In the U.S., the opioid crisis is about too many opioids. In some other parts of the world, the opioid problem is about the exact opposite — a lack of access to powerful pain management drugs. As pharmaceutical companies are being sued in the U.S. for flooding the market with opioids, doctors in West Africa say they can't even get hold of those painkillers.
When prescribed appropriately, opioids can be vital tools in hospitals and clinics. The drugs make patients more comfortable and can speed recovery.
At Gambia's only teaching hospital, Dr. Kebba Marenah says managing pain is part of the challenge of practicing medicine in Gambia.
"I think most of the things we do here orthopedic-wise cause pain," says the 37-year-old orthopedic surgeon.
Marenah is prepping to oversee two operations in the surgical theater. He's pulling on scrubs.
"When you deal with the bones, there's lot of pain receptors," he says. "If you've ever seen orthopedic surgeons, we are always holding hammers and saws and drills and things like that. So afterward, all the patients are expected to have some amount of pain. You have to try and mitigate that in some way, but it's difficult sometimes."
It's particularly difficult in places like Gambia — for several reasons.
Gambia is one of the world's poorest countries. Per capita income, according to the World Bank, is less than $1,000 per person per year.
Various medications, including painkillers, are often in short supply at public clinics in the country. Marenah is Gambian but recently worked for more than a decade as an orthopedic surgeon in the United Kingdom. He saw how effective morphine, hydrocodone and other opioids were in managing pain in Europe. But he doesn't have regular access to them in Gambia.
"There's lots of shortages here," the doctor says. "Shortages of medications. Shortages of staff. Even space. We don't have a dedicated space to deal with patients after an operation."
Most women who give birth in public clinics in Gambia get no pain medication — no epidural, no anesthesia, no nitrous oxide gas. The only exception is if the midwife has to do an episiotomy. She'll use a local anesthetic before making the cut.
Even after major surgery, the common treatments for pain are similar to what many Americans have in their medicine cabinets for routine headaches — acetaminophen, aspirin and ibuprofen.
Marenah says there's a lot of postoperative screaming in the wards, particularly among children.
"I remember when I first turned up, I'd have to leave the ward when they were doing dressings because I couldn't handle the screams," he says. "But you get used to it, which isn't great. But it's what you have to do to survive in this environment."
Two tough surgeries
One day this summer, the operating theater has been divided in half with a screen so Marenah can supervise two surgeries at the same time. On the left is a 14-year-old who fractured his knee in a soccer game after colliding with a goalie. His parents say he was just about to score. On the right is a 29-year-old man who was in a nasty car crash a week earlier; his tibia is now protruding from his shin.
Both patients are given spinal anesthetics. It makes their legs go numb.
The teenager at one point asks, "What's my leg doing up there?" as the nurses prep him for the operation. Eventually they put up a sheet so he can't see the pins, drills and pliers that Marenah will be wielding. On the right side of the room, the car crash patient will have a steel pin driven vertically into his leg to stabilize his tibia.
Pain is unavoidable in operations like these, says Marenah.
In the U.K., he notes, both these patients would be completely asleep under general anesthesia. But not in Gambia.
Too few anesthesiologists
Momodou Mousa Baro, the head of the College of Nursing at American International University West Africa, says one of the reasons general anesthesia is used sparingly is a lack of anesthesiologists.
"Ninety-eight percent of anesthesia services are done by nurses," Baro says. "Right across the country in all health facilities where operations take place, what you find are nurse anesthetists." The only anesthesiologists working in Gambia are doctors on loan from China or Cuba.
Gambia's specially trained nurses can do many of the procedures that an anesthesiologist would. But there aren't many of these nurses, and they tend to work mainly in operating rooms.
They also aren't present in labor and delivery wards.
"Pain management in obstetrics is nonexistent here," says Musa Marene, an OB-GYN at the hospital. Women in labor, he says, are "expecting a lot of pain."
Baro adds, "In the Gambia, we do not even do epidurals, because they're expensive."
It's not that there's no pain medication at all in Gambia. The most common analgesic is paracetamol, also known as acetaminophen and sold under the brand name Tylenol in the United States. There's also aspirin and ibuprofen, aka Advil.
But the only narcotic pain medication that clinicians can regularly access is tramadol — a relatively mild synthetic opioid. Tramadol was only recently reclassified as a controlled substance in the U.S., meaning a prescription is needed to buy it. The Drug Enforcement Administration now lists tramadol as a Schedule IV drug, two rungs down from powerful (and highly addictive) Schedule II opioids like Vicodin, OxyContin and fentanyl.
Back in the surgical ward, Marenah has just finished resetting the bones in the 14-year-old's knee. Marenah had to fairly aggressively twist the leg back into place. Then he drilled three holes through the boy's knee and secured the joint with wires.
