Health-seeking dynamics and uptake of ethnomedical therapies for chronic pain among people who use drugs in Nigeria

doi:10.21203/rs.3.rs-3999632/v1

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Research Article

Health-seeking dynamics and uptake of ethnomedical therapies for chronic pain among people who use drugs in Nigeria

https://doi.org/10.21203/rs.3.rs-3999632/v1

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This study explored health-seeking practices and utilization of ethnomedical therapies for chronic pain management among people who use drugs (PWUD) in Nigeria. Data were generated through in-depth interviews with PWUD who had chronic pain (n=26) recruited through snowball sampling in Uyo, Nigeria. Interviews were recorded, transcribed verbatim, coded and analysed thematically. Participants reported challenges with biomedical pain management, including a lack of cure for pain and low adherence to medications due to financial constraints and restrictions on access to pharmaceutical opioids due to concerns about diversion and extra-medical use. These challenges contributed to inadequate biomedical management of chronic pain and encouraged utilization of herbal remedies, including those originating from other ethno-linguistic settings. While some preferred herbal remedies to biomedical care, others used these remedies due to inability to access biomedical pain management. Further, while some found herbal remedies to be helpful in reliving pain, others experienced adverse reactions and sought emergency medical services for this reason. As a result, they disavowed ethnomedical therapies and reaffirmed trust in biomedicine. Participants choose between biomedicine and ethnomedical therapies in managing chronic pain, although these choices were often shaped by structural inequality and the wider context of medical pluralism. Findings indicate a need to promote diversity and choice in healthcare and ensure access to safe, equitable and culturally-appropriate care through expansion of health insurance and formal regulation of ethnomedical providers.

Biomedicine

chronic pain

ethnomedical therapies

herbal remedies

medical pluralism

people who use drugs

Chronic pain has been described as a global health priority owing to its ubiquity, and associated disability and mortality [1]. It is experienced as an ‘intractable condition’ [2], and patients are often disappointed with treatment due to the fact that most existing treatment options produce only modest improvements in physical and emotional functioning [3]. Chronic pain affects about 30% of the world’s population [4], with prevalence estimate of approximately 20% of the adult population in Europe and North America [5–7]. Prevalence is higher in other regions of the world, including and especially Africa (estimated at 57%) [8]. Studies have shown inequalities in the distribution of chronic pain across groups, with individuals from lower socioeconomic groups bearing a disproportionate burden [9]. Further, social inequities impact the management of chronic pain. Studies point to discrimination in diagnosis and treatment settings, and poverty and lack of social support as contributors to under-treatment of chronic pain [10, 11]. The effects of chronic pain include disability and inability to work, which can exacerbate socioeconomic problems [12].

People who use drugs have long been identified as a major at-risk group for chronic pain [13, 14]. In North America, studies suggest that the prevalence of chronic pain would be three times higher among people who use drugs than in the general population [15, 16]. People who use drugs also have a significant unmet need for chronic pain management. They face difficulty accessing biomedical pain management due to stigmatization by healthcare providers, and report dissatisfaction with existing services [17, 18]. Biomedical management of chronic pain for people who use drugs is complicated by physicians’ reluctance to prescribe opioid medications due to increased concerns following recent restrictions on opioid dispensing instituted as part of measures to curb opioid-related harms [19]. Studies have shown how inadequate pain management, linked to institutional policies and negative experiences with providers, lead people who use drugs to adopt different approaches to self-manage pain, including using illegal drugs [20, 21]. Utilization of ethnomedical therapies for the management of chronic pain among people who use drugs is an under-explored topic, although use of alternative medicines for chronic pain has been reported in general population surveys [22, 23].

In this study, I draw on in-depth interviews with people who use drugs living with chronic pain to explore the use of ethnomedical therapies, particularly herbal remedies, for chronic pain management in Nigeria, and the contexts and conditions that shaped their use of these therapies. I situate the analysis within the context of medical pluralism and ethno-cultural patterning of health-seeking behaviours in Nigeria, including utilization of diverse therapies for health needs based on perceived efficacy, accessibility, affordability and responsiveness to economic conditions and cultural values of care-seekers [24]. Anthropological research has revealed dynamism and versatility of health-seeking based on ethnic identity, including uptake of therapies across geographic and ethno-linguistic borders [24, 25]. Building on these studies, I explore the challenges of biomedical pain management for people who use drugs, seeking to highlight how these challenges inform uptake of ethnomedical therapies including those from other ethno-linguistic backgrounds. I also explore contradictions in health-seeking practices and how treatment choices are shaped by structural constraints. The findings will help to broaden understanding of chronic pain management in the context of medical pluralism, as well as inform policies to foster equitable and culturally-appropriate healthcare for people who use drugs.

Paradigmatically, the analysis developed in this article is grounded in a postmodern view of healthcare, which critiques the dominance of western biomedicine and emphasize a need to include multiple perspectives that reflects the complexity of medical practice [26]. A postmodern approach to healthcare recognizes diversity, multiplicity, fragmented specialization, consumerism and choice, which sustains difference and minority identities [27]. As Saks [27] has shown, a postmodern approach recognizes the legitimacy of complementary and alternative medicine in pluralist medical and cultural landscapes. The approach thus lends itself to a patient-centered model of care, which emphasize patients’ values, needs and desires [28]. Following this perspective, I analyse the dynamism and contradictions that characterize the participants health-seeking practices, and the needs, concerns and values that influenced their treatment-seeking decisions. The analysis shows the challenges of biomedical chronic pain management for people who use drugs, indicating a need for approaches based on diversity, equity and cultural-safety.

