SCD; (2) SCD patients age <18 years.

Study tool

A pre-tested self-administered, closed-ended instrument, pre-validated for use in adults with SCD was used. It consisted of 23 items representing self-medication practice and the presence of pentazocine dependency with a Cronbach alpha of 0.90. Sociodemographic, disease characteristics variables, and information on the pattern of self-medicated analgesic use and steroid dependency were collected. Outcome variables were the pattern of self-medication and presence of pentazocine dependency.

Statistical analysis

Data collected were analyzed using SPSS version 22 (SPSS Inc., Chicago, Illinois, USA). Descriptive analysis was expressed as percentages. Fisher's exact test was used to establish between association sociodemographic variables and self-medication practice and pentazocine dependency. Regression analysis was performed to establish possible predictors. Statistical significance assessed using P values and 95% confidence intervals. We considered P < 0.05 statistically significant in the statistical analysis.

Ethical clearance

The study was approved by the Institution research ethics committee of UNTH and AEFUTH. Patients were informed about the study and signed an informed consent form after acceptance to participate.


  Results Top


Sociodemographic characteristics of the respondents

A total of 111 survey participants returned questionnaires giving 100% response rate. Most patients were female 60.4%, and majority of them were below the age of 30 years with a mean age of 22.4 ± 3.6 years. In respect to occupation, 62.2% were students, whereas teachers were 4.5%. Majority had sickle cell anemia (SS), while avascular necrosis was the most frequent complication 45.2% [Table 1].
Table 1: Sociodemographic characteristics of the respondents (n=111)

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Analgesic medications used during painful crisis

Majority of participants 54.9% reported they received both oral and parenteral analgesic formulations during acute painful episodes. The analgesic most frequently administered was paracetamol 54.1% and the least administered was morphine 4.5%. Pentazocine was the most frequently administered parenteral analgesic 41.4% [Table 2].[10] Most participants procured these drugs through out-of-pocket expenses [Table 3]. Only 28.8% reported they self-medicated with hospital delays before the commencement of treatment being the most frequent reason for self-medication [Table 3].
Table 2: Participants analgesic use during crisis (n=111)

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Table 3: Participants report on procurement of self-medicated analgesic drugs (n=111)

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Self-medication practice and pentazocine dependency [Table 4]
Table 4: Participants practice of self.medication and pentazocine dependency (n=111)

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The most frequent self-medicated oral analgesic is paracetamol group 50.5% and pentazocine is the most frequently self-medicated parenteral analgesic agent. The least self-medicated agent was morphine 0.9% and 22.5% of the participants reported to have pentazocine dependency even when they were not having painful crisis. Almost all 98.2% procured pentazocine over the counter (OTC).

Factors associated with self-medication practice and pentazocine dependency of participants

[Table 5] shows relationship between sociodemographic characteristics and self medication practice and pentazocine dependency of participants. We found that the occupation of participants was significantly associated with pentazocine dependency with P < 0.001.
Table 5: Relationship between sociodemographics and self.medication practice and pentazocine dependency of participants (n=111)

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  Discussion Top


We found out the prevalence of analgesia self-medication and pentazocine dependency was high among sickle cell patients in Southeast Nigeria. Majority of the participants were between the age of 20–30 years, this is similar to another study conducted in Nigeria by Nazuaye and Uwadiae where the participants were between 18 and 30 years.[14] Majority of participants in this study were females, and more than half were students. These findings too are similar to some studies conducted by Makanjuola and Nazuaye where the largest participants were students.[5],[14] This is different from another study conducted in Benin City where the median age of participants was 32 years.[4]

Our study revealed that paracetamol (50.5%) was the most frequently self-medicated by adults with SCD than some other analgesics. The findings could be due to the cost of other opioid drugs that are more expensive than paracetamol. It could also be a reason why it was reported that many adults with SCD were inadequately treated.[5],[15] This study revealed that above average 58.6% had 0–3 painful crisis per year. This result is different as 0.8 painful episodes per year was reported in other studies.[15],[17] The study revealed that most of the participants 94.6% procured drugs by out-of-pocket expense, and 28.8% were through self-medication. This would confirm the suspicion that many pharmacies and chemists sell drugs to patients without prescription. Hospital delays before the commencement of treatment was a reason for self-medication. Prompt treatment of patients could bring a reduction to self-medication by analgesics for painful crisis. Furthermore, standard necessary treatment procedure for health-care providers will possibly reduce hospital delays.

In this study, pentazocine was the most used parenteral analgesic agent. This could be because pentazocine normally reduces painful crisis better than paracetamol. We also found out that the majority of participants who had pentazocine dependency bought drugs OTC in patent chemist shops. This is similar to another study that reported easy access to the drug over the pharmacy, chemist shops, and other retail medicine outlets in the country.[14] This showed that there is either no policy or enforcement of laws regulating procurement of drugs by patients. It was reported in another study that pentazocine is a less dependence producing analgesic compared with morphine.[5] Another study reported that they could get the drugs by obtaining analgesic prescription from multiple sources, and sharing analgesics between patients in hospital.[12] In the assessment of factors associated with self-medication and pentazocine dependency, we found no significant relationship between sociodemographic characteristics and self-medication practices, but the occupation was statistically associated with pentazocine dependence.