"So I didn't have to really open the skin at all, but it still will be painful," Marenah says as nurses wrap the boy's leg. "Because I think you saw how I had to bend it back into place at the start. So he will be sore."
If Marenah had been doing this operation in England, not only would the teen have been unconscious, but a local anesthetic would have been administered around the joint to ease the pain as he woke up.
The extra injection of local anesthetic "is not standard practice here," Marenah says. Plus, "it's a bit difficult to get sometimes."
Meanwhile, the operation on the other table is continuing.
An orthopedic surgeon from China is hammering the rod into the 29-year-old's leg. The first couple of attempts didn't go so well, and they've had to back out the pin and try again.
But Marenah is confident.
He says these pins can work incredibly well.
"So when we did these in the U.K., the following day they were up and walking," he says. "And they usually went home the next day."
Patients who had a broken leg one day were walking out onto the streets of London the next, he says. But they were walking only because their pain was well controlled with a combination of an anti-inflammatory drug such as ibuprofen, paracetamol and a powerful opioid such as dihydrocodeine or even oxycodone.
Marenah says this man won't be walking out of the hospital tomorrow. The patient is already clearly uncomfortable. As the hammering continues, he grips the operating table and starts taking deep breaths.
Marenah says the man won't be in too much pain in the first few hours after leaving the operating room because his legs will still be numb from the spinal anesthetic.
But "when that wears off in about six hours' time, then there's usually some screaming on the wards," Marenah says. "It just takes some getting used to for the patient and the staff as well. Even the following day they're usually very ginger and tentative to get up because of course they haven't got the pain relief that they need."
Marenah says it will probably be several days, maybe even a week, before the patient can put any weight on his leg, but eventually he'll recover and should regain full use of this leg.
Baro, of American International University West Africa, says pain relief is even more critical after surgeries on the chest or abdomen.
The fear is the patient won't breathe well, Baro says. "And that causes the patient to lie down without breathing deeply, reducing the amount of oxygen he's taking in. The other thing is there is a tendency of patients not moving about, being bedridden, which could [put the patient at greater risk of] pneumonia, which could be killing. So due to all these things, proper pain relief has a lot to do with quick patient recovery."
Potholed road trip
For the 14-year-old who just had knee surgery, the start of his recovery is a trip on a gurney to the pediatric ward. Not only is the pediatric ward across the hospital compound — it's actually in another building across a busy street.
There are no rails on the gurney, and the teenager slides around on the flat steel platform as the orderly pushes him through the potholed street.
Finally he arrives at the crowded kids' ward. His legs are still numb from the anesthetic during surgery.
His father, Hassan Emmanuel Kamara, says the family knows that the boy's recovery will take time.
"We are a family," he says. "We just try to support him as much as possible."
Kamara is a pastor and a teacher, which he describes as really a volunteer position. He says he hopes the hospital will be able to give his son pain medication but if not he'll try to buy it at a pharmacy.
"It is not easy, but we'll try our best to raise money to buy medication that he may need."
Standing just outside the crowded pediatric ward, Kamara sums up pain management in Gambia — families do the best with what they've got, and sometimes that means bearing the pain.
Marenah, the orthopedic surgeon, wishes he could do more to make Kamara's son more comfortable.
This teen will be hurting for the next few days. But despite that, Marenah says, this operation was a success.
RACHEL MARTIN, HOST:
All right. Here in the United States, too much access to opioids has led to rampant addiction and overdose. But we're going to hear now from a part of the world facing the exact opposite problem - a lack of powerful pain medications. In the Gambia in West Africa, doctors want greater access to opioids. They say they can help speed a patient's recovery. NPR's Jason Beaubien traveled there recently as part of our ongoing look at treating pain. And a note - this story does contain some uncomfortable medical details.
JASON BEAUBIEN, BYLINE: It's mid-morning at the Gambia's only teaching hospital. Orthopedic surgeon Kebba Marenah is talking with several nurses about two operations that they're about to start.
KEBBA MARENAH: You can just put a wire just to bring it in to the right place. It's not going to be perfect.
BEAUBIEN: Marenah is a fit 37-year-old. He's pulling on scrubs. He and his staff are looking up at X-rays of leg bones on a lightbox on the wall. A curtain divides the operating room in two. On the left is a 14-year-old. He fractured his knee in a soccer game in a collision with a goalie. His parents say he almost scored. On the right is a 29-year-old man. He was in a nasty car crash a week earlier, and his tibia is now protruding from his shin. Dr. Marenah says, in operations like these, pain is unavoidable.
MARENAH: If you've ever seen an orthopedic surgeon, we are always holding hammers and saws and drills and things like that. So afterwards, all the patients are expected to have some amount of pain.