Chronic pain and healthcare provision in Nigeria

Chronic pain is a major public health problem in Nigeria. The 2008 World Mental Health Survey, which produced the most comprehensive population-level data on chronic pain prevalence available, found that approximately 30% of Nigerians aged 18 years and older had chronic pain [29]. Studies have reported high prevalence of chronic pain among different groups ranging from 50% among secondary school students in the south-west [30], to 62% among fishermen in the south-south geopolitical zone [31], and 73.5% among professional drivers in the north-west [32]. Chronic pain is often associated with terminal illnesses, mental health problems and functional disability [33, 34]. High levels of poverty and difficult working conditions, as well as limited access to healthcare services exacerbate the experience and level of pain [34].

In Nigeria, a range of therapeutic systems exist for the treatment of chronic pain, including biomedicine, ethnomedical therapies, patent medicine stores and faith healing. Biomedical chronic pain management is often inaccessible to most health-seekers due to cost and low expertise in diagnosis and treatment. The public healthcare sector is characterized by under-funding, lack of essential equipment and supplies, and inefficiency [35]. In 2018, only 4% of the federal budget was allocated to health (which is below the 15% commitment in the 2005 Abuja Declaration). Healthcare is financed through out-of-pocket expenses (65% of total health expenditures), resulting in low access to services for the poor [36]. The National Health Insurance Scheme (NHIS), adopted in 2005 to achieve universal health coverage, covers about 4% of Nigerians and mostly formal sector workers [37], excluding those who work in the informal sector. Further, international migration of medical personnel due to poor wages and difficult working conditions, has exacerbated the crisis of public healthcare in Nigeria, contributing to loss of trust in the public healthcare system among Nigerians [38]. Negative attitudes of healthcare workers towards patients from lower socioeconomic backgrounds, often due to lack of incentives, shortage of equipment and poor remuneration, create further barriers to utilization of public health facilities [39].

Studies have reported infrequent assessment, poor diagnosis and inadequate treatment of pain in health facilities in Nigeria [40, 41]. People who use drugs face even greater challenges accessing pain management, and some have reported negative encounters with healthcare workers, including stigma and suspicions of seeking drugs to consume extra-medically [42]. Current restrictions on supply of prescription opioids imposed by the Nigerian government to curb extra-medical use has created further barrier to prescription opioids for patients with a history of drug use, contributing to under-treatment of chronic pain for people who use drugs [42]. Faced with barriers to biomedical pain management, affected patients often turn to alternative therapies. For example, Mbada et al. [43] have reported on the utilization of alternative and complementary medicine for chronic musculoskeletal pain in the general public in southwestern Nigeria. Utilization of patent medicine stores for pain treatment in the general public has also been reported [44]. Igwesi-Chidobe et al. [35] explored use of faith/spiritual healing for chronic low back pain management in rural southeastern Nigeria. The present study contributes to this literature by exploring utilization of herbal remedies for chronic pain management among people who use drugs, an under-researched population in the literature on alternative pain management approaches.

Study setting

The study was designed to explore how people manage chronic pain in the context of illicit drug use and lived experiences of social marginalization. It utilized qualitative methods of data collection and analysis to generate findings that could inform interventions to improve chronic pain management for people who use drugs. The study was conducted in Uyo, the administrative capital of Akwa Ibom state, in the south-south geo-political zone of Nigeria. The city has a land area of 188.035 km². The estimated population of Uyo is 1,294,729 people [45]. Inhabitants include members of different ethnic nationalities such as Hausa, Yoruba and Igbo. The indigenes are the ethnic Ibibio people, a semi-Bantu group [46]. A large proportion (51%) live in extreme poverty [47], which means living on less than one dollar per day. This translates into significant material deprivation, including inability to meet basic needs such as food, shelter and healthcare for majority of people. Most residents earn a living from an expansive and poorly regulated urban informal sector. Population growth and urban expansion have surpassed infrastructural development and provision of basic amenities such as healthcare, housing, electricity and transportation. There is a growing problem of drug use, involving use of both licit and illicit drugs such as alcohol, heroin, cannabis and pharmaceutical drugs. About 12.5% of the population aged 15–64 years used any drug in the past year according to the most recent nation-wide survey [48].

Sampling and participants

Eligible participants were those currently using drugs (i.e., using an illicit drug at least once in the past 30 days) who had chronic pain. A total of 26 participants (21 male and 5 female) were recruited through snowball sampling, where participants are asked to identify others who meet the inclusion criteria and those individuals are in turn asked for further recommendations. Recruitment and interviews lasted between April and June 2022. I relied on contacts from previous research to recruit the first four participants from different locations to facilitate inclusion of people from diverse drug-using networks in the sample. These initial participants started a referral process for the recruitment of others. Participants were aged 21 to 44 years (mean = 32). Most women declined invitation to participate in the study possibly due to fear of stigma. Twenty of the participants were unmarried. Twelve had secondary-level education. Eight were employed in the formal sector in low-wage jobs. Others engaged in informal economic activities such as commercial transportation and carpentry. All participants had chronic pain identified by somatic symptoms, the most common being chest pain. They used different types of drugs, including cocaine, cannabis, and alcohol.

