Page 22 Guide to Pain Management in Low-Resource Settings

10 Olaitan A Soyannwo

and over-the-counter (OTC) medications. Th ese can be postgraduate health care students, and also incorpo-
simple analgesics, herbal preparations, or complementa- rated into continuing education programs. Several or-
ry drugs. Self-prescription and recommendations from ganizations have produced comprehensive educational
nonmedical practitioners (friends, relatives, other pa- packages, protocols, and guidelines for clinical practice,
tients, patent medicine vendors, and traditional medi- including IASP (www.iasp-pain.org). However, these
cal practitioners) are common. Such recommendations items must be adapted to be cost eff ective and culturally
may be eff ective for simple, uncomplicated pain, but appropriate.
when pain is severe or persistent, patients then go to
the hospital as a last resort. In the hospital setting, most Poor attitudes among health care professionals
pain problems are treated by general medical practi- Often patients are denied appropriate analgesics when
tioners, family physicians, or fi rst-line specialists such prescribed because the health professionals who are
as orthopedic surgeons, neurologists, and oncologists. supposed to administer the drugs are too busy, are not
Pain management specialists and dedicated pain clinics interested, or refuse to believe the patient’s complaint.
or acute pain teams are few and sometimes nonexistent
Inadequate resources
in many resource-poor countries. Th us, although re-
lief of pain is part of the fundamental right to the high- Due to staffi ng, equipment, and fi nancial constraints,
est attainable standard of health, this aim is diffi cult to facilities for pain services are grossly inadequate or non-
achieve in low-resource countries, where most of the existent in many developing countries. Th e inadequate
population lives in rural areas. Frequently, health care is resources preclude the organization of acute pain teams
delivered by a network of small clinics—some without and chronic pain clinics, which are widely used in de-
doctors or essential analgesics. Even when doctors are veloped countries to provide eff ective pain control using
available, for example for surgery, patients expect pain evidence-based methods, education, advice on diffi cult
as an inevitable part of surgical intervention, and de- pain problems, and research. In the developing world,
spite the high incidence of reported pain, may still rate improvements in acute pain management are most like-
“pain relief” as satisfactory. ly to result from eff ective training programs, use of mul-
timodal analgesia, and access to reliable drug supplies.
Why is it diffi cult to provide
Lack of opioid analgesics
eff ective pain management?
Moderate to severe pain requires opioid analgesics for
Lack of knowledge treatment as proposed by the WHO analgesic ladder,
Inadequate knowledge among health care profession- which has also been adopted by the World Federation
als in low-resource countries is one of the major ob- Societies of Anaesthetists (WFSA). Unfortunately, in
stacles to eff ective pain management. Comprehensive many low-resource countries, fears (opiophobia), con-
pain assessment and multimodal treatment approach- cerns, and myths about opioid use focus more on toler-
es are poorly understood since pain is mostly taught ance, dependence, and addiction, which should normal-
as a symptom of disease rather than an experience ly not preclude appropriate medical use of opioids. In
with physical, psychosocial, and other dimensions. 1996, the International Narcotics Control Board (INCB)
Lack of training and myths may lead to unreasonable made recommendations which led to the publication of
fears of side eff ects of opioid analgesics and errone- the WHO guideline manual “Achieving Balance in Na-
ous beliefs about the risk of addiction, even in cancer tional Opioid Control Policy (2000)”. Th e manual ex-
patients. Patients may also have a poor understanding plains the rationale and imperative for the use of opioid
of their own medical problems, and may expect pain, analgesics.
which they think has to be endured as an inevitable
Lack of government priority
part of their illness.
Hence appropriate education is essential for National policies are the cornerstone for implementa-
all health professionals involved in pain management, tion of any health care program, and such policies are
and multidisciplinary teamwork is central to successful lacking in many low-resource countries. Eff ective pain
pain management. Pain education should be included management can only be achieved if the government
in the curricula and examination of undergraduate and includes pain relief in the national health plan. Policy