|Year : 2019 | Volume
| Issue : 3 | Page : 94-98
Pentazocine addiction among sickle cell disease patients and perception of its use among health-care workers
Akinsegun Akinbami1, Ola Bola2, Ebele Uche1, Mulikat Badiru1, Olusola Olowoselu3, Aishatu Maude Suleiman4, Benjamin Augustine4
1 Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos, Nigeria
2 Department of Behavioural Medicine, Lagos State University College of Medicine, Lagos, Nigeria
3 Department of Haematology and Blood Transfusion, College of Medicine, University of Lagos, Lagos, Nigeria
4 Department of Haematology and Blood Transfusion, Ahmadu Bello University, Zaria, Kaduna State, Nigeria
|Date of Web Publication||14-Nov-2019|
Dr. Ebele Uche
Department of Haematology and Blood Transfusion, Lagos State University College of Medicine, Lagos
Source of Support: None, Conflict of Interest: None
BACKGROUND: Prolonged use of pentazocine in sickle cell disease (SCD) because of chronic pain may result in mental dependence (addiction) and/or physical dependence leading to withdrawal symptoms on suddenly stopping its use. This study was aimed at determining the prevalence of pentazocine addiction among SCD patients and health-care worker (HCW) perception on its use.
MATERIALS AND METHODS: This was an interviewer-administered, questionnaire-based, cross-sectional study. The study involved clients attending the Lagos State University Teaching Hospital sickle cell clinic and the hospital HCWs. Consenting participants filled a World Health Organization structured questionnaire developed and extracted from ASSIST which is A - Alcohol, S - Smoking and S - Substance, I - Involvement, S - Screening, and T - Test. The HCWs were evaluated using a pretested, validated questionnaire.
RESULTS: A total of 350 participants were recruited consisting of 169 (48.3%) males and 181 (51.7%) females. ASSIST report showed 88% of them had low score of 0–3, 10% had moderate score of 4–26, while 2% (7 of 350) had high score of >27. A total of 61 HCWs were interviewed, and 18% and 8.2% of them believed 40%–60% and more than 60%, respectively, of the SCD patients were addictive to pentazocine.
CONCLUSION: While the issue of drug addiction should not be ignored, the appropriate treatment of SCD patients in Nigeria who are prevented from getting high-quality care should be appropriately addressed. The risk of addiction is overestimated among HCW.
Keywords: Health-care workers' perception, pentazocine addiction, sickle cell disease
|How to cite this article:|
Akinbami A, Bola O, Uche E, Badiru M, Olowoselu O, Suleiman AM, Augustine B. Pentazocine addiction among sickle cell disease patients and perception of its use among health-care workers. J Appl Hematol 2019;10:94-8
|How to cite this URL:|
Akinbami A, Bola O, Uche E, Badiru M, Olowoselu O, Suleiman AM, Augustine B. Pentazocine addiction among sickle cell disease patients and perception of its use among health-care workers. J Appl Hematol [serial online] 2019 [cited 2020 Jan 24];10:94-8. Available from: http://www.jahjournal.org/text.asp?2019/10/3/94/271025
| Introduction|| |
Sickle cell disease (SCD) is a hereditary disorder in which glutamine on the sixth position of the β hemoglobin chain is replaced with valine as a result of a single point mutation resulting from the replacement of adenine with thymine on its deoxyribonucleic acid structure. The implication of the mutation is sickling of the red blood cells (RBC). The sickled RBC impede free fiow of blood of affected vessels causing obstruction, congestion, hypoxia, lactic acidosis, all contributing to the pathophysiology of pain, the telltale sign of sickle cell painful vaso-occlusive crises (VOC).