Interviews

Data were generated through in-depth interviews based on a topic guide containing open-ended questions to allow the participants to elaborate on their responses. This flexibility made it possible to explore new themes as they emerged during the interviews. Topics explored in the interviews included healthcare issues related to chronic pain, social and structural factors influencing health-seeking decisions, experiences of stigma in healthcare settings, and alternative pain management approaches utilized. Interviews took place in locations that were suitable for the participants (e.g., bars, cafeteria, drop-in centre for PWUD). This was intended to make them feel comfortable and safe, and to improve the quality of data. Each interview lasted between 35 minutes and 1 hour. Participants were provided adequate information about the research. They gave informed (verbal) consent before interviews, including for audio-recording of responses. Each participant was gifted five hundred-naira (N500/US$1.20) in appreciation. Interviews were transcribed verbatim, checked for accuracy and participants were given pseudonyms for identity protection.

Data analysis

Transcripts were coded based on prior themes in the topic guide (deductive codes) and codes developed through immersion in the transcripts (inductive codes). Data was coded manually by developing codes directly from the data based on key words and concepts in participants’ accounts [49]. This approach helped to improve analytic rigour and transparency. After completing coding, and following Braun and Clarke [50], I searched for and identified themes and sub-themes in the data (e.g., ‘health-care choices’, ‘treatment-seeking trajectory’, ‘barriers to biomedical care’, ‘alternative therapies’, ‘adverse effects’). The themes identified in the data were reviewed by two colleagues and, in the process, coded data that were not suited for particular themes were relocated to more appropriate themes or new ones were created for them. Next, I refined and named the themes (‘challenges with biomedical pain management, ‘utilization of ethnomedical therapies, and ‘adverse effects of ethnomedical therapies), and recorded the patterns of meaning in them. Based on availability, I also asked three participants to assess the analysis for narrative accuracy and interpretive validity (i.e., member checking). They all reported that the analysis captured their intended meanings.

Ethics

All participants were provided adequate information about the study and they gave informed consent to participate in the interviews. The present study used qualitative methods, not experimental methods. Therefore, no guidelines or regulations for reporting experiments with humans was followed. The study was approved by the health research ethics committee of the University of Uyo Teaching Hospital, Akwa Ibom State, Nigeria.

Challenges of biomedical pain management

Accounts highlighted a number of problems related to biomedical care that made it a less viable approach to pain management for most participants. One of such problems was that biomedicine did not provide a lasting solution to pain. Most participants wanted a cure for pain (‘I want something that will cure it, as in forever’). This quest was motivated by a desire to be free from the disruptive effects of chronic pain as well as for the restoration of normal functioning (‘I want to be able to live my life; not to be struggling like this’). Biomedical care was seen as providing only temporary relief from pain, contrary to expectations. Ete-Obong (Male 38, plumber), who had sought care for chronic waist pain at a tertiary health facility, stated:

When I had that pain, I went to the teaching hospital... They gave me drugs to be taking, but the drugs could not cure the pain. They only relieved it for a while. So, the thing lingered like that and will resurface from time to time. When it happens like that, I will go to the hospital. I found out that hospital treatment does not cure chronic pain.

Ete-Obong ‘found out’ through experience that biomedicine does not cure pain, and not from what other people told him. This is important because experiences of failed treatment expectations motivated the quest for alternative therapies. Ete-Obong was not the only person disappointed by the lack of biomedical cure for chronic pain. Ini-Obong (Male 41, mechanic), who had utilized hospital care for chronic chest pain, corroborated:

The pain I had was in one part of my chest like this. When it happens, if I lift a light object like this it will pain me severely. It is up to four months now. The last time I went to the hospital for check-up, the drugs I was given then gave me some relieve from the pain. But when I lift something I will like feel the pain again. I feel it in like one part of my chest.

Ini-Obong worked as an automobile mechanic, which involved lifting objects of different sizes and weights. Inability to perform such tasks due to chronic chest pain could adversely affect his livelihoods. For others, the problem with biomedical care was non-adherence to medications. They described the difficulty involved in taking medications regularly to control their pain in order to engage in daily activities. Mandela (Male 27, security) explained:

The drugs do work. if I continue to take them, I will be relieved. But if I take today and tomorrow, then Monday I don’t, and instead take hard drugs, the pain will still be there. But I have observed that if I take the drugs straight (i.e., consistently), there will be no problem for like one month. But if like, because I feel I know too much, I take today and tomorrow and when I get to the club and use a lot of hard drugs; the effect of the drugs (i.e., pain medications) might not be there.

As seen in Mandela’s account, non-adherence to medications is linked to lack of biomedical cure for chronic pain because patients are required to take these medications routinely to control pain. Apart from consumption of illicit drugs (as in Mandela’s example), non-adherence to medications was also due to limited funds to procure the medications. ‘How will you continue to take the drugs’, asked Mary (Female 27, unemployed), ‘when you don’t even have money to buy them?’. This suggests that financial barriers can make biomedical care unviable to some chronic pain patients by constraining access to essential medications. Restrictions on the supply of opioid analgesics (e.g., tramadol) due to concerns about diversion and extra-medical use also constrained access to pain medications even where patients could afford them. Ete-Obong, who was quoted earlier, narrated how he was denied opioid analgesics by a nurse due to a history of recreational opioids use:

[The] woman gave me drugs, but she didn’t give me the one that should cure the pain because she said I will abuse it. She didn’t give me those ones. She gave me those light ones, and those ones she cut it in half and did not give me full card. She said it is because when I go, the ones she said I should be taking two I may take up to three... She gave me half card and said when it finishes I should come back.

