Do you have any ideas for how one would most cost-effectively treating arthritis pain in a low income country?
On access to NSAIDS, I don’t think access is that bad in lower income countries. NSAIDs are in every drug shop in every village here, but the issue is with HOW they are given.
Okay, this is good to know. Ditto with the bit about gastritis and peptic ulcers.
I also don’t really know what you mean by “palliative care centers” in low income countries
We weren’t sure what type of facilities had the biggest supply problems that could be ameliorated, so we were unsure. Good to know palliative care units may have relatively more access problems.
Migraines are not super common, difficult to diagnostically separate from other conditions, and specific drugs for them are very expensive. My fairly strong instinct is that can’t imagine this ever being a high impact area of intervention.
Could you explain a bit more? This doesn’t seem entirely right, but you have more expertise here.
It seems like they’re relatively common. In Sharma et al., (2020) they say: “We examine two headache disorders: migraines and cluster headaches. The former are common, affecting around one in six people… Disability-Adjusted Life Years lost in 2019, according to the Global Burden of Disease, were 42 million for migraines, 46 million for malaria, and 47 million for depression (source).”
I don’t know anything about diagnosing migraines, so I’ll trust you there.
I get that specific migraine drugs are very expensive, but we specifically mentioned using NSAIDs, which seem relatively effective “Common NSAIDs can eliminate most pain from migraines in half of all cases: aspirin, 52% (Kirthi et al., 2013) or ibuprofen, 57% (Rabbie et al., 2013).”
I know these are only shallow investigations, but if you don’t have access to experts on pain in LMIC countries (which probably exist, especially in the palliatve care field) I think you could potentially even save time early in your investigation process by talking to a few medical professionals in lower income countries to get more ideas and screen out a couple of these interventions.
Fair. Reaching out and talking to experts is not something we emphasized in these reports. The short calendar window for completing these reports made this difficult. Could we reach out to you if / when we look further into these topics?
Arthritis—same as treating most other pain - large amounts of paractamol, ibuprofen (and other nsaids) and diclofenac gel is what we do for arthritis.
I’m the opposite of an expert on migraines, and it looks like I’m technically just wrong. They are super common even in low income countries in the medical literature. After being here for 9 years I think I’ve only clearly diagnosed a migraine twice after seeing many thousands of patients. Maybe many with headaches (that we give ibuprofen to) might technically qualify as migraines but we just diagnose as tension headache. The migraine diagnosis is hardly made by anyone here.
Even with that I’m super dubious about that global burden of disease study which puts Migraine Dalys that nsanely high, but I don’t know enough to specifically criticise.
What this means is that there would be multiple barriers to working on migraines—poor understanding by local clinicians (like me), teaching about correct treatment, then availability. Seems tricky and obviously local doctors here don’t see it as a priority
Hi Nick,
A quick comment to thank you for engaging with our work and for your insights. This is super interesting.
Arthritis—same as treating most other pain - large amounts of paractamol, ibuprofen (and other nsaids) and diclofenac gel is what we do for arthritis.
This suggests that this could be really cost-effective, considering the price of NSAIDs! However, wouldn’t issues of side effects also occur here? Or is this less of an issue because the gains would be higher?
Side effects issue is also there, but like I said it’s more a thing to be aware of, that the intervention can’t be too just spray ibuprofen into the masses (like is often done with malaria medication, ORS for diarrhoea etc.) because there is a relatively common, dangerous side effect. If it’s given after asking the right questions and with good advice, it’s no problem at all—in high income countries. we give out relatively large amounts of NSAIDs without being overly concerned
Preventing the side effects issue is more about good administration, and medications being given after good history taking and diagnosis by a clinician. In high income countries we have no qualms about giving l large amounts of nsaids, as long as we aren’t giving them to people with gastritis, people are taking them with water and food and People understand what symptoms to look for to stop.
It just means it’s a bad idea up have noon qualified prior giving them out like lollies, which does happen a lot. In many western countries nsaids are sold at supermarkets, which shows you it’s not a game changing problem, just one to be careful about.
Nick,
This is super helpful feedback.
Do you have any ideas for how one would most cost-effectively treating arthritis pain in a low income country?
Okay, this is good to know. Ditto with the bit about gastritis and peptic ulcers.
We weren’t sure what type of facilities had the biggest supply problems that could be ameliorated, so we were unsure. Good to know palliative care units may have relatively more access problems.
Could you explain a bit more? This doesn’t seem entirely right, but you have more expertise here.
It seems like they’re relatively common. In Sharma et al., (2020) they say: “We examine two headache disorders: migraines and cluster headaches. The former are common, affecting around one in six people… Disability-Adjusted Life Years lost in 2019, according to the Global Burden of Disease, were 42 million for migraines, 46 million for malaria, and 47 million for depression (source).”
I don’t know anything about diagnosing migraines, so I’ll trust you there.
I get that specific migraine drugs are very expensive, but we specifically mentioned using NSAIDs, which seem relatively effective “Common NSAIDs can eliminate most pain from migraines in half of all cases: aspirin, 52% (Kirthi et al., 2013) or ibuprofen, 57% (Rabbie et al., 2013).”
Fair. Reaching out and talking to experts is not something we emphasized in these reports. The short calendar window for completing these reports made this difficult. Could we reach out to you if / when we look further into these topics?
Can always reach out to me!
Arthritis—same as treating most other pain - large amounts of paractamol, ibuprofen (and other nsaids) and diclofenac gel is what we do for arthritis.
I’m the opposite of an expert on migraines, and it looks like I’m technically just wrong. They are super common even in low income countries in the medical literature. After being here for 9 years I think I’ve only clearly diagnosed a migraine twice after seeing many thousands of patients. Maybe many with headaches (that we give ibuprofen to) might technically qualify as migraines but we just diagnose as tension headache. The migraine diagnosis is hardly made by anyone here.
Even with that I’m super dubious about that global burden of disease study which puts Migraine Dalys that nsanely high, but I don’t know enough to specifically criticise.
What this means is that there would be multiple barriers to working on migraines—poor understanding by local clinicians (like me), teaching about correct treatment, then availability. Seems tricky and obviously local doctors here don’t see it as a priority
Hi Nick, A quick comment to thank you for engaging with our work and for your insights. This is super interesting.
This suggests that this could be really cost-effective, considering the price of NSAIDs! However, wouldn’t issues of side effects also occur here? Or is this less of an issue because the gains would be higher?
Thanks Sam
Side effects issue is also there, but like I said it’s more a thing to be aware of, that the intervention can’t be too just spray ibuprofen into the masses (like is often done with malaria medication, ORS for diarrhoea etc.) because there is a relatively common, dangerous side effect. If it’s given after asking the right questions and with good advice, it’s no problem at all—in high income countries. we give out relatively large amounts of NSAIDs without being overly concerned
Preventing the side effects issue is more about good administration, and medications being given after good history taking and diagnosis by a clinician. In high income countries we have no qualms about giving l large amounts of nsaids, as long as we aren’t giving them to people with gastritis, people are taking them with water and food and People understand what symptoms to look for to stop.
It just means it’s a bad idea up have noon qualified prior giving them out like lollies, which does happen a lot. In many western countries nsaids are sold at supermarkets, which shows you it’s not a game changing problem, just one to be careful about.