SCD is common in Nigeria with prevalence values ranging from 2% to 3%. The sickle cell trait (HbAS) individuals are carriers of the disease and have a normal hemoglobin and a sickled hemoglobin; they are usually asymptomatic and the prevalence ranges from 10% to 40% in sub-Saharan Africa. The severe SCD patients are symptomatic and are referred to as HbSS or HbS βo thalassaemia seen in 2% of Nigerians. SCD is referred to as compound or double heterozygote if they are HbSC and HbS β+ thalassaemia or sickle cell anemia. World Health Organization (WHO) recognized SCD as a global public health problem in 2006. It also included SCD in 2010 Global Burden of Diseases, Injuries, and Risk factors.
Painful VOC in SCD mostly affect hands, legs, chest, back, and abdomen. While some SCD patients require hospitalization because of severe painful VOC, Smith et al. reported that most crises are attended to at home by patients and do not result in acute health-care visit by implication, they have a tendency to drug abuse.
Pain, a telltale sign of SCD, often times is treated with pentazocine. The main stay of treatment of VOC pain crises in SCD is pentazocine; it controls pain, improves functional capacity, and reduces hospitalization in most SCD patients.
Pentazocine is an opioid (narcotic) analgesic used for moderate to severe pain. It works in the brain and the nervous system to decrease pain. It is the only opioid analgesic available over the counter in most pharmacies in Nigeria unlike morphine and pethidine whose sales are strictly regulated. It is therefore often used in the management of VOC in SCD. Prolonged use of pentazocine in SCD may result in mental dependence (addiction) and/or physical dependence leading to withdrawal symptoms on suddenly stopping its use.
Through a WHO validated questionnaire, the study assessed the proportion of SCD patients addicted to pentazocine and its severity, thus determining the prevalence of addicted individuals.
This study also evaluated perception of health-care workers (HCWs) on the use of pentazocine so as to identify patients with pseudoaddiction and those with true addiction, thus creating awareness about abuse of pentazocine use in SCD if any.
| Materials and Methods|| |
The study involved clients attending SCD clinic in Lagos State University Teaching Hospital (LASUTH) and the hospital HCWs.
Design and duration of study
This was an interviewer-administered, questionnaire -based, and descriptive, cross-sectional study. The study was conducted from September 2017 to February 2018.
Ethics committee's approval reference number LREC.06/10/867 was obtained from Health Research and Ethics Committee of LASUTH.
Questionnaire used was developed and extracted from ASSIST which is A-Alcohol, S-Smoking and S-Substance, I-Involvement, S-Screening, and T-Test. It is a brief screening questionnaire to find about people's use of psychoactive substances. It was developed by the WHO and an international team of substance use researchers as a simple method of screening for hazardous, harmful, and dependent use of alcohol, tobacco, and other psychoactive substances. It contains demographic information and relevant questions relating to drug addiction.
Perception of HCWs was assessed by another structured questionnaire to determine their views on liberal versus restrictive use of pentazocine vis-a-vis risk of abuse and addiction.
- All consenting HCWs listed for participation
- All consenting SCD clients attending adult clinic in the hospital.
- Nonconsenting HCWs
- Nonconsenting clients of SCD clinic.
Sample size determination
Sample size for SCD clients was determined by the formula designed for determination of single proportion non comparative study.
n=n = Z2pq/d2
n = sample size
Z = Z statistic for a level of confidence of 95%, which is conventional, Z value is 1.96
p = expected prevalence
q = 1−p
d = precision
Z = 1.96
p = prevalence of 31% of drug abuse in SCD patients was used
P = 0.31
q = 1−p
d = 0.05
n = (1.96)2 × 0.31× (1−0.31)/(0.05)2
n = 3.8416 × 0.31 × 0.69/0.0025
n = 0.8217/0.0025
n = 328.68
n = 328.66
At level of significant α = 0.06 and estimated prevalence of 0.31 for drug abuse in SCD patients with 95% confidence interval (CI) and standard deviation (SD) ± 2 and marginal error = 5%, the sample size should be at least 350.
A total of 350 clients were enrolled.
