Experts worry over drug abuse among SCD patients

Victor Ayeni

Aside from swelling, delayed growth and infections, one of the symptoms people living with Sickle-Cell Disease often struggle with is pain episodes, which can last from hours to days.

SCD, a serious inherited blood disorder, is caused by a mutation in the HBB (haemoglobin subunit beta) gene, leading to abnormal, sickle-shaped red blood cells that block blood flow and cause severe health complications.

The World Health Organisation estimates that in 2021, 7.74 million people were living with SCD globally, with 515 000 new births, primarily in sub-Saharan Africa, which accounts for nearly 80 per cent of global cases.

“Sickle-cell disease causes substantial under-five mortality: 81 100 deaths in 2021, making it the 12th leading cause of death in this age group when considering the total mortality burden.

“Traditional mortality recording underestimates sickle-cell disease impact – actual deaths are 11 times higher than cause-specific statistics suggest (376 000 vs 34 400 deaths in 2021),” the WHO noted.

Speaking with Sunday PUNCH, a Registrar in Obstetrics and Gynaecology, Dr Paul Anejodo, explained that SCD is caused by haemoglobin deformation.

He clarified that a haemoglobin molecule is made up of four polypeptide chains that form a protein.

“The main type of haemoglobin is Hgb A, which has two alpha polypeptide chains and two beta chains. SCD occurs when there is a small mutation in the beta chain of Hgb A, where glutamate is changed to valine.

“Hgb S forms a rigid polymer chain of Hgb S molecules, which produces long, rigid erythrocytes that tend to get stuck inside blood vessels, resulting in a vaso-occlusive crisis. This disease is inherited from parents with AS or SS genotypes who marry each other,” Anejodo stated.

He further disclosed that the symptoms are often caused by the crises they develop, which include anaemia, bone and muscle pain, joint swelling, fatigue, and yellowing of the eyes and skin.

“The patients depend heavily on painkillers because the majority of them do not take the necessary preventive measures to avert the crises. The crises include vaso-occlusive crisis, splenic sequestration, aplastic crisis, and hyperhaemolytic crisis, and these crises cause a lot of pain,” Anejodo noted.

Pain, painkillers and opioids

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With pain being a significant symptom of SCD, the management of pain and the drugs used for people living with the disorder have been the subject of debate among medical doctors, pharmacists, pain therapists and researchers.

According to Sickle Cell Disease News, while mild pain is managed with acetaminophen or non-steroidal anti-inflammatory drugs like ibuprofen, moderate to severe crises require prescription opioids like morphine, oxycodone, or fentanyl.

People living with SCD are advised to always consult a doctor for a personalised plan and seek emergency care for severe, unmanageable pain.

But sources within the health sector are calling for more clinical judgement among health professionals, disclosing that some SCD patients have sadly become addicted to painkillers and opioids.

“Years ago, we had a SCD patient in Port Harcourt (Rivers State) who would come to us with different stories, which we believed were fabricated, in an attempt to obtain pentazocine. Pentazocine is an opioid, but we always refused to sell it to her without a prescription.

“She would become angry, aggressive, and sometimes break down in tears. ‘You just want me to suffer. I’m in pain. You can’t understand what I’m going through,’ she would say,” a pharmacist, who identified himself simply as Chinedum, told Sunday PUNCH.

“While we wanted every patient to receive the best possible care, we also had to adhere to the principles of pharmacotherapy by ensuring appropriate treatment, preventing medication errors, and working with other healthcare professionals to achieve the best outcomes for patients. Opioids are not routine medications like paracetamol; they require proper medical indication, appropriate dosing, and careful monitoring.

“If patient safety is not your priority, you might simply pity an SCD patient asking for an opioid and hand it over. But we knew better. We would insist that she go to the hospital and obtain a doctor’s prescription for pentazocine before we could dispense it. It is one of the most commonly abused drugs among SCD patients,” Chinedum added.

Confirming the growing trend of drug abuse among SCD patients, a source at a state-owned hospital said the facility had treated several such patients.

“We have been seeing a growing rise in drug addiction and one of our findings is that these drugs – and I am referring to opioids – are readily available in pharmacies. That’s why health professionals do all they can to wean patients off it once they monitor them and find out that they are having cravings for it.

“We have seen a growing pattern of opioid addiction among patients with HbSS, which is the most common and typically the most severe form of SCD, due to the pain they experience.

“There was an SCD patient who was always demanding morphine (an opioid), and even after a dose of it was administered to him, he kept fighting with the nurse and secretly went to the fridge and drank morphine, and collapsed there in the ward,” the source said.

In the United States, studies from the National Institutes of Health peg the addiction rate among SCD at about 10 per cent, which is similar to the general chronic pain population.

But a study in North-West Nigeria found an opioid use disorder prevalence of 11.7 per cent, and another in Uganda reported rates between 5.3 per cent and 8.5 per cent.

Some experts have argued that patients require these medications due to severe, recurring vaso-occlusive crises, adding that physiological dependence and tolerance to opioids are expected and necessary for managing chronic pain.

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They noted that this is not the same as psychological addiction. They further explained that when patients’ pain is undertreated, they may exhibit behaviours like seeking prescriptions from multiple doctors or being assertive at pharmacy stores.

This is often labelled as drug-seeking behaviour, but some medical experts argue that this is actually “pseudoaddiction”, a desperate attempt to get adequate pain relief.

“Because of stigma and the opioid epidemic, physicians sometimes withhold or under-prescribe necessary pain medications. This under-treatment can actively worsen a patient’s health-related quality of life,” a National Institutes of Health study says.

