Page 354 Guide to Pain Management in Low-Resource Settings

342 Claudia Schulz-Gibbins

patients. Good communication and explanations What can we use for chronic
about the existing possibilities of therapy and about back pain?
the prognosis can reduce fears and helplessness, and
enable patients to cope better with the disease and its Chronic back pain, in most cases, is musculoskeletal in
accompanying challenges. Particularly in Kenya, reli- origin, accompanied by poor coping skills along with
gious support has been reported as being helpful. other “yellow fl ags.” A special problem in coping with
back pain is the fact that sometimes no suffi cient expla-
What are the options in chronic nation can be given to the patient regarding the cause
noncancer pain? and origin of the pain. For example, a diagnosis of “non-
specifi c back pain” leads to an extreme uncertainty on
In the context of chronic abdominal pain, which is quite the part of the patient, often leading to increased fear of
often diffi cult for the patient to locate and come to serious pathology and the desire for repeated diagnos-
terms with, often together with the threat of incurability tic procedures. Often there is an iatrogenic component
and looming death. Commonly, the physician wonders, when repeated investigations are ordered—partly be-
“Why is the patient coming now?” Possible reasons for cause the patient insists on it, and partly because the
the patient can be a fear of serious diseases after deaths physician may be uncertain: “Is there a tumor or a seri-
in the family, psychological comorbidities, emotional ous disk prolapse causing the pain?” Th ere may be a re-
distress because of sexual abuse, but also trouble with- luctance “to miss something.”
in the actual context of life and poor coping strategies,
Practical consequences
which may lead to an increase in the pain.
A comprehensive compilation of all available fi ndings,
Practical consequences as well as discussion with colleagues about previous di-
Indicators of stress mentioned above should be looked agnosis and treatment, can be useful to get a complete
for, which can aff ect the development and maintenance picture about the patient. Th e patient should be advised
of pain. Th erapeutic interventions including a good ex- against unnecessary and often very expensive invasive
planation of the disease, continuing psychological sup- diagnostic procedures.
port, advice on balanced nutrition, and so on should be After considering all possible factors including
added over time. psychiatric comorbidity or risks of chronifi cation, a
treatment plan can be developed. Good models on
interactions, for example between depression and
How can we tackle chronic pain, can help the patient to cope successfully
chronic headache? with pain.

Most headaches have no organic cause. Very often we
fi nd interactions between headache and dysfunction- References
al patterns of the muscles, such as increased tension, [1] American Psychiatric Association. Diagnostic and statistical manual of
which can then, by itself, become a trigger for head- mental disorders, 4th ed. Washington, DC: American Psychiatric Asso-
ciation; 1994.
ache. Social stress factors such as excessive demands at [2] Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathol-
ogy: research fi ndings and theoretical considerations. Psychosom Med
the workplace or poor coping strategies with stress, can
2002;64:773–86.
make headaches intense and chronic. [3] Fishbain D, Cutler R, Rosomoff H. Chronic pain-associated depres-
sion: antecedent or consequence of chronic pain? A review. Clin J Pain
1997;13:116–37.
Practical consequences [4] Gureje O, von Korff M, Kola L, Demyttenaere K, He Y, Posada-Villa
J, Lepine JP, Angermeyer MC, Levinson D, de Girolamo G, Iwata N,
Important in the treatment of headache is describing to Karam A, Guimaraes Borges GL, de Graaf R, Browne MA, Stein DJ,
Haro JM, Bromet EJ, Kessler RC, Alonso J. Th e relation between mul-
the patient that stress can lead to an increase in the in-
tiple pains and mental disorders: results from the World Mental Health
tensity and frequency of the headache. Th e most impor- Surveys. Pain 2008;135:82–91.
[5] Merskey H, Lau CL, Russell ES, Brooke RI, James M, Lappano S,
tant psychological interventions are education in coping Neilsen J, Tilsworth RH. Screening for psychiatric morbidity. Th e pat-
skills and in the importance of stress management, and tern of psychological illness and premorbid characteristics in four
chronic pain populations. Pain 1987;30:141–57.
the reduction of hyperactivity with lessons in cognitive [6] Murray SA, Grant E, Grant A, Kendall M. Dying from cancer in devel-
oped and developing countries: lessons from two qualitative interview
behavioral therapy, relaxation techniques, and so on. studies of patients and their carers. BMJ 2003;326:368.