Others did not consider pain to be a condition that warranted going to the hospital. Account highlighted a view of pain as something that required coping or self-management, especially with the help of friends and relations. This is captured in the following comment by Edidiong (Male 39, commercial transporter):

I didn’t go to the hospital because my condition was not a hospital something. It was just a hook that I used to feel in my side. I didn’t know, but they [relatives] now told me that it is the cold wind that I expose myself to that is causing the pain.

In the above quote, pain is portrayed as an occupational hazard that requires coping, and not as a condition that warrants a medical response. The different challenges narrated by the participants contributed to making biomedical care less viable as an approach to chronic pain management, and encouraged most of participants to seek ethnomedical therapies.

Utilization of ethnomedical therapies

Majority of study participants expressed a preference for treating pain with ethnomedical therapies, particularly herbal remedies. Accounts captured different ways of preparing and utilizing herbs for the treatment of pain and other conditions. For example, Amanam (Male 31, landscaper), who said he has never been to the hospital, boils and drinks bitter leaf (Vernonia amygdaline) for his back pain:

…I use bitter leaf. I used to boil it and drink. Even with injury, I put a lot of bitter leaf on the wound to heal it. If I do that for one week, I will not feel the pain again. That is my way that I am explaining. I don’t use tablets or anything. I use bitter leaf and that heat will work.

On the other hand, Obot (Male 22, estate agent) uses herbs for enema or boils and drinks them for pain relief. In his words:

To me, I take enema. I use some native herbs. I pound it, soak it in water, distil it and keep until the next day. Very early I use it to take enema and go my way. If it is heat that is disturbing me, I take that herb. I will get the herb, pound and soak it in water and drink. Then I go my way.

Peter (Male 27, private security) similarly uses herbs for enema to treat pain. He held the view that herbs consumed through enema detoxifies the body, and also contain properties for relieving pain:

I used these our natural roots. I also take enema because you have to take purge. As a man who takes hard things (psychoactive drugs) and do difficult work, you have to take enema to flush your system. It will keep you so that even when you are working, sickness and pain will not affect your body… The herbs have chemicals that can wash somethings from your system and cure pain.

In some cases, utilization of ethnomedical therapies for pain management was based on recommendations from members of participants’ social network, particularly friends and relations. In some ethno-linguistic groups in Nigeria, it is common for people to share their health problems with friends and relations, and for the latter to offer suggestions on where and how to access treatment. For example, Beatrice was advised by family members to manage her pain condition with ethnomedical therapies:

When you tell people about your problem, different solutions will be offered. They will say it is this or that. They will encourage you to go to the herbalist so that he can give you some herbs to use for the condition. So, last week my brother suggested that I handle it the native way. That I should take native medicine for the pain.

Beatrice was counselled to manage pain the ‘native way’. This means to utilize indigenous therapeutic resources (including native herbs) in managing pain, an approach that stands in contrast to biomedicine. Ime (Male 35, unemployed) similarly stated:

People told me about different natural herbs. They say boil this one and drink. Use this one to bath. Rob it on your body. They listed different kinds of things that I don’t even know. They used to give me herbs like that and I will drink it.

Not all study participants who utilized ethnomedical therapies did so because of preference. Accounts indicated that some participants utilized these therapies out of necessity, mostly due to inability to afford biomedical care. In these cases, ethnomedical therapies became a way of managing chronic pain for those who are structurally excluded from biomedical care. The following quote from Akpan (Male 24, unemployed), illustrates this point:

I have gone to the hospital and they wrote so many drugs and said I should take it to the pharmacy. Most of the time the problem is money. That is why I go to native; because I have no help. So, when it happened last month, I said let me take native. Even some of the native herbs are there at home. It is all these herbs that Yoruba people prepare and put them into containers for people to drink.

Here, Akpan, an ethnic Ibibio, utilized Yoruba ethnomedical therapies to treat his pain. This is an adjunct to previous studies which show how people cross ethno-linguistic boundaries in search of ethnomedical therapies in Nigeria [24, 25]. Similar to Akpan, Ukeme (Male 38, Laundry services), who preferred ethnomedical therapies to pharmaceutical drugs nevertheless linked use of ethnomedicine to inability to utilize biomedical care due to financial barriers. In his words:

Naturally, me as I am I don’t really believe in taking medications to start with. If it (pain) happens like this. I will use herbs. I will go to herbalists and they will mix the herbs. I use it to solve my problem because the money is not there to go to the hospital to begin with. There is no money. It is not as if the hospital is not good. But if the money is not there, it is not there. So, you have to look for another solution so that you will not die.

Most of the participants who utilized ethnomedical therapies for pain treatment found them to be helpful, but none reported being cured through this approach. They indicated that they felt much better when they used these therapies. For example, Princewill stated:

The major thing I do is to go to those who deal with native herbs. They will prepare the herbs in hot drinks for me and I drink and see the effects. Based on the description that I gave the woman, how I feel and how I spit blood when I cough. The woman now prepared different types of herbs for me. I drank it and for the two days I stayed there I felt the benefits. As for hospital, I have not gone because of how things are these days.

To sum up, utilization of ethnomedical therapies, partly informed structural barriers to accessing biomedical care, was seen as an affordable and more effective alternative for chronic pain management by some of the participants. As I show in the next section, not all those who had used ethnomedical therapies considered them beneficial and efficacious.

Adverse effects of ethnomedical therapies

Some of the participants who used ethnomedical therapies to treat pain reported adverse reactions that prompted them to seek biomedical intervention. In these cases, biomedical care was sought in response to medical complications linked to utilization of ethnomedical therapies, even though it was not utilized initially due to financial barriers. Emma (Male 38, estate agent) recalled:

I once bought native medicine from these Yoruba people, but it didn’t cure the pain. The thing even became worse. I was almost going to die. So, I opened up to my mumsy [mother] before they took me to the hospital.

