Guide to Pain Management in Low-Resource Settings


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Guide to Pain Management in Low-Resource Settings
Edited by Andreas Kopf and Nilesh B. Patel
INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN®

IASP
®
 • SEATTLE
Guide to Pain Management in Low-Resource Settings
Educational material written for general distribution 
to health care providers by a multidisciplinary 
and multinational team of authors
Editors
Andreas Kopf, MD
Department of Anesthesiology
Charité Medical University
Berlin, Germany 
Nilesh B. Patel, PhD
Department of Medical Physiology
University of Nairobi
Nairobi, Kenya

© 2010 IASP
®
International Association for the Study of Pain
®
All rights reserved. Th
  is material may be used for educational and training purposes with proper citation of the source. 
Not for sale or commercial use.
Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions 
expressed have not involved any verifi cation of the fi ndings, conclusions, and opinions by IASP®. Th
  us, opinions expressed in 
Guide to Pain Management in Low-Resource Settings do not necessarily refl ect those of IASP or of the Offi
  cers and Councilors. 
No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, neg-
ligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid 
advances in the medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and 
drug dosages. Th
  e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or 
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the 
text. Errors and omissions are expected.
Supported by an educational grant from the International Association for the Study of Pain
A preliminary version of this text was printed in 2009

iii
Contents
Foreword 
vii
Introduction 
ix
Basics
1. History, Defi nitions, and Contemporary Viewpoints 
3
Wilfried Witte and Christoph Stein
2. Obstacles to Pain Management in Low-Resource Settings 
9
Olaitan A Soyannwo
3.  Physiology of Pain 
13
Nilesh B. Patel 
4.  Psychological Factors in Chronic Pain 
19
 Harald C. Traue, Lucia Jerg-Bretzke, Michael Pfi ngsten, and Vladimir Hrabal
5.  Ethnocultural and Sex Infl uences in Pain 
27
Angela Mailis-Gagnon
6.  Pharmacology of Analgesics (Excluding Opioids) 
33
Kay Brune
7.  Opioids in Pain Medicine 
39
Michael Schäfer
8.  Principles of Palliative Care 
47
Lukas Radbruch and Julia Downing
9. Complementary Th
  erapies for Pain Management 
59
Barrie Cassileth and Jyothirmai Gubili
Physical and Psychological Patient Evaluation
10. Pain History and Pain Assessment 
67
Richard A. Powell, Julia Downing, Henry Ddungu, and Faith N. Mwangi-Powell
11. Physical Examination: Neurology 
79
Paul Kioy and Andreas Kopf
12. Physical Examination: Orthopedics 
87
Richard Fisher 
13. Psychological Evaluation of the Patient with Chronic Pain 
93
Claudia Schulz-Gibbins
Management of Acute Pain
14. Pain Management after Major Surgery 
103
Frank Boni
15. Acute Trauma and Preoperative Pain 
115
O. Aisuodionoe-Shadrach
16. Pain Management in Ambulatory/Day Surgery 
119
Andrew Amata
17. Pharmacological Management of Pain in Obstetrics 
123
Katarina Jankovic

iv
Contents
Management of Cancer Pain
18. Abdominal Cancer, Constipation, and Anorexia 
137
Andreas Kopf
19. Osseous Metastasis with Incident Pain 
147
M. Omar Tawfi k
20. Lung Cancer with Plexopathy 
155
Rainer Sabatowski and Hans J. Gerbershagen
21. Lung Cancer with Breathing Problems 
163
Th
 omas Jehser
22. Hematologic Cancer with Nausea and Vomiting 
169
Justin Baker, Paul Ribeiro, and Javier Kane
Management of Neuropathic Pain
23. Painful Diabetic Neuropathy 
179
Gaman Mohammed
24. Management of Postherpetic Neuralgia 
183
Maged El-Ansary
25. Central Neuropathic Pain 
189
Maija Haanpää and Aki Hietaharju
26. Th
  e Management of Pain in Adults and Children Living with HIV/AIDS 
195
 Glenda E. Gray, Fatima Laher, and Erica Lazarus
Management of Chronic Noncancer Pain
27. Chronic Nonspecifi c Back Pain 
207
 
