美国国家公共电台 NPR A Place Where The Opioid Problem Is Upside Down

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A Place Where The Opioid Problem Is Upside Down

RACHEL MARTIN, HOST:

All right. Here in the United States, too much access to opioids has led to rampant¹ addiction² 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 ongoing³ look at treating pain. And a note - this story does contain some uncomfortable medical details.

JASON BEAUBIEN, BYLINE⁴: 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 protruding⁵ 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 painkillers⁸, are in short supply. And even if Marenah can get powerful opioids for his patients, nurses on the general wards⁷ 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 ward⁶ when they were doing dressings⁹ 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 spinal¹⁰ block. It makes their legs go numb¹¹. 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 vertically¹² from his knee to almost his ankle to stabilize¹³ 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 specially¹⁴ 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 surgical¹⁵ operating rooms. They aren't present in labor¹⁶ 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 resetting¹⁷ 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 joint¹⁸ 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 anesthetic¹⁹ 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 generic²⁰ versions of Tylenol and Advil and aspirin²¹. The only narcotic²² that clinicians sometimes dispense²³ is a synthetic²⁴ opioid called Tramadol. It's considered less powerful and less addictive²⁵ than opioids like oxycodone or morphine.

Meanwhile, the operation on the other table is continuing. An orthopedic surgeon from China is literally²⁶ 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 tranquil²⁷ 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 flare²⁸ 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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