Ekom (Male 21, painting) had a similar experience with Hausa herbal remedies, which resulted in him being taken to the hospital by a relation for the management of medical complications. In addition to highlighting adverse effects of using ethnomedical therapies, Ekom’s example highlights a pattern of health-seeking for chronic pain characterized by movements between different therapeutic methods:

My own, somebody advised me to call these Hausa people who sell these native medicines on the streets. He gave me hundred naira, and said I should buy it and drink that it will relieve me. When I bought the medicine and drank, the thing now became worse than before. I called my uncle and told him that I am really feeling unwell. There is something I drank and it is making the situation worse. He now took me to the hospital.

Unlike Akpan, who used Yoruba ethnomedical therapies to good effect, Emma and Ekom both experienced adverse effects from using Yoruba and Hausa therapies respectively. This shows that participants’ experiences with using ethnomedical therapies was not uniform. Similar to Emma, John (Male 26, unemployed), who used ethnomedicine due to lack of better alternatives, advised others against using it:

When I became sick, the family brought money and said they should buy native medicine for me to take. Everything, including things I don’t know about was in it. Local herbs and all. They gave me and I drank. Like they say, ‘a beggar has no choice’… I almost died. So, I don’t advice anyone to use herbs…

Like John, David (Male 36, security) used ethnomedical therapies due to inability to utilize biomedical care. He also experienced adverse effects that made him advise against its use, while reaffirming confidence in the efficacy of biomedicine. I quote him extensively:

I almost died from using herbs. That pain I was experiencing was disturbing me in my chest. I went and cut some leaves. I put so many things. Like eight different types of herbs, according to what I was told. I boiled it and inhaled it. I also did enema with it. I used to go to toilet up to fifteen times in a day. I almost died. So, that herb thing I don’t advice anybody to use it. Sometimes why I use it is because there is no help. Going to the hospital is the number one thing because when you go to the hospital, I like where they go straight to the point and tell you this is the test and they give you the solution and say do this and that. I believe in going for hospital test than to use local herbs because, using my own example, I almost died. I don’t advice people to use herbs.

As seen above, severe adverse effects from consuming herbal remedies reinforced faith in the efficacy and safety of biomedicine. On the other hand, inability to utilize biomedical care due to social and financial barriers encouraged reliance on herbal remedies for pain control.

Some participants did not like using ethnomedical therapies to manage health conditions due to potential adverse effects. This stands in contrast to other’s preference for the use of ethnomedical therapies due to perceived efficacy (discussed in the previous section). These contrasting views further show diversity of experiences with ethnomedical therapies among the participants. Nkweini (Male 26, civil service) stated:

I don’t use anything native. I don’t drink herbs or roots. That is my problem because this native does not work with every person’s body. Especially any native you go to use now they will say you should use it with hot drink. Not everyone takes hot drinks. They say the hot drink is what will make it active and quickly resolve the problem. That is why I have not been able to use native.

The phrase ‘does not work with every person’s body’ captures the relativity of individual’s experiences with using ethnomedical therapies for chronic pain management. Overall, the findings show diversity in the ethnomedical therapies used to manage chronic pain, and also in the participants experiences of utilizing these therapies.

This qualitative study explored how the participants choose between biomedicine and ethnomedical therapies to manage chronic pain, and the factors and contexts that shaped their choices. Findings revealed a number of challenges with biomedical pain management, which made it less viable for some participants and motivated them to use ethnomedical therapies. A key factor was the expectation of a cure. Participants sought a cure for pain in order to reverse its negative effects and to return to normal functioning, including being able to undertake economic activities. Across interviews, however, biomedicine was said to offer only temporary relief from pain, and not a cure. Previous studies have shown that patients are often dissatisfied with treatment due to the fact that most treatment options produce only modest improvements in physical functioning [3]. This study builds on this finding to highlight how this outcome encouraged some participants to resort to ethnomedical therapies in a search for more efficacious therapies. The search for more effective therapies was informed by a desire to regain functioning and to re-engage with economic activities [12]. The study thus highlights how the socioeconomic impacts of chronic pain influences healthcare expectations and treatment-seeking decisions.

Poor adherence to pain medications due to illicit drug use, inability to procure medications owing to low finances, and restrictions on prescribing of opioid analgesics for patients with a history of drug use also contributed to inadequate biomedical management of chronic pain for most of the participants. Studies from North America have shown how restrictions on prescribing of opioids for patients with addiction risk factors (such as pre-existing drug use problems) and prejudices toward people with opioid use disorder considered to be ‘drug-seeking addicts’ limits access to pharmaceutical opioids for pain management, contributing to undertreatment of chronic pain in this population [19]. In Nigeria, previous research has described barriers to accessing pharmaceutical opioids for pain management resulting from healthcare provider stigma and current restrictions on prescription of opioid analgesics for pain relief for people with a history of drug use [42]. Building on these findings, the present study shows how restrictions on access to opioids, operating as part of multi-level barriers to medication adherence that included socioeconomic barriers and illegal drug use, contributed to under-treatment of chronic pain. This implies that in addition to treating co-occurring substance use disorders, health policy changes and expansion of health insurance coverage are needed to improve uptake of biomedical care for chronic pain patients experiencing marginalization linked to poverty and drug use.