Mathew O.B. Olaogun and Andreas Kopf
28. Headache 
213
 
Arnaud Fumal and Jean Schoenen 
29. Rheumatic Pain 
221
Ferydoun Davatchi
Diffi
  cult Th
  erapeutic Situations and Techniques
30. Dysmenorrhea, Pelvic Pain, and Endometriosis 
229
 
Susan Evans
31. Pain Management Considerations in Pregnancy and Breastfeeding 
235
Michael Paech
32. Pain in Sickle Cell Disease 
245
Paula Tanabe and Knox H. Todd
33. Complex Regional Pain Syndrome 
249
 
Andreas Schwarzer and Christoph Maier
34. Pain Management in Children 
255
Dilip Pawar and Lars Garten
35. Pain in Old Age and Dementia 
269
Andreas Kopf
36. Breakthrough Pain, the Pain Emergency, and Incident Pain 
277
Gona Ali and Andreas Kopf
37. Pain Management in the Intensive Care Unit 
283
Josephine M. Th
  orp and Sabu James
38. Diagnostic and Prognostic Nerve Blocks 
293
Steven D. Waldman

Contents
v
39. Post-Dural Puncture Headache 
299
Winfried Meissner
40. Cytoreductive Radiation Th
 erapy 
303
Lutz Moser 
41. Th
  e Role of Acupuncture in Pain Management 
307
Natalia Samoilova and Andreas Kopf
Planning and Organizing Pain Management
42. Setting up a Pain Management Program 
317
M.R. Rajagopal
43. Resources for Ensuring Opioid Availability 
321
David E. Joranson
44. Setting up Guidelines for Local Requirements 
329
Uriah Guevara-Lopez and and Alfredo Covarrubias-Gomez
Pearls of Wisdom
45. Techniques for Commonly Used Nerve Blocks 
337
Corrie Avenant 
46. Psychological Pearls in Pain Management 
341
Claudia Schulz-Gibbins
47. Clinical Physiology Pearls 
345
Rolf-Detlef Treede
48. Herbal and Other Supplements 
349
Joel Gagnier
49. Profi les, Doses, and Side Eff ects of Drugs Commonly Used in Pain Management 
351
Barbara Schlisio
Appendix
Glossary 
359
Andreas Kopf

vii
Foreword
Th
  e belief that pain treatment is a human right has been 
accepted by many for a long time, but in 2004 the state-
ment that “the relief of pain should be a human right” 
was felt to be of suffi
  cient importance for it to be pub-
lished following the launch of the fi rst Global Campaign 
Against Pain in Geneva in 2004 by the International 
Association of Pain (IASP), the European Federation 
of Chapters of the IASP (EFIC), and the World Health 
Organization (WHO). Unfortunately, however, a large 
number of those who suff er pain, and especially the 
people of developing countries, do not receive treat-
ment for acute and, more especially, chronic pain.
Th
 ere are various reasons for this problem, 
which include a lack of adequately trained health pro-
fessionals, the unavailability of drugs, especially opi-
oids, and a fear of using opioids because there is an 
erroneous belief that inevitably the use of these drugs 
will cause addiction. Th
 e fi rst major step in improv-
ing services for pain patients is to provide an educated 
workforce in developing countries—not only doctors 
and nurses, but district offi
  cers and other health work-
ers. A survey by IASP in 2007 revealed that among its 
members in developing countries, very few believed 
they had received an adequate education in the under-
standing and management of pain as undergraduates. 
In most regions of the world, less than half had been 
trained in pain management, even though it was a sig-
nifi cant part of their daily work. It is not surprising, 
therefore, that 91% said that lack of education was the 
main barrier to good pain management in their part of 
the world.
It is clear that in many developing countries, re-
lief of pain is not a priority, and that concern with infec-
tious diseases such as malaria, tuberculosis, and above 
all HIV/AIDS takes precedence. In fact, 75% of those 
who responded to the IASP survey considered a lack of 
government priorities for pain management as the sec-
ond most common barrier to good treatment. Almost as 
many reported that a fear of addiction to opioids among 
doctors, nurses, and health providers was a barrier to 
the availability and use of those drugs, although, in fact, 
such fear is primarily a consequence of poor education.
Th
  e production of this manual is timely because 
it will fi ll a major gap in the knowledge of those who 
deal with people in pain in developing countries. It cov-
ers the basic science of pain, and perhaps uniquely, the 
rationale for the use of natural medicines. It also pro-
vides background knowledge and advice on the man-
agement of the major painful disorders occurring in de-
veloping countries, including the two major scourges of 
the present time—cancer and HIV/AIDS.
Th
  is is a book that should be available to all 
who are responsible for providing treatment for pain, 
whether acute or chronic, and whether they work in 
cities, towns, or in a much more rural settings, because 
all will fi nd it an invaluable aid to their practice.
Professor Sir Michael Bond
Glasgow, Scotland
August 2009