The prevalence of analgesia self-medication was 28.8% and higher among males 61.5% than females 38.5% in our study. It is similar to the report in some studies.[14],[15],[16] Pentazocine dependency among those who self-medicated was 22.5%. The result from our study is supported by some studies which stated that drug dependency resulting from self-medication to treat sickle cell crisis was more than 20%,[14],[15] but it is higher than 17% opioid-dependent found in another study by Sagir et al. in Northern Nigeria.[18] Some patients who were addicted to analgesics reported frequent disappointment while in the emergency room.[3],[13],[15] Health professionals should have sufficient understanding of SCD and ensure proper analgesic administration to reduce morbidity, complications, and low quality of life associated with painful episodes.[14] It was reported that pain management in SCD should rely on bed rest, fluid hydration, and administration of opioid analgesics according to the pain intensity.[14]


  Conclusion and Recommendations Top


This study shows a high prevalence of self-medication and dependency on pentazocine facilitated by high hospital delays in the management of painful bone crises. Furthermore, there is the high purchase of pentazocine OTC in patent chemist shops. There is a need to reduce hospital delays with stricter regulation surveillance and monitoring of accessibility of opioids analgesics like pentazocine. There should be better legislation with enforcement against indiscriminate sales of opioid drugs without doctor prescriptions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rees DC, Olujohungbe AD, Parker NE, Stephens AD, Telfer P, Wright J, et al. Guidelines for the management of the acute painful crisis in sickle cell disease. Br J Haematol 2003;120:744-52.  Back to cited text no. 1
    
2.
Beyers CM. Self-Medication Practices of Adults with Sickle Cell Disease: Design and Methodology: Honors Scholar Theses; 2013. p. 323. Availablefrom: http://digitalcommons.uconn.edu/srhonors_theses/323. [Last accessed on 2013 Mar 05].  Back to cited text no. 2
    
3.
Armiya'u AY, Garba BI, Haliru DG. Intravenous pentazocine dependence in a young sickle cell anemia patient: A case report. Case Rep Int 2016;5:1-4.  Back to cited text no. 3
    
4.
Adewoyin A, Adeyemi O, Davies N, Ojo M. Clinical and socio-demographic determinants of pentazocine misuse among patients with sickle cell disease, Benin City, Nigeria: A case-control study. Pan Afr Med J 2019;34:88.  Back to cited text no. 4
    
5.
Makanjuola AB, Olatunji PO. Pentazocine abuse in sickle cell anaemia patients: A report of two cases vignettes. Afr J Drug Alcohol Stud 2009;8:59-64.  Back to cited text no. 5
    
6.
Lang DW, Pilon RN. Naloxone reversal of morphine-induced biliary colic. Anesth Analg 1980;59:619-20.  Back to cited text no. 6
    
7.
Paula Martins A, da Costa Miranda A, Mendes Z, Soares A, Ferreira P, Nogueira A. Self-medication in a Portuguese urban population: A prevalence study. Pharmacoepidemiolo Drug Saf 2002;11:409-414.  Back to cited text no. 7
    
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Alford DP, German JS, Samet JH, Cheng DM, Lloyd-Travaglini CA, Saitz R. Primary care patients with drug use report chronic pain and self-medicate with alcohol and other drugs. J Gen Intern Med 2016;31:486-91.  Back to cited text no. 8
    
9.
Jenerette CM, Brewer C. Health-related stigma in young adults with sickle cell disease. J Natl Med Assoc 2010;102:1050-5.  Back to cited text no. 9
    
10.
Jenerette CM, Phillips RC. An examination of differences in intrapersonal resources, self-care management, and health outcomes in older and younger adults with sickle cell disease. South Online J Nurs Res 2006;7:1-24. Available from: www.sciepub.com. [Last retrieved on 2012 Jan 03].  Back to cited text no. 10
    
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Jenerette CM, Valrie CR. The influence of maternal behaviors during childhood on self-efficacy in individuals with sickle cell disease. J Fam Nurs 2010;16:422-34.  Back to cited text no. 11
    
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Kotila TR, Busari OE, Makanjuola V, Eyelade OR. Addiction or pseudoaddiction in sickle cell disease patients: Time to decide – A case series. Ann Ib Postgrad Med 2015;13:44-7.  Back to cited text no. 12
    
13.
Onyencho VC, Pindar SK, Mshelia AA, Ibrahim AW, Wakil AM, Balogun AG. A report of personality disposition and pentazocine abuse in sickle cell anaemia patients: A report of two cases. Pyrex J Med Med Sci 2016;3:1-4.  Back to cited text no. 13
    
14.
Nazuaye GN, Uwadiae E. Pentazocine dependence among sickle cell disease patients attending out patient specialist sickle cell clinic in Benin city, Nigeria. Nigerian J Pschiatry 2016;14:1-7.  Back to cited text no. 14
    
15.
Alao AO, Westmoreland N, Jindal S. Drug addiction in sickle cell disease: Case report. Int J Psychiatry Med 2003;33:97-101.  Back to cited text no. 15
    
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Pasquale N, Francesco S, Laura S, Paolo DF, Paolo C. Pain syndromes in sickle cell disease: An update. Pain Med 2009;10:470-80.  Back to cited text no. 16
    
17.
Platt OS, Thorington BD, Brambilla DJ, Milner PF, Rosse WF, Vichinsky E, et al. Pain in sickle cell disease. Rates and risk factors. N Engl J Med 1991;325:11-6.  Back to cited text no. 17
    
18.
Sagir GA, Umma AI, Modu BK. Opioid dependence among people with haemophilia in a low-resource tropical setting. Prevalence and risk factors in northern Nigeria. J Haem Pract 2019;6:19-28.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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