Chronic pain was seen by some participants as a condition that could be self-managed with ethnomedical therapies from diverse ethno-linguistic backgrounds. This builds on previous findings on self-management of chronic pain among individuals with a history of drug use. For example, Boucher et al. [20] have described self-medication with non-prescription drugs, while Behar et al. [21] reported the use of non-pharmacological approaches and consumption of illegal drugs. This study contributes to the existing literature by describing self-management of chronic pain with ethnomedical therapies, particularly herbal remedies, often following dissatisfaction with biomedical care. This approach to chronic pain self-management should be understood within the unique context of healthcare-seeking in Nigeria, where a variety of therapeutic traditions such as biomedicine, ethnomedical therapies and faith healing coexist and health-seekers choose alternately from these options to address their health conditions [24]. The findings further show that alternation between different therapeutic methods is partly the product of social and structural barriers to utilization of biomedical services. In other words, study participants in most cases switched to ethnomedical therapies because they could not adequately utilize biomedical services due to cost, lack of social support and inequitable health policies.

Further, research on utilization of ethnomedical therapies in Nigeria has documented a pattern of utilization where individuals cross ethno-linguistic borders in search of potent therapies for their conditions. For example, Izugbara and colleagues [24, 25] have documented trans-ethnic travels for ethnomedical care where members of the Igbo ethno-linguistic group in south-eastern Nigeria travel to Ibibio ethnic group in the south-south to obtain efficacious ethnomedical therapies for different conditions. This study contributes to the literature on utilization of ethnomedical therapies across ethno-linguistic borders by capturing how the management of chronic pain in the context of social marginalization involves utilization of ethnomedical therapies from other ethno-linguistic groups due to affordability and reputation of therapeutic efficacy. Unlike in previous research, participants in the present study did not travel across geographical borders in search of ethnomedical therapies. Instead, they used ethnomedical therapies from other ethnolinguistic backgrounds that were already available within their localities. These therapies were peddled by medicine dealers from other ethno-linguistic settings, suggesting a reversed pattern of transethnic travel for ethnomedicine where medicine dealers move across ethno-linguistic borders in search of markets for their remedies. The finding captures a key emphasis in the postmodern approach to healthcare, which is the importance of cultural values in treatment choices [27], although these choices were made in the context of structural constraints.

Interviews revealed complexity and dynamism in health-seeking for chronic pain. For example, some participants utilized ethnomedical therapies as a treatment of choice owing to what they considered the detoxifying and pain-relieving effects of some herbal remedies. This suggests a preference for herbal remedies over biomedical pain treatment. Others utilized ethnomedical therapies as an alternative approach due to economic barriers to biomedical care. In this scenario, the choice was not based on personal preference, but on structural constraints. On one hand, ethnomedical therapies were used because they were responsive to economic needs and cultural values of participants. On the other hand, it was partly influenced by financial cost and other factors that made biomedical care inaccessible to these participants. This shows that utilization of ethnomedicine is paralleled by under-utilization of biomedicine. Although the choice of ethnomedicine was based on cultural values, socioeconomic conditions operated as the wider context shaping these choices. The implication of this finding for policy is that while it is important to promote diversity and choice in healthcare, expanding the options available to patients, especially the poor and marginalized, through removal of structural barriers to biomedicine, is equally essential.

Findings also highlight contradictions in healthcare service utilization within the context of medical pluralism. On one hand, ethnomedical therapies were seen by some participants as a more effective therapeutic method than biomedicine. On the other hand, some refused to utilize ethnomedical therapies mostly due to concerns about adverse reactions. Those who had experienced adverse reactions and medical complications associated with utilization of herbal remedies disavowed these remedies and (re)affirmed confidence in biomedical care. Overall, findings reveal diversity in the healthcare experiences of the participants. Viewed from a postmodern standpoint, findings show dynamism and pragmatism in health-seeking influenced by diverse factors and considerations, including shifting notions of therapeutic reputation as well as participants expectations, experiences and social locations. Worthy of note is the situation where those who could not utilize biomedicine owing to socioeconomic barriers eventually used it after experiencing adverse reactions from herbal remedies. This buttresses the importance of expanding options for patients so they can choose healthcare approaches that are suitable and appropriate for them. This approach, which resonates with a patient-centered model of care, could help to reduce risks and improve health outcomes for people who use drugs.

The study has a number of limitations that should be considered. First, the study population consists of people with a history of drug use in an urban centre in south-south Nigeria. This means that the findings may not be generalized to other populations and settings. Also, there may have been biases in how participants portrayed their preferred therapeutic method vis-à-vis alternatives. For example, adverse reactions from herbal remedies may have been exaggerated to disavow it (previous studies show minimal side-effects from herbal remedies used for chronic pain – see Mbada et al., [43]). Crucially, under-representation of women in the sample makes it difficult to adequately capture their experience of using ethnomedical therapies to manage chronic pain. Future studies should focus on women and other marginalized patient groups to enable better understanding of uptake of ethnomedical therapies for chronic pain.

The study has shown how chronic pain patients with a history of drug use choose between biomedicine and ethnomedical therapies to manage chronic pain. It further shows how such choices where shaped by participants’ healthcare expectations, the reputations of different therapeutic traditions, lived experience of utilization of therapeutic method, and structural barriers to biomedical care. Health-seeking and chronic pain management practices were situated within a wider context of structural inequality and a pluralist medical landscape. Findings highlight a need to tailor interventions to the needs and experiences of chronic pain patients experiencing poverty and marginalization linked to illegal drug use. This calls for improving access to biomedical care for chronic pain through addressing social and structural barriers to service utilization. One way this could be achieved is to expand health insurance coverage to include the informal sector, where most of our participants worked. It is also important to promote diversity and choice in healthcare service, including access to safe ethnomedical therapies for those who prefer them. Formal regulation of ethnomedical providers, research to build the evidence base for the efficacy and safety of different herbal remedies are key to ensuring access to equitable and culturally-safe healthcare for chronic pain for people who use drugs.