ix
Introduction
Pain is widely undertreated, causing suff ering and fi -
nancial loss to individuals and to society. It is believed 
that health care of all patients should include assess-
ment of pain and its impact on the patient, specifi c ef-
forts by health care professionals to control pain, and 
the development of programs to generate experts in 
pain management. Additionally, clinical and basic sci-
ence research is to be encouraged to provide better 
care in the future. Th
  e aim of these eff orts is to ensure 
that pain control receives high priority in the health 
care system.
Th
 is book, Guide to Pain Management in Low-
Resource Settings, is intended to encourage research 
on pain mechanisms and pain syndromes and help 
improve the management of patients with acute and 
chronic pain by bringing together basic scientists, phy-
sicians, and other health professionals of various disci-
plines and backgrounds who have an interest in pain.
Th
 e target audience is basic research and preclinical 
staff , surgical and internal medicine practitioners of all 
disciplines, anesthetists and anesthesiologists, all ad-
vanced nursing staff , and local health care workers in 
district and mission hospitals, as well as medical and 
nursing students.
In low-resource settings, many health care 
workers have little or no access to basic, practical in-
formation. Indeed, many have come to rely on obser-
vation, on advice from colleagues, and on building 
experience empirically through their own treatment 
successes and failures. Th
  e disparity of theoretical and 
practical availability of information is due to several 
factors, including unequal distribution of Internet ac-
cess, and also a failure of international development 
policies and initiatives, which have tended to focus 
on innovative approaches for higher-level health pro-
fessionals and researchers while ignoring, relatively 
speaking, other approaches that remain essential for 
the vast majority of primary and district health work-
ers. Th
 e information poverty of health workers in 
low-resource settings is exacerbating what is clearly a 
public health emergency. Primary and district health 
workers should be at the center of eff orts to address 
this crisis. Th
  e availability of health information may 
provide confi dence in clinical decision-making, im-
proving practical skills and attitudes to care.
Information on pain and pain management is 
crucial. All health care workers will see patients suf-
fering from pain. Pain is the main reason for seeking 
medical help. Th
  us, any physician, nurse, or other clini-
cal worker needs to have basic knowledge about the 
pathophysiology of pain and should be able to use at 
least simple fi rst-line treatments. Unlike “special pain 
management,” which should be reserved for specialist 
physicians with specifi c postgraduate training in com-
plex pain syndromes, knowledge of “general pain man-
agement” is a must for all other health care workers to 
prepare them for the majority of patients in pain with 
common pain syndromes.
Th
  e editors intend that with the help of this 
Guide the reader will be know how to identify patients 
suff ering from pain, understand the nature of pain and 
its infl uence on the patient’s life, know the methods of 
analgesia that can provide eff ective pain management 
for most patients, know how to apply those methods 
and how to classify them in graduated schemes in-
cluding nonpharmacological approaches, and know 
how to evaluate the effi
  ciency of pain management. 
Th
  e main focus of the Guide is to address the follow-
ing four pain syndromes: acute post-traumatic post-
operative pain, cancer pain, neuropathic pain, and 
chronic noncancer pain.
Th
  e editors understand the barriers and future 
needs regarding good pain management. Th
 ese barriers 
include lack of pain education and a lack of emphasis 
on pain management and pain research. In addition, 
when pain management does feature in government 
health priorities, there are fears of opioid addiction, 
the high cost of certain drugs, and in some cases, poor 
patient compliance. In developing countries, the avail-
able resources for health care understandably focus on 
the prevention and treatment of “killer” diseases. Yet 
most such disease conditions are accompanied by un-
relieved pain, which is why pain control matters in the 
developing world, according to Prof. Sir Michael Bond. 
Th
 e WHO recommends that “since in most parts of 
the world, the majority of cancer patients present with 