BEAUBIEN: But in the Gambia, managing that pain can be difficult. First, the Gambia is one of the poorest countries in the world. Many medications, including painkillers, are in short supply. And even if Marenah can get powerful opioids for his patients, nurses on the general wards aren't trained to administer or monitor them. Dr. Marenah spent the last 13 years working in the United Kingdom. He says one of the striking things about returning home is the contrast in pain management.
MARENAH: I remember when I first turned up, I’d have to leave the ward when they were doing dressings because I couldn’t handle the screams. But you get used to it, which is not great, but it’s what you have to do to survive in the environment.
BEAUBIEN: In the operating room, Dr. Marenah does have access to anesthesia. For the two surgeries on this day, each patient will get a spinal block. It makes their legs go numb. It's highly effective. At one point, the 14-year-old asks - what's my leg doing up there? - as a nurse moves him around on the bed. The patient on the right is getting a steel pin driven vertically from his knee to almost his ankle to stabilize his broken tibia. In the U.K., both these patients would be completely asleep under general anesthesia - but not here. That's partly because this country of 2 million people doesn't have any anesthesiologists. The only ones working in the Gambia are doctors on loan from China or Cuba.
MOMODOU MOUSA BARO: So 98% of anesthesia services are done by nurses.
BEAUBIEN: Momodou Mousa Baro heads the College of Nursing at the American International University West Africa in the Gambian capital.
BARO: Right across the country in all health facilities where operations take place, what you find there are nurse anesthetists.
BEAUBIEN: These specially trained nurses can do many of the procedures that a full anesthesiologist would. But there aren't many of them, and they tend to work mainly in surgical operating rooms. They aren't present in labor and delivery wards, leaving most women here to give birth with no pain medication at all.
MARENAH: We're finished now. Do you want to see?
BEAUBIEN: Back at the surgical ward, Dr. Marenah just finished resetting the bones in the teenager's knee. He twisted the leg back into place, drilled three holes through the top of the knee and secured the joint with wires.
MARENAH: So we didn't have to really open the skin at all. But it still will be painful because, I think, you saw how I had to bend it back into place at the start. So he will be sore afterwards.
BEAUBIEN: If Marenah had been doing this operation in England, the boy would have gotten a local anesthetic around the joint to ease the pain as he wakes up - but, again, not here. The pain meds that are readily available in the Gambia are generic versions of Tylenol and Advil and aspirin. The only narcotic that clinicians sometimes dispense is a synthetic opioid called Tramadol. It's considered less powerful and less addictive than opioids like oxycodone or morphine.
Meanwhile, the operation on the other table is continuing. An orthopedic surgeon from China is literally hammering a rod into the 29-year-old's leg. The first couple of attempts didn't go so well, and they had to back out the pin and try again. But Dr. Marenah is confident it will all work. He says these pins are highly effective.
MARENAH: So when we did these in the U.K., the following day they're up and walking. And they usually went home even the next day.
BEAUBIEN: Broken leg one day, walking out onto the streets of London the next but only because their pain was well controlled with opioids. Dr. Marenah doesn't predict such a tranquil post-surgical recovery for this guy. The patient is clearly uncomfortable. He's gripping the table as the hammering continues. And he's still under the spinal anesthetic.
MARENAH: When that wears off in about six hours' time, then there's usually some screaming on the wards. And it just takes some getting used to for the patient and the staff as well.
BEAUBIEN: In the absence of a strong pain medication, it'll be several days - maybe a week - before this man can put any weight on his leg. These patients are also likely to experience flare ups of what Dr. Marenah calls breakthrough pain. In the U.K., Marenah would treat this with oral morphine, but morphine isn't available on the wards here.
For the 14-year-old who just had knee surgery, his recovery starts on a trip on a gurney to the pediatric ward. The children's ward is actually in another building across the street from the main hospital. There are no rails on the gurney and he slides around as the orderly pushes him through the potholed street.
UNIDENTIFIED PERSON: (Shouting in foreign language).
BEAUBIEN: Finally, he arrives at the crowded kids' ward. His legs are still numb from the anesthetic during surgery. His father, Hassan Emmanuel Kamara (ph) says they know his recovery will take time.
HASSAN EMMANUEL KAMARA: We're a family. We just try to support him as much as possible.
BEAUBIEN: Kamara worries about his son being in pain, but he recognizes that he just had surgery. He doesn't expect his son to be comfortable. Dr. Marenah wishes he had stronger pain meds for his patients. This teen will be hurting for the next few days. But despite that, Marenah says, this operation was a success.
MARENAH: At least now he's got a straight leg and he's not going to suffer for the rest of his life.
BEAUBIEN: They may not have access to strong opioids, but Dr. Marenah and the other caregivers here have confidence that their patients will heal. And eventually, the pain will go away. Jason Beaubien, NPR News, the Gambia.
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