Competing interests:

The authors declare no financial and non-financial interests that are directly on in-directly related to this work.

Ethical approval:

The study was approved by health research ethics committee of the University of Uyo Teaching Hospital, Akwa Ibom State, Nigeria.

Author Contribution

EEN - conceptualization; data curation; formal analysis; investigation; methodology; project administration; validation;visualization; writing—original draft and editing

Data Availability

Data available upon request

Zimmer, Z., Zajacova, A., & Grol-Prokopczyk, H. (2020). Trends in pain prevalence among adults aged 50 and older across Europe, 2004 to 2015. Journal of Aging and Health, 32(10), 1419–1432.
Lillrank, A. (2003). Back pain and the resolution of diagnostic uncertainty in illness narratives. Social Science & Medicine, 57(6), 1045–1054.
Turk, D. C., Wilson, H. D., & Cahana, A. (2011). Treatment of chronic non-cancer pain. The Lancet, 377(9784), 2226–2235.
Cohen, S. P., Vase, L., & Hooten, W. M. (2021). Chronic pain: an update on burden, best practices, and new advances. The Lancet, 397(10289), 2082–2097.
Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain, 10(4), 287–333.
Schopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada. Pain research and management, 16, 445–450.
Morris, L. D., Daniels, K. J., Ganguli, B., & Louw, Q. A. (2018). An update on the prevalence of low back pain in Africa: a systematic review and meta-analyses. BMC Musculoskeletal Disorders, 19(1), 1–15.
Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, L., … Helmick, C. (2018). Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. Morbidity and Mortality Weekly Report, 67(36), 1001.
Craig, K. D., Holmes, C., Hudspith, M., Moor, G., Moosa-Mitha, M., Varcoe, C., & Wallace, B. (2020). Pain in persons who are marginalized by social conditions. Pain, 161(2), 261.
Ghoshal, M., Shapiro, H., Todd, K., & Schatman, M. E. (2020). Chronic noncancer pain management and systemic racism: Time to move toward equal care standards. Journal of pain research, 13, 2825–2836.
Nelson, E. U. E., & Kitchen, C. (2023). Cannabis use for pain relief in the context of health service barriers: Accounts of street-involved Nigerian women suffering chronic pain. Drug and Alcohol Review, 42(2), 309–317.
Allen, C., Murphy, A., Kiselbach, S., VandenBerg, S., & Wiebe, E. (2015). Exploring the experience of chronic pain among female Survival Sex Workers: a qualitative study. BMC Family Practice, 16, 1–8.
Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., … Vallerand, A. H. (2003). The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain medicine, 4(3), 277–294.
Clark, M. R., Stoller, K. B., & Brooner, R. K. (2008). Assessment and management of chronic pain in individuals seeking treatment for opioid dependence disorder. The Canadian Journal of Psychiatry, 53(8), 496–508.
Heimer, R., Zhan, W., & Grau, L. E. (2015). Prevalence and experience of chronic pain in suburban drug injectors. Drug and alcohol dependence, 151, 92–100.
Bell, K., & Salmon, A. (2009). Pain, physical dependence and pseudoaddiction: Redefining addiction for ‘nice’ people?. International Journal of Drug Policy, 20(2), 170–178.
Buchman, D. Z., Ho, A., & Illes, J. (2016). You present like a drug addict: patient and clinician perspectives on trust and trustworthiness in chronic pain management. Pain Medicine, 17(8), 1394–1406.
Dassieu, L., Kaboré, J. L., Choinière, M., Arruda, N., & Roy, É. (2019). Chronic pain management among people who use drugs: A health policy challenge in the context of the opioid crisis. International Journal of Drug Policy, 71, 150–156.
Behar, E., Bagnulo, R., Knight, K., Santos, G. M., & Coffin, P. O. (2020). “Chasing the pain relief, not the high”: experiences managing pain after opioid reductions among patients with HIV and a history of substance use. PloS one, 15(3), e0230408.
Boucher, L. M., Shoemaker, E. S., Liddy, C. E., Leonard, L., MacPherson, P. A., Presseau, J., … Kendall, C. E. (2022). “They’re all struggling as well”: social and economic barriers and facilitators to self-managing chronic illness among marginalized people who use drugs. International Journal of Qualitative Studies on Health and Well-being, 17(1), 2082111.
Artus, M., Croft, P., & Lewis, M. (2007). The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain. BMC family practice, 8(1), 1–14.
Grazio, S., & Balen, D. (2011). Complementary and alternative treatment of musculoskeletal pain. Acta Clinica Croatica, 50(4), 513–530.
Izugbara, C. O., Etukudoh, I. W., & Brown, A. S. (2005). Transethnic itineraries for ethnomedical therapies in Nigeria: Igbo women seeking Ibibio cures. Health & Place, 11(1), 1–14.
Izugbara, C. O., & Afangideh, A. I. (2005). Urban women’s use of rural-based health care services: the case of Igbo women in Aba City, Nigeria. Journal of Urban Health, 82, 111–121.
Holmes, D., Murray, S. J., Perron, A., & Rail, G. (2006). Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. International Journal of Evidence‐Based Healthcare, 4(3), 180–186.