x
Introduction
advanced disease … the only realistic treatment option 
is pain relief and palliative care.” Due to the limited re-
sources for health care, the WHO further proposes that 
in the future, palliative instead of curative approaches to 
treatment should be encouraged.
However, it is a sad reality that the medicines 
that are essential for relieving pain often are not avail-
able or accessible. Th
  ere are numerous reports, some of 
them published in major medical and science journals, 
about the defi cits of adequate pain management, pre-
dominantly in developing countries in all regions of the 
world. It is sincerely believed that with relatively minor 
input (referring not to eff orts to change the situation 
but to the availability of essential drugs and techniques), 
the quality of analgesic treatment for cancer and HIV/
AIDS patients in low-resource countries might be con-
siderably improved, as documented by local initiatives 
around the world. Th
  e IASP has recently produced an 
atlas of pain training and pain facilities in developing 
countries. More information on this atlas can be found 
on the IASP website (www.iasp-pain.org).
For the pain specialist in developed countries, 
plenty of detailed information is available, but for the 
non-pain specialist and other health care providers, in-
cluding nurses and clinical staff  in many other regions 
of the world, who have to deal with patients in pain, 
there is a lack of a basic guide or manual on pain mech-
anisms, management, and treatment rationales. Th
 is is 
of particular concern in areas of the world where, out-
side the main urban areas, there is no access to infor-
mation about pain etiology or management and no ac-
cess to a pain specialist. 
Th
 e IASP Developing Countries Task Force 
(now the Developing Countries Working Group) was 
founded to encourage ongoing medical education and 
clinical training in low-resource countries and is sup-
porting local eff orts to raise awareness of pain. Th
 e ed-
ucational grant program, the “Initiative for Improving 
Pain Education,” addresses the need for improved edu-
cation about pain and its treatment in developing coun-
tries by providing educational support grants. Th
 ese 
grants are intended to improve the scope and availabil-
ity of essential education for pain clinicians of all disci-
plines, taking into account specifi c local needs. Follow-
ing a joint proposal by the University of Nairobi (N. B. 
Patel) and the Charité University Medicine Berlin (A. 
Kopf ), the IASP awarded one of the grants to a book 
project on pain management in low-resource countries. 
Th
  e result is this Guide, which is intended to provide 
concise and up-to-date-information in a novel curricu-
lum structure for the medical practitioner in countries 
belonging to the developing world. It will also serve 
medical faculties by suggesting core curriculum topics 
on pain physiology and management. It is believed that 
the project will encourage medical colleges to integrate 
these educational objectives into their local student and 
nursing curriculums. It will provide the non-pain spe-
cialist with basic relevant information—in a form that 
is easily understood—about the physiology of pain and 
the diff erent management and treatment approaches 
for diff erent types and syndromes of pain. 
Any practitioner who deals with pain problems 
must be aware of the entire range of pathophysiological 
and psychopathological problems that are commonly 
encountered in pain patients, and must therefore have 
access to a reasonable range of medical, physical, and 
psychological therapies to avoid imposing on the pa-
tients and society any additional fi nancial and person-
al costs. Th
  e aim of these eff orts is to ensure that pain 
control receives higher priority, especially in the treat-
ment of cancer and HIV/AIDS patients, as well as for 
postoperative and injury-related acute pain. Th
 erefore, 
this book will encourage the management of patients 
with acute and chronic pain, since it is well understood 
from the literature that even basic education has a con-
siderable impact on the quality of analgesic therapy for 
the patient.
Th
  e editors appreciate the enthusiasm and ef-
forts put in by the volunteer authors of this Guide, 
without whom this book would not have been possible. 
Many have experience in the problems faced by health 
care providers in the developing world. Th
 ey have 
tried to project their thoughts into particular situations 
and settings: “Can I cope with what is expected of me, 
working as a doctor or nurse or health care provider in 
a developing country and facing a wide range of pain 
problems?” Th
  is question has presumably passed uneas-
ily through the minds of many practitioners. Th
 e pur-
pose is to provide the reader with various approaches to 
the management of some common pain management 
problems. It is by no means intended to be a defi nitive 
reference. Treatment algorithms presented are based 
on the review of available literature and experience in 
pain clinics, with a specifi c view on the potential local 
limitations in the developing world. Instead of a text-
book approach with independent chapters written in a 
systematic manner, the Guide tries to follow a problem-
orientated learning path. Th
  e chapters are intended to 

