Page 270 Guide to Pain Management in Low-Resource Settings

258 Dilip Pawar and Lars Garten

depressant eff ect as well. Th e most common opioid side because severe withdrawal symptoms may occur. All
eff ect is constipation, not respiratory depression. It is im- instructions should be written out clearly (Fig. 1).
portant to note that pain acts as a natural antagonist to
the analgesic and to the opioid side eff ects of respiratory Pain assessment
depression. However, opioid analgesics should be given
cautiously if the age is less than 1 year. Opioids are not How is pain assessed?
recommended for babies aged less than 3 months, unless
Th e visual analogue scale (VAS) is the gold standard for
very close monitoring in a neonatal intensive care unit is
assessment of pain in adults. Th e traditional scale is a
available, as there is higher risk of respiratory depression
10-cm (100-mm) scale with markings at 1-cm intervals
and low blood pressure.
from 0 to 10. Zero denotes “no pain” and 10 denotes
When can children be treated at home “excruciating pain.” Th e patient is asked to identify the
with oral opioids? mark on the scale that corresponds to his/her degree of

With proper instruction, the administration of oral pain. Th is VAS has been found to be eff ective in chil-
opioids by parents at home is safe. Parents have to be dren from 5–6 years on. Younger children present a
taught that oral opioids are strong pain killers and have real challenge, and the VAS has been modifi ed for ease
to be given to their child as prescribed. Frequency and of comprehension of children by incorporating facial
regularity are important to prevent the return of the expressions at either end or at intervals in the scale. In
pain, and this has to be made clear. Parents have to be a 10-step ladder scale with a toy, a child is asked how
prepared for opioid side eff ects (nausea and drowsi- many steps the toy would be able to climb if it had the
ness, which usually go away after a few days and do same degree of pain. All these scales have been used for
not come back; constipation always occurs). Preven- children 3–5 years of age (Fig. 2).
tive remedies such as dried papaya seeds or a laxative Besides perception of pain, a noxious stimulus
such as senna at night should always be given. Parents produces other physiological and behavioral changes,
should be told to contact a health worker if (1) the which are more marked in children and maybe utilized
pain is getting worse (the dose may be increased), (2) to assess pain. Th e most common changes are:
an extra dose of oral opioid was given to the child, (3) 1) Facial expression with certain degree of pain
drowsiness comes back, or (4) the dose was reduced. (CHEOPS, Oucher, Facial)
Opioid medication MUST NOT be stopped suddenly, 2) Heart rate

Fig. 1. Medication instructions (from: World Health Organization. Palliative care: symptom management and end-of-life care.
Interim guidelines for fi rst-level health workers. World Health Organization; 2004. Reprinted with permission.)