Page 331 Guide to Pain Management in Low-Resource Settings

Setting up a Pain Management Program 319

• First, an introductory advocacy program for the Setting realistic goals: It may be prudent to start
general public and professionals is needed. All with something easily achievable. If the service is part
professionals in the hospital and in the neighbor- of a large department of anesthesiology that already
hood should be off ered the opportunity to attend has a considerable role in postoperative management,
such a program. Th e more people are sensitized, it may be easiest to start a postoperative pain manage-
the better the response to your pain manage- ment program. A cancer hospital may fi nd it easiest to
ment service. All the professionals involved in start with an outpatient facility for cancer pain manage-
some way with the pain management program, ment. A stand-alone service may fi nd it easiest to start a
including nurses, should be able to evaluate pain chronic pain service.
and should understand the fundamentals of pain Multidisciplinary approach: Ideally, pain man-
management. agement should be a multidisciplinary eff ort. Volun-
• Second, the professionals who deliver pain care teers, social workers, nurses, general practitioners,
should all have at least a few weeks’ “hands-on” anesthetists, oncologists, neurologists, psychiatrists,
training such as the certifi cate course described and other specialists all have their roles to play. Howev-
above. er, all these people sitting around a table to care for one
• Th ird (and ideally), at least one or two members patient is an ideal that can never be achieved. It would
of the team should, at the earliest opportunity, make better sense to have a system for consultations
gain the level of expertise that can be obtained when necessary. At the same time, the better the inter-
with a fellowship or diploma program. action is between the social worker, the nurse, and the
pain therapist, the better the outcome is likely to be.
What are the challenges regarding
drug availability? What are the challenges regarding
the goal of pain management?
Matters related to opioid availability, particularly regu-
latory issues, have been dealt with in detail in a sepa- Quality of life as the objective: Th e goal of management
rate chapter. Aff ordability of drugs is a matter of par- should be improved quality of life rather than just treat-
ticular concern in developing countries. Sadly, very ment of pain as a sensation. All the symptoms of the pa-
often, the most expensive medication would be avail- tient must be treated. Given that anxiety and depression
able in developing countries, while the inexpensive form part of the pain problem, there should be routine
drugs tend to slowly fade away and go off the market. screening of patients for psychosocial problems.
Organizations such as regional chapters of Interna- Partnership with the patient and family: Suc-
tional Association for Study of Pain (IASP) have a big cessful pain management would mean an essential part-
role to play in infl uencing national or regional drug nership between the patient, the family, and the thera-
policy so that aff ordable essential drugs are available. pist. Th e nature of the problem and treatment options
Such an eff ort, for example, has resulted in availability must be discussed with the patient and family and a
of a week’s supply of oral morphine for the price of a joint plan arrived at. In developing countries, lack of lit-
loaf of bread in Uganda. eracy is often pointed out as the reason for not giving
enough explanations to the patient. Professionals need
What are the challenges regarding to remember that formal education and intelligence are
institutional policy? not synonymous. Th e illiterate villager, with his experi-
ence of a hard life, is usually able to understand prob-
Whether the pain service is part of a hospital or a lems very well if we remember to avoid jargon and
stand-alone service, some clear policy decisions are speak in his language. And often he will be more capa-
needed. If the service is successful, the demand is likely ble of making diffi cult decisions than a more sophisti-
to be enormous, and soon the service will be fl ooded cated, educated patient.
with patients and the service may fi nd it impossible to Aff ordability of treatment: Aff ordability of a
reach all the needy. Th e following points would be use- treatment modality should be taken into consideration
ful as guiding principles. when treatment options are discussed.