Page 118 Guide to Pain Management in Low-Resource Settings

106 Frank Boni

changes caused by pain threaten the wellbeing and the need treatment, these fi gures suggest that only about
rehabilitation of the patient. Pain is part of the “stress half of patients will need postoperative analgesia after
response complex” to prepare the patient for “fi ght or major surgery. A closer look at publications, which are
fl ight.” Poorly administered analgesia can have some mostly from developed countries, reveals that these fi g-
unwanted eff ects. When we decide to treat pain, we ures are for patients who have had analgesia during and
have to consider the cost implications involved. One after operations and yet still had pain. A good propor-
must therefore understand the pain process and make tion of patients in developing countries will not com-
good use of available resources judiciously, wherever plain of pain—although they may be in agony—because
one is practicing. of cultural and other reasons.
In the absence of reliable data in poorly re-
Some frequently asked questions sourced countries, we can only assume that most pa-
regarding pain after major tients will have moderate to severe pain after major sur-
gery. Th e real incidence of untreated postoperative pain
surgery include:
may never be known because it would be unethical to
• How common is pain after major surgery? carry out properly controlled studies by deliberately al-
• What is the nature of pain and how do we mea- lowing some patients to have pain after major surgery.
sure the severity?
• What are the consequences of inadequate analge- What type of pain is caused
sia after major surgery? by surgical trauma?
• What are our goals in postoperative pain man-
agement? All patients (except a few with abnormal physiology)
• How do patients and type of surgery aff ect our will have acute pain due to actual tissue damage. Most
pain management? pain experts will call such pain “nociceptive pain.” Th e
• Do newborn and unconscious patients have pain tissue damage will provoke chemical and nerve stimula-
after surgery? tion at the local as well as the systemic levels, which can
• What are the pain therapy methods available to provoke many complex responses.
us after major surgery? Th e pain may be due to surgical incisions, tis-
• What roles can patients, relatives, and medical sue manipulation, injury during operations, or position-
staff s play? ing of the patient. On the other hand, the pain may have
• Can we justify the costs and the risks involved in nothing to do with the surgery or the positioning on the
the management of pain? operating room table. It may, for example, be due to pre-
• Does opioid use postoperatively lead to addiction existing arthritis, chest pain, or headache from any cause.
in later life? Whatever the cause or nature of the pains, it is
• Should strong opioids be avoided in very ill poor- the severity that matters most to the patient. A simple
risk patients? and frequently used classifi cation has four levels of pain:
• Is pain threshold higher in patients in less affl uent No pain Grade 0
countries? Mild pain Grade 1
Th ere are many more questions, some of which Moderate pain Grade 2
have been partly answered by the two case scenarios Severe pain Grade 3
presented. Th ese questions can, however, be generalized It is generally accepted that grades 0 and 1 may not
to cover a wider range of patients and issues found in need any treatment, but grades 2 and 3 should be treat-
poorly resourced countries. ed because they can cause signifi cant morbidity.

What is the incidence of pain after What consequences of pain do we
major surgery? expect after major surgery?

Moderate pain has been estimated to be present in Pain, as part of the so-called “postoperative stress syn-
about 33% and severe pain in 10% of patients after ma- drome,” can cause considerable morbidity and even
jor surgery. If all patients with moderate and severe pain mortality. Pain is usually accompanied by hormonal,