Determining sample size for HCW, a prevalence of 25% was used.
n = (1.96)2 × 0.25× (1−0.25)/(0.05)2
n = 3.8416 × 0.25 × 0.75/0.0025
n = 0.7203/0.0025
n = 28.8
At level of significant α = 0.06 and estimated prevalence of 0.25 for HCW with 95% CI and SD ± 2 and marginal error = 12%, the sample size should be at least 29.
A total of 61 HCW were enrolled.
Calculation of pentazocine involvement score by Alcohol, Smoking and Substance Involvement Screening Test questionnaire
Pentazocine abuse's score
- No intervention – 0–3
- Relief brief intervention – 4–26
- More routine Treatment – 27+.
Alcohol, Smoking and Substance Involvement Screening Test feedback report
- Low – 0–3
- Moderate – 4–26
- High – 27+
- Low – Client is at low risk of health and other problems from the current pattern of use
- Moderate – Moderate risk of health and other problems from the current pattern of use
- High – High risk of experiencing severe problems (health, social, financial, and legal relationship) as a result of the current pattern of use and are likely dependent.
Data analysis and presentations
The data were recorded and analyzed with IBM SPSS Statistics for Windows, Version 20.0 Armonk, New York, USA. The data obtained were expressed as rates and frequencies.
| Results|| |
A total of 350 SCD participants were recruited; the age and gender distributions of participants are presented in [Figure 1] and [Figure 2].
A total of 78% of the participants had never used pentazocine while 15.1% had and 6.9% could not confirm its use or otherwise. In the past 3 months, 87.4% had never used pentazocine, only 2.3% had used it weekly, and 1.7% daily.
In response to a question on how often have they had a strong desire or urge to use pentazocine, almost 94.3% never had a strong desire or urge in the past 3 months; only 2% had a daily strong desire to use pentazocine.
Almost all participants (96.9%) confirmed use of pentazocine has not led to health, social, legal, or financial problems, only 1.7% of them have not been affected. Similarly, almost all participants (97.7%) denied being affected when asked how often they failed to do what was normally expected of them in the past 3 months.
The question on whether a friend or relative or anyone expressed concern about use of pentazocine, only 2.9% confirmed they had relative or friend complained about use of pentazocine.
Furthermore, a high percentage of them i.e. 95.7% had no problem about cutting down or stopping pentazocine use. A total of 93.4% had never used any other drug injection for nonmedical use. ASSIST feedback report in SCD is presented in [Table 1].
|Table 1: Alcohol, Smoking and Substance Involvement Screening Test feedback report in sickle cell disease|
Click here to view
A total of 61 HCW were interviewed [Table 2]. This consisted of 25 (41%) males and 36 (59%) females. Majority of them, i.e., 36 (59%) were between 30 and 40 years, followed by 12 (19.7%) who were <30 years. The least of the participants were 4 (6.6%), who were >50 years.
Participants were recruited from the following departments, Internal Medicine 14 (23%), Haematology 12 (19.7%), Family Medicine 11 (18%), others were General Outpatient Department, Anaesthesia, Nursing and Obstetrics and Gynaecology.
The category of physicians included is presented in [Table 3]. A total of 36.1% of the respondents have 1-5 and 5-10 years of practice each, while 18% of the participants had year of practice between 10 and 20 years. Almost all participants, i.e., 56 of 61 (91.8%) have ever administered pentazocine and 41 (67.2%) considered themselves to be generous with its use. A total of 27.9% believed pentazocine is addictive to majority of patients between 20% and 40%. While 18% of the HCWs believed 40%–60% were addictive, 8.2% of them believed more than 60% of sickle cell anemia were addictive to pentazocine.
A total of 27 (44.3%) participants will be willing to administer pentazocine while 32 (52.5%) will not be willing.
| Discussion|| |
To the best of our knowledge, this is thefirst study in Nigeria to use WHO's pretested and validated ASSIST questionnaire which categorizes the risk into low, moderate, and severe to evaluate risk of pentazocine addiction in SCD and we also correlated the risk to the perception of HCWs.