xi
Introduction
be suffi
  ciently broad and understandable to be of value 
to the nonspecialist. Th
  e structure, including questions 
and answers, pearls of wisdom, and illustrative case re-
ports, as well as valuable literature suggestions for fur-
ther reading, will, we hope, make the Guide a helpful 
companion and aid to pain management. All readers 
are invited to contribute to the improvement of further 
editions by sending their comments and suggestions to 
the editors.
Th
 e  Guide does have some shortcomings. 
Although pain management has been a topic of in-
creased interest for at least two decades, developing 
countries have few initiatives in this direction, and 
little is known about the needs, characteristics, and 
treatment modalities with regard to pain. Refresher 
courses, workshops, medical schools, conferences, 
and schools of anesthesia usually have not actively 
incorporated pain management in their training pro-
grams for students, residents, clinical offi
  cers,  and 
nurses. Th
  erefore, knowledge about the local charac-
teristics of pain and treatment-related modalities is 
scarce, which has made it diffi
  cult for us to determine 
the relevance of some of the topics but will, we hope, 
not limit the usefulness of the Guide.  Th
 e authors, 
with their wide international background, have tried 
to provide an ubiquitous view on pain management. It 
is the hope of the editors that the Guide will be use-
ful to readers from a variety of regions of the world 
and from a variety of medical health care providers. 
Depending on feedback from the readers, the editors 
plan to produce a second volume with an emphasis on 
the general terms and requirements of good pain man-
agement, and possibly revised editions as well as edi-
tions in other common languages.
Andreas Kopf, Berlin, Germany
Nilesh Patel, Nairobi, Kenya
September 2009
Th
  e guide is dedicated to Professor Mohammed Omar Tawfi k, Cairo, Egypt, 
whose professional life was dedicated to the teaching and dissemination of 
pain management.
Acknowledgment
Since its founding in 1973, IASP has consistently supported pain research and 
treatment eff orts in developing countries. Th
  e editors wish to express their 
gratitude towards the IASP, which has supported this project continuously 
with advice and review of the material and an educational grant enabling the 
dissemination of this Guide to Pain Management in Low-Resource Settings.

