Historical perspectives and trends in the management of pain for cancer patients in oman.

INTRODUCTION

Sultanate of Oman is the second largest country in the Gulf, with a population of 2,867,428 (2008) of which 35.2% is under 15 years and only 3.7% above 65 years. Incidence of newly diagnosed cancers is also the second highest in the Gulf with 11%. Research conducted between 1997-2007 revealed that the most frequent cancers in males: stomach 10%, non-Hodgkins lymphoma 8.6% and prostate 7% while in females: breast 18.9%, thyroid 8.3% and cervix uteri 6.5%. A population-based registry was established in 1996 to compile an accurate database and monitor cancer trends. There is a rigorous follow up of reported cases. Unfortunately most patients report at the hospitals in advanced stages which complicate pain management. All treatment modalities of cancer are available in Oman at the two centers, Royal Hospital and SQUH. There is a continuous effort to develop national educational guidelines, protocols for cancer treatment, palliative care and pain management (PM).

HISTORICAL PERSPECTIVES AND TRENDS IN THE MANAGEMENT OF PAIN

In 1970s Omanis used traditional medicine, wassam (moxibustion), to treat pain. In 1988 severe pain was treated in hospitals with intramuscular opioid, whenever necessary (PRN). 1989 SQUH approved use of both parenteral and oral narcotics, received its first consignment, and started PM. The Ministry of Health (MOH) was concerned with possible misuse and for 8 years, thereafter, SQUH was the only hospital allowed to import, stock, prescribe and dispense oral narcotics. Legal requirement to obtain opioids in Oman involves MOH and World Health Organization (WHO) and there is a control as to who can prescribe for both inpatient and outpatient. The drugs available to control pain include non opioids, weak opioids, but the only strong opioids used for severe cancer pain are morphine and Fentanyl. This is complemented with adjuvant drugs. We use the "WHO Ladder" to guide us in the management of pain. Three different cases have been presented to see how PM of cancer patients has evolved from using only non-opioid in 1993, to using intramuscular pethidine in 1995, then to using morphine with adjuvants in 1999. Referral of patients to the PM Team has improved the pain control and at present even without referral, pain is controlled more effectively.

CONCLUSION

There is no doubt that the Sultanate of Oman has progressed tremendously since 1970. The Government is working very hard and is taking major steps to improve cancer care in order to meet the International Bench Mark. Each 5 year plan focuses on actual needs. One of the important needs that have been addressed is the management of pain which has significantly improved. Factors that have improved PM in Oman include the introduction of the PM Teams, training of Nurses and Doctors, follow up of the PM services in the clinical areas, authorizing MOH hospitals to use oral opioids, opening of the National Oncology Centre with Radiation Therapy, inter institutional discussions and development of guidelines, implementation of WHO Guidelines on PM and audits, peer reviews and research.