Contrary to the HCWs' widely held belief of high prevalence of pentazocine dependence among SCD patients, our study reported only 2% of SCD patients scored 27 and above and are therefore at high risk of experiencing severe problems (health, social, financial, legal relationship) as a result of the current pattern of use and are severely dependent. This could be compared with the perception of 27.9% of HCWs who believed pentazocine is addictive to majority of patients between 20% and 40%. An appreciable percentage of 27.9% HCW reported in this study believed in high addiction rate among SCD patients. This is similar to Shapiro et al.'s study who reported 53% of emergency physicians and 20% hematologists believed in high addiction rate among SCD.
The 2% prevalence of high-risk pentazocine addiction obtained in this study is also similar to a Nigerian value of 2.9% obtained by Madu et al.; they however did not categorize severity of addiction into low, moderate, and severe which could account for the slightly higher prevalence. However, a much higher prevalence of 17.8% of opiate dependency was obtained by Ahmed and Ibrahim in Maiduguri, Nigeria this high prevalence was from a cohort of opiate dependent SCD patients. The use of a low sample size of 73 in the study compared to 350 non-opiate dependent cohort of SCD patients in our study coupled with a cultural and geographical variation between Maiduguri and Lagos could all account for the difference. A possibility of pseudoaddiction on the Maiduguri subjects could also explain the difference.
Our study also reported 10% of the SCD had moderate score of 4–26 and possess moderate risk of health and other problems from the current pattern of use, while 18% of the HCW believed 40%–60% was addictive and 8.2% of HCW believed more than 60% of SCD patients were addictive to pentazocine.
Most HCW routinely overestimate the risks and prevalence of opioid addiction. Pack-Mabien et al. reported that over 60% of nurses believed opioid addiction is prevalent in SCD, while 50% of emergency department physicians and 25% of haematologists believed more than one-fifth of SCD patients are addicted to opioids.
Failure to differentiate between physiologic tolerance and dependence versus addictive behaviors may account for some of the distorted perceptions of HCW.
Pseudoaddiction is an addiction-like behaviors occurring as a result of pain under treatment by physicians. This is consequent upon fear of causing or exacerbating addictions among SCD patients. This may be mislabeled as drug-seeking behavior and inappropriately considered as addiction. On the contrary, tolerance developed as a result of chronic opioid use may amount to a patient with acute pain crisis to ask for higher dose of opioid.
Some physicians cautiously use minimal doses of opioids in SCD patients because of their perceived belief of addiction risk while some believe under treatment of SCD painful crises with opioids may result in pseudoaddiction.
In the middle of these two opinions is the risk of addiction to opioids because several authors have reported increased substance abuse in SCD patients.,,, While Meghani et al. reported that the rate of drug abuse by SCD patients is not different from that of general public.
Limitations of this study are reliability on the information provided by the patients and HCWs to draw conclusions on pentazocine addiction. Some of their responses might not be accurate, thus affecting the quality of data reported. No behavioral medicine specialist participated in this study; they also manage pentazocine addiction in SCD patients and might have different experiences of the issue of addiction.
| Conclusion|| |
While the issue of drug addiction should not be ignored, the appropriate treatment of SCD patients in Nigeria who are disadvantaged getting high quality care should be appropriately addressed. The risk of addiction is overestimated among HCW.
The authors are grateful to Mr. Qassim Akinlotan who administered the questionnaires and entered the data in SPSS.
Financial support and sponsorship
Confiicts of interest
There are no confiicts of interest.
| References|| |
Isaacs WA, Hayhoe FG. Steroid hormones in sickle cell anaemia. Nature 1967;215:1139-42.
World Health Assembly: Resolutions and Decisions Annexes. WHA 59/2006/REC/1. Geneva: World Health Organization; 2006.