However, the standard manual used by psychiatrists and psychologists, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, defines OUD as a problematic pattern of opioid use leading to clinically significant impairment or distress.

The DSM noted that OUD is manifested by at least two of 11 defined criteria occurring within a year, which include, “Opioids are often taken in larger amounts or over a longer period than was intended, and a great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.”

Providing balanced care

In an interview with Sunday PUNCH, a Lagos-based pharmacist, James Uche, explained that in SCD, the patient has sickle-shaped red blood cells.

“These cells are rigid, stiff, and sticky, and this makes them unable to carry oxygen properly because they are unable to pass through the narrow capillaries, hence causing a jam and reducing proper oxygen supply.

“A normal red blood cell is oval and has enough surface area to take in oxygen and transport it around the body. Therefore, people living with SCD have issues with anaemia, and they have a lot of pain crises. Sometimes, too, they may have infections. These patients are more often than not in pain.

“There is a tendency for them to abuse drugs such as non-steroidal anti-inflammatory drugs (diclofenac, meloxicam, piroxicam, aceclofenac, etc.), analgesics (paracetamol), and opioids (tramadol, codeine and pentazocine). Mainly, most SCD patients use NSAIDs and opioids,” Uche explained.

He further explained that in his practice, he had attended to many persons living with SCD who requested painkillers due to the pain that they go through, which he described as touching.

The pharmacist clarified that most NSAIDs act as non-selective inhibitors of two enzymes known as cyclooxygenase-1 and cyclooxygenase-2.

“The first enzyme, COX-1, produces prostaglandins that help protect the stomach lining, while the second enzyme, COX-2, is produced when there’s an injury or inflammation. Due to the mechanism of action of most NSAIDs, which are non-selective inhibitors of both enzymes, repeated use can expose the stomach lining to injury, resulting in peptic ulcers.

“Prostaglandins also help dilate blood vessels leading to the kidneys, so when patients use these painkillers too frequently for a long time, especially on an empty stomach, they could also develop kidney injuries.

“The issue of comorbidities could also arise. This happens when a patient has two or more conditions, for example, having SCD and being hypertensive. When such a person uses NSAIDs with antihypertensive drugs, these drugs antagonise each other, leading to reduced efficacy of the antihypertensive drugs,” he added.

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While NSAIDs are regarded as manageable, the use of opioids by SCD patients has raised concerns among health professionals due to their attendant negative effects.

A major, naturally occurring opioid prescribed by medical experts to manage severe, acute or chronic pain is morphine.

Derived from the opium poppy plant, Papaver somniferum, morphine works by binding to opioid receptors in the central nervous system to alter the brain’s perception of and emotional response to pain.

“From morphine, other synthetic forms have been made. Two of the most commonly abused opioids by SCD patients are tramadol and pentazocine. From its pharmacology, pentazocine binds to the kappa opioid receptors to elicit its analgesic effects. But at the same time, it also weakly binds to the mu opioid receptors to produce its therapeutic response of alleviating pain.

“The challenge with this opioid is its significant effect on the central nervous system. It can predispose patients who use it indiscriminately to dependence, making them develop excessive cravings for the drug, and it also triggers side effects such as euphoria, restlessness, agitation, and withdrawal symptoms. Therefore, patients may develop such strong cravings that they would want to sell everything they have to buy the drug.

“Pentazocine is often administered intravenously, subcutaneously or intramuscularly, so this presents the possibility of the injection site becoming infected due to repeated drug use and multiple injections by individuals living with SCD. The abuse of this particular opioid can make the patient more eager to seek other opioids, and this can also expose them to blood-borne infections such as HIV and hepatitis due to the sharing of needles,” Uche explained.

The pharmacist, however, stated that some people living with SCD seek healthier methods of alleviating or preventing pain crises by using Ciklavit – a multivitamin derived from the herb Cajanus cajan – and hydroxyurea, which they also use to prevent pain crises.

“When these persons come to the pharmacy, they look better managed because they do not have the same problems as those who are heavily dependent on and addicted to painkillers.

“One thing about medicine is that it only works well at recommended doses. But when you use it indiscriminately and at doses that are not recommended, then you start having issues that may ultimately be life-threatening,” Uche added.

Also speaking with Sunday PUNCH, a pharmacist and sickle-cell ambassador, Perpetua Nnabuenyi, pointed out that preventing drug addiction among SCD patients requires a coordinated effort from both individuals and healthcare institutions.

“At the individual level, patients should adhere to prescribed medications, avoid self-medication, attend regular follow-up appointments, and receive continuous education on the safe use of pain medicines. Family members and caregivers also have a role in encouraging medication adherence and recognising early signs of drug dependence.

“At the institutional level, healthcare facilities should implement evidence-based pain management protocols, strengthen prescription monitoring, train healthcare professionals on responsible opioid prescribing, and integrate psychological support into sickle cell care.

“Leveraging health data to monitor prescribing patterns and evaluate treatment outcomes will enable timely interventions and improve patient safety. Preventing drug addiction is a shared responsibility that protects both the health and quality of life of people living with sickle cell disease,” Nnabuenyi said.

On his part, the Registrar of Obstetrics and Gynaecology, Anejodo, highlighted ways that people living with SCD can be helped to prevent them from becoming overly dependent on painkillers.

“This includes preventing all forms of infection, such as malaria, urinary tract infections, upper respiratory tract infections and diarrhoea. You need to stay hydrated by drinking water, avoid strenuous exercise or stress, ensure you stay or live in well-ventilated areas, and do not climb to high altitudes,” he advised.

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