Pain management among patients with bone malignancies at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Cancer-related bone pain (CRBP) poses a substantial orthopaedic challenge in its management. Opioids remain the first treatment option for CRBP, but many Sub-Sahara patients continue to receive suboptimal pain management with analgesics. Published data are scarce on CRBP in resource-limited settings, including Kenya. Objective: To describe the use of analgesics in the management of CRBP at MTRH and determine the proportion of patients satisfied with their pain control on analgesics. Methods: A prospective descriptive study was conducted between March 2019 - March 2020 with 96 adult patients, consecutively sampled after obtaining consent and followed up daily for five days. Eligible patients had histo-pathologically confirmed primary tumour, osseous lesion(s) on radiographs, and cognitive capacity to rate pain on a Numerical Rating Scale. Data was collected using validated questionnaires drafted from the Brief Pain Inventory. Within the past 24 hours, self-assessed pain scores were reported on a scale of 0 (No pain) to 10 (worst Pain). Adequacy of analgesics use was assessed using the Pain Management Index (PMI). The PMI was calculated by subtracting a patient's pain intensity score from the analgesic score. A negative PMI indicated suboptimal treatment. Pain control satisfaction was evaluated as a single response question (Satisfied, Not Sure, or Dissatisfied). Descriptive statistics were used to summarise patients with moderate-severe CRBP, a negative PMI, and those satisfied with pain control. Associations were examined in multiple logistic regression models. Ethical approval was obtained. Results: The median age was 57 (range19 to 90) years. More males (52.1%) than females (47.9%) were recruited. The commonest malignancy was Prostate cancer (25%). At baseline, 86.5% reported CRBP, with 69.8% having moderate-severe pain, 13.5% had no CRBP. Twenty-eight patients (29.2%) had pain and no analgesics; of these, 19 (19.8%) had moderate-severe Pain. On follow-up, the proportion of CRBP ranged from 83.3% to 86.5%. That of moderate to severe pain ranged from 57.3% to 62.5%. Twenty-one patients (21.9%) with pain the entire study duration received no prescribed analgesics. Opioids were prescribed to 29.2% at baseline and 15.6% on follow-up. CRBP was sub-optimally managed in 61.5% at baseline. This proportion ranged from 59.4% to 65.6% on follow-up. Multiple bone lesions (p=0.006, AOR: 0.192) and age over 60 years (p=0.013, AOR: 0.953) were significantly associated with suboptimal pain management. Overall, 70.8% were satisfied with their pain control. Patients prescribed opioids (p=0.041, AOR: 0.027) had an increased likelihood of having pain control satisfaction. Conclusion: A high proportion of patients with bone malignancies at MTRH report CRBP. Majority of the patients receive suboptimal pain management with analgesics. Recommendations: Efforts to include appropriate pain screening, assessment, evidence-guided treatment, and patient follow up are necessary to provide adequate CRBP management and satisfactory outcomes.