Fleming AF, Storey J, Molineaux L, Iroko EA, Attai ED. Abnormal haemoglobins in the Sudan savanna of Nigeria. I. Prevalence of haemoglobins and relationships between sickle cell trait, malaria and survival. Ann Trop Med Parasitol 1979;73:161-72.
Murray CJ, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al.
GBD 2010: A multi-investigator collaboration for global comparative descriptive epidemiology. Lancet 2012;380:2055-8.
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.
Smith WR, Penberthy LT, Bovbjerg VE, McClish DK, Roberts JD, Dahman B, et al.
Daily assessment of pain in adults with sickle cell disease. Ann Intern Med 2008;148:94-101.
Brookoff D, Polomano R. Treating sickle cell pain like cancer pain. Ann Intern Med 1992;116:364-8.
Makanjuola AB, Olatunji PO. Pentazocine abuse in sickle cell anemia patients. A report of two cases vignettes. Afr J Drug Alcohol Stud 2009;8:59-64.
Henry-Edwards S, Humeniuk R, Ali R, Poznyak V, Monteiro M. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): Guidelines for Use in Primary Care (Draft Version 1.1 for Field Testing). Geneva: World Health Organization; 2003.
Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for prevalence studies. Arch Orofac Sci 2006;1:9-14.
Elander J, Lusher J, Bevan D, Telfer P. Pain management and symptoms of substance dependence among patients with sickle cell disease. Soc Sci Med 2003;57:1683-96.
Pack-Mabien A, Labbe E, Herbert D, Haynes J Jr. Nurses' attitudes and practices in sickle cell pain management. Appl Nurs Res 2001;14:187-92.
Shapiro BS, Benjamin LJ, Payne R, Heidrich G. Sickle cell-related pain: Perceptions of medical practitioners. J Pain Symptom Manage 1997;14:168-74.
Madu AJ, Korubo K, Okoye H, Ugwu N, Efobi C, Nwogoh B, et al
. Survey of pentazocine addiction and opioid use in adult sickle cell anaemia patients: The perspective of healthcare providers. Haematol Int J 2018;2:000133.
Ahmed SG, Ibrahim UA. The prevalence of therapeutic opiate dependence among patients with sickle cell disease in Maiduguri, North-East Nigeria. Niger J Pharm 2001;32:56-9.
Kotila TR, Busari OE, Makanjuola V, Eyelade OR. Addiction or pseudo-addiction in sickle cell disease patients: Time to decade-a case series. Ann Ib Postgrad Med 2015;13:44-7.
Labbé E, Herbert D, Haynes J. Physicians' attitude and practices in sickle cell disease pain management. J Palliat Care 2005;21:246-51.
Elander J, Lusher J, Bevan D, Telfer P, Burton B. Understanding the causes of problematic pain management in sickle cell disease: Evidence that pseudoaddiction plays a more important role than genuine analgesic dependence. J Pain Symptom Manage 2004;27:156-69.
Weissman DE, Haddox JD. Opioid pseudoaddiction – An iatrogenic syndrome. Pain 1989;36:363-6.
Lusher J, Elander J, Bevan D. Analgesic addiction and pseudo-addiction in painful chronic illness. Clin J Pain 2006;222:316-24.
Boulmay B, Lottenberg R. Cocaine abuse complicating acute painful episodes in sickle cell disease. South Med J 2009;102:87-8.
Dohrenwend A, Sehgal R. Lost between the cracks: Pain patients denied inpatient treatment for illicit drug addiction. Psychosom Med 2005;67:677-8.
Alao AO, Westmoreland N, Jindal S. Drug addiction in sickle cell disease: Case report. Int J Psychiatry Med 2003;33:97-101.
Meghani SH, Polomano RC, Tait RC, Vallerand AH, Anderson KO, Gallagher RM, et al.
Advancing a national agenda to eliminate disparities in pain care: Directions for health policy, education, practice, and research. Pain Med 2012;13:5-28.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]