Contributing Authors
xii
Oseremen Aisuodionoe-Shadrach, MBBS
Department of Surgery
University of Abuja
Abuja, Nigeria
manshaddie@yahoo.com
Dr Gona Ali
Faculty of Medicine
University of Sulaymaniyah
Sulaymaniyah, Iraq
gona7272@yahoo.com
Andrew O. Amata, MBBS
Department of Anaesthesia and Intensive Care
Georgetown Public Hospital Corporation
Georgetown, Guyana
aoamata@yahoo.com
Corrie C. Avenant, MB ChB
Fontainebleau, Randburg
South Africa
corrie@drcavenant.co.za
Justin N. Baker, MD
Department of Pediatric Medicine
Division of Palliative and End-of-Life-Care
St. Jude Children’s Research Hospital
Memphis, Tennessee, USA
justin.baker@stjude.org
Dr Frank Boni
Department of Anesthesiology
University of Ghana Medical School
Accra, Ghana
frank_boni@hotmail.com
Kay Brune, MD
Institute of Pharmacology and Toxicology
Friedrich-Alexander University of Erlangen-Nürnberg
Erlangen, Germany
brune@pharmakologie.med.uni-erlangen.de
Barrie Cassileth, PhD
Integrative Medicine Service
Memorial Sloan-Kettering Cancer Centre
New York, New York, USA
cassileth@mskcc.org
Alfredo Covarrubias-Gomez, MD
Vasco De Quiroga 15, Col. Seccion XVI
Torelio Guerra, Tlalpan
Mexico City 14000, Mexico
covarrubiasalfredo@gmail.com
Ferydoun Davatchi, MD
Rheumatology Research Center
Division of Rheumatology
Tehran University for Medical Sciences
Tehran, Iran
fddh@neda.net
Dr Henry Ddungu, MD
African Palliative Care Association
Kampala, Uganda
hddungu@gmail.com
Julia Downing, PhD
African Palliative Care Association
Kampala, Uganda
julia.downing@apca.co.ug
Maged El-Ansary, MD
Department of Anesthesiology
Al-Azhar University
Cairo, Egypt
maged@elansary.com
Susan Evans, MD
Endometriosis Care Centres of Australia
Adelaide, Australia
sfe@internode.on.net
Richard C. Fisher, MD
Orthopedic Overseas Division
Health Volunteers Overseas
Washington, DC, USA
richard.fi sher@ucdenver.edu
Arnaud Fumal, MD
Neurology and Headache Research Unit
University of Liège
Liège, Belgium
arnaud.fumal@chu.ulg.ac.be
Joel Gagnier, ND, MSc, PhD
Department of Epidemiology
School of Public Health
University of Michigan
Ann Arbor, Michigan, USA
jgagnier@umich.edu
Dr Lars Garten
Otto Heubner Centre for Pediatric and Adolescent Medicine
Charité University Hospitals
Berlin, Germany
lars.garten@charite.de
Comments and questions to the editors and authors via email are welcomed.