Saks, M. (1998). Medicine and complementary medicine: challenge and change. In: Scambler, G. & Higgs, P. (eds.). Modernity, medicine and health: medical sociology towards 2000. (pp. 199–215). New York: Routledge.
Constand, M. K., MacDermid, J. C., Dal Bello-Haas, V., & Law, M. (2014). Scoping review of patient-centered care approaches in healthcare. BMC health services research, 14, 1–9.
Tsang, A., Von Korff, M., Lee, S., Alonso, J., Karam, E., Angermeyer, M. C., … Watanabe, M. (2008). Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. The journal of pain, 9(10), 883–891.
Adegoke, B. O., Odole, A. C., & Adeyinka, A. A. (2015). Adolescent low back pain among secondary school students in Ibadan, Nigeria. African Health Sciences, 15(2), 429–437.
Dienye, P. O., Birabi, B. N., Diete-Spiff, K. O., & Dienye, N. P. (2016). The burden of low back pain among fishermen: A survey in a rural fishing settlement in Rivers State, Nigeria. American Journal of Men's Health, 10(6), NP89-NP98.
Rufa’i, A. A., Sa’idu, I. I. A., Ahmad, R. I. Y., Elmi, O. S., Aliyu, S. U., Jajere, A. M., & Digil, A. A. (2015). Prevalence and risk factors for low back pain among professional drivers in Kano, Nigeria. Archives of environmental & occupational health, 70(5), 251–255.
Gureje, O., Von Korff, M., Kola, L., Demyttenaere, K., He, Y., Posada-Villa, J., … Alonso, J. (2008). The relation between multiple pains and mental disorders: results from the World Mental Health Surveys. PAIN®, 135(1–2), 82–91.
Igwesi-Chidobe, C. N., Sorinola, I. O., Kitchen, S., & Godfrey, E. L. (2018). Unconventional practitioners’ causal beliefs and treatment strategies for chronic low back pain in rural Nigeria. Health services insights, 11, 1178632918808783.
Oyekale, A. S. (2017). Assessment of primary health care facilities’ service readiness in Nigeria. BMC health services research, 17(1), 1–12.
Odunyemi, A. E. (2021). The Implications of Health Financing for Health Access and Equity in Nigeria. In Argawal, A. & Kosgi, S. (eds.) Healthcare Access (pp. 1–16). London: IntechOpen.
Olaniyan, O., & Oburota, C. S. (2019). Equitable health care financing and universal health care coverage in Nigeria. African Journal of Health Economics, 8, 25–31.
Salami, B., Dada, F. O., & Adelakun, F. E. (2016). Human resources for health challenges in Nigeria and nurse migration. Policy, Politics, & Nursing Practice, 17(2), 76–84.
Anyebe, E. E., Olisah, V. O., Garba, S. N., Murtala, H. H., & Danjuma, A. (2021). Barriers to the provision of community-based mental health services at primary healthcare level in northern Nigeria–A mixed methods study. International Journal of Africa Nursing Sciences, 15, 100376.
Faponle, A. F., Soyannwo, O. A., & Ajayi, I. O. (2001). Post operative pain therapy: a survey of prescribing patterns and adequacy of analgesia in Ibadan, Nigeria. The Central African journal of medicine, 47(3), 70–74.
Kolawole, I. K., & Fawole, A. A. (2003). Postoperative pain management following caesarean section in University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria. West African journal of medicine, 22(4), 305–309.
Nelson, E. U. E. (2022). Structural violence and barriers to pain management during an opioid crisis: accounts of women who use drugs in Nigeria. Health Sociology Review, 31(3), 232–246.
Mbada, C. E., Adeyemi, T. L., Adedoyin, R. A., Badmus, H. D., Awotidebe, T. O., Arije, O. O., & Omotosho, O. S. (2015). Prevalence and modes of complementary and alternative medicine use among peasant farmers with musculoskeletal pain in a rural community in South-Western Nigeria. BMC complementary and alternative medicine, 15(1), 1–7.
Abdu-Aguye, S. N., Shehu, A., & Ahmad, U. I. (2017). Management of musculoskeletal pain in retail drug outlets within a Nigerian community: a descriptive study. Pharmacy Practice (Granada), 15(1).
World Bank. (2020). Population Stat 2017–2020. Geneva. Accessed on 14 August, 2020. https://populationstat.com/nigeria/uyo.
Ekong, E. E. (2001). The Sociology of The Ibibio: A Study of Social Organization and Change. Uyo: Modern Business Press.
National Bureau of Statistics (2010). National poverty rates for Nigeria: 2003–200 and 2009–2010. Abuja: NBS.
United Nations Office on Drugs and Crime (2019). Drug use in Nigeria 2018. Vienna: UNODC.
Linneberg, M. S., & Korsgaard, S. (2019). Coding qualitative data: A synthesis guiding the novice. Qualitative Research Journal, 19(3), 259–270.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

No competing interests reported.

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Health-seeking dynamics and uptake of ethnomedical therapies for chronic pain among people who use drugs in Nigeria

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Abstract

Introduction

Chronic pain and healthcare provision in Nigeria

Methods

Study setting

Sampling and participants

Interviews

Data analysis

Ethics

Results

Challenges of biomedical pain management

Utilization of ethnomedical therapies

Adverse effects of ethnomedical therapies

Discussion

Conclusion

Declarations

Author Contribution

Data Availability

References

Additional Declarations

Status:

Version 1