xiii
Contributing Authors
Hans J. Gerbershagen, MD, PhD
Department of Anesthesiology
Division of Perioperative and Emergency Care
University Medical Center Utrecht
Utrecht, Th
 e Netherlands
h.j.gerbershagen-2@umcutrecht.nl
Glenda E. Gray, MD
Perinatal HIV Research Unit
University of Witwatersrand
Diepkloof, South Africa
gray@pixie.co.za
Jyothirmai Gubili, MS
Integrative Medicine Service
Memorial Sloan-Kettering Cancer Centre
New York, New York, USA
gubilij@mskcc.org
Uriah Guevara-Lopez, MD, MSc
Department of Pain Medicine and Palliative Care
National Institute of Medical Sciences
Mexico City, Mexico
uriahguevara@yahoo.com.mx
Maija Haanpää, MD, PhD
Department of Neurosurgery
Helsinki University Hospital
Helsinki, Finland
maija.haanpaa@orton.fi 
Aki Hietaharju, MD, PhD
Pain Clinic
Department of Neurology and Rehabilitation
Tampere University Hospital
Tampere, Finland
aki.hietaharju@pshp.fi 
Vladimir Hrabal, Dr phil.
Department of Medical Psychology
University of Ulm
Ulm, Germany
praxis@dr-hrabal.de
Sabu Kumar James, MBBS
Department of Anaesthesiology
University of Glasgow
Glasgow, Scotland
United Kingdom
sabu.james@lanarkshire.scot.nhs.uk
Katarina Jankovic, MD
Department of Anesthesiology
MP Shah Hospital
Nairobi, Kenya
katarina@krstdesign.com
Th
  omas Jehser, MD
Pain and Palliative Care Department
Havelhöhe Hospital
Berlin, Germany
tjehser@havelhoehe.de
Lucia Jerg-Bretzke, PhD
Medical Psychology
Department of Psychosomatic Medicine and Psychotherapy
University of Ulm
Ulm, Germany
lucia.bretzke@uni-ulm.de
David E. Joranson, MSSW
Pain & Policy Studies Group
University of Wisconsin Carbone Cancer Center
School of Medicine and Public Health
Madison, Wisconsin, USA
dejoranson@uwcarbone.wisc.edu
Javier R. Kane, MD
Department of Pediatric Medicine
Division of Palliative and End-of-Life Care
St. Jude Children’s Research Hospital
Memphis, Tennessee, USA
javier.kane@stjude.org
Paul G. Kioy, MBchB, MMed
Department of Medical Physiology
University of Nairobi
Nairobi, Kenya
medphys@uonbi.ac.ke
Andreas Kopf, MD
Pain Unit, Department of Anesthesiology
Charité University Hospitals
Berlin, Germany
Visiting Professor, Department of Medical Physiology
University of Nairobi, Kenya
andreas.kopf@charite.de
Fatima Laher, MBBCh
Perinatal HIV Research Unit
University of Witwatersrand
Diepkloof, South Africa
laherf@phru.co.za
Dr Erica Lazarus
Perinatal HIV Research Unit
University of Witwatersrand
Diepkloof, South Africa
Christoph Maier, MD
Department of Pain Management
Clinic for Anesthesiology
University Clinic Bergmannsheil
Ruhr-University
Bochum, Germany
christoph.meier@ruhr-uni-bochum.de
Angela Mailis-Gagnon, MD
Comprehensive Pain Program
Toronto Western Hospital
Toronto, Ontario, Canada
angela.mailis@uhn.on.ca

xiv
Contributing Authors
Winfried Meissner, MD
Department of Internal Medicine
University Medical Centre
Jena, Germany
winfried.meissner@med.uni-jena.de
Dr Gaman Mohammed
Diabetes Centre
Avenue Healthcare
Nairobi, Kenya
send2gaman@yahoo.com
Lutz Moser, MD
Department of Radiology
Charité University Hospitals
Berlin, Germany
lutz.moser@charite.de
Faith N. Mwangi-Powell, PhD
African Palliative Care Association
Kampala, Uganda
faith.mpowell@apca.co.ug
Mathew O.B. Olaogun, PT
Department of Medical Rehabilitation
Obafemi Awolowo University
Ife-Ife, Nigeria
mobolaogun@yahoo.co.uk
Michael Paech, MBBS, FRCA, FANZCA, 
FFPMANZCA
Division of Anaesthesiology
University of Western Australia
Crawley, Western Australia
Australia
michael.paech@health.wa.gov.au
Nilesh B. Patel, PhD
Department of Medical Physiology
University of Nairobi
Nairobi, Kenya
npatel@uonbi.ac.ke
Dilip Pawar, MBBS
Department of Anesthesiology
All India Institute of Medical Sciences
New Delhi, India
dkpawar@gmail.com
Michael Pfi ngsten, PhD
Pain Clinic
Department of Anaesthesiology
University Medicine
Göttingen, Germany
michael.pfi ngsten@med.uni-goettingen.de
Richard A. Powell, MA, MSc
African Palliative Care Association
Kampala, Uganda
tony.powell@apca.co.ug
Lukas Radbruch, MD
Palliative Care Unit
University Hospital Aachen
Aachen, Germany
lradbruch@ukaachen.de
M.R. Rajagopal, MD
Pallium India (Trust)
Trivandrum, Kerala
India
mrraj47@gmail.com
Dr. Raul Ribeiro, MD
Department of Oncology
International Outreach Program
St. Jude Children’s Research Hospital
Memphis, Tennesee, USA
raul.ribeiro@stjude.org
Rainer Sabatowski, MD
Interdisciplinary Pain Clinic
University Hospital Carl-Gustav Carus
Dresden, Germany
rainer.sabatowski@uniklinikum-dresden.de
Dr Natalia Samoilova
Department of Pain Medicine
National Research Centre of Surgery B.V. Petrosky
Russian Academy of Medical Science
Moscow, Russia
natalia.samoylova@gmail.com
Michael Schäfer, MD, PhD
Department of
 
Anesthesiology
Charité University Hospitals
Berlin, Germany
micha.schaefer@charite.de
Barbara Schlisio, MD
Department of Anesthesiology
University Medical Centre
Tübingen, Germany
barbara.schlisio@med.uni-tuebingen.de
Dr Jean Schoenen
Headache Research Unit
Department of
 
Neurology and GIGA Neurosciences
Liège University
Liège, Belgium
jschoenen@ulg.ac.be
Claudia Schulz-Gibbins, Dipl.-Psych.
Department of Anesthesiology
Charité University Hospitals
Berlin, Germany
claudia.schulz-gibbins@charite.de

Contributing Authors
xv
Andreas Schwarzer, MD, PhD
Department of Pain Management
Clinic for Anesthesiology
University Clinic Bergmannsheil
Ruhr-University
Bochum, Germany
andreas.schwarzer@ruhr-uni-bochum.de
Olaitan A Soyannwo, MB BS, MMed
Department of Anesthesia
Ibadan College of Medicine
Ibadan, Nigeria
folait2001@yahoo.com
Christoph Stein, MD
Department of Anesthesiology
Charité University
Berlin, Germany
christoph.stein@charite.de
Paula Tanabe, RN, PhD
Department of Emergency Medicine
Institute for Healthcare Studies
Northwestern University
Chicago, Illinois, USA
ptanabe2@nmff .org
Mohamed Omar Tawfi k, MD, MBBCh
(deceased, June 2009)
Pain Unit
National Cancer Institute
Cairo University
Cairo, Egypt
Josephine M. Th
  orp, MRCP, FFARCS
Anaesthetic Department, Monklands Hospital
Airdrie, Lanarkshire
Scotland, United Kingdom
jo_thorp@btinternet.com
Knox H. Todd, MD, MPH
Department of
 
Emergency Medicine
Beth Israel Medical Center
New York, New York, USA
ktodd@chpnet.org
Dr Harald C. Traue
Medical Psychology
Department of Psychosomatic Medicine and Psychotherapy
University of Ulm
Ulm, Germany
harald.traue@uni-ulm.de
Rolf-Detlef Treede, MD
Department of Neurophysiology
Faculty of Medicine Mannheim, University of Heidelberg
Mannheim, Germany
rolf-detlef.treede@medma.uni-heidelberg.de
Steven Waldman, MD
Th
  e Headache and Pain Centre
Leawood, Kansas, USA
sdwaldman@ptfi rst.org
Wilfried Witte, MA
Department of Anaesthesiology
Charité University Hospitals
Free University of Berlin
Berlin, Germany
wilfried.witte@charite.de

Basics

3
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Wilfried Witte and Christoph Stein
Chapter 1
History, Defi nitions, and Contemporary Viewpoints
Th
 e experience of pain is fundamental and has been 


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