Guide to Pain Management in Low-Resource Settings

part of the cultural development of all societies. In the 
history of pain, “supernatural” powers played an equally 
important role as natural factors. To view pain as the re-
sult of a “communication” between mankind and divine 
powers has been a fundamental assumption in many 
societies. Th
  e more societies are separated from West-
ern medicine or modern medicine, the more prevalent 
is this view of pain. On the other hand, a purely medi-
cal theory based on natural phenomena independent of 
divine powers developed very early on. It happened to a 
greater extent in ancient China, while in ancient India 
medicine was heavily infl uenced by Hinduism and Bud-
dhism. Pain was perceived in the heart—an assumption 
familiar to ancient Egyptians. Th
  e medical practitioners 
in pharaonic times believed that the composition of 
body fl uids determined health and disease, and magic 
was indiscriminable from medicine.
Ancient Greek medicine borrowed heavily 
from its Asian and Egyptian predecessors. Th
 e intro-
duction of ancient medical knowledge into medieval 
Europe was mainly mediated through Arabic medicine, 
which also added its own contributions. Latin was the 
language of scholars in medieval Europe, and ideology 
was guided by Judeo-Christian beliefs. Despite mul-
tiple adaptations, medical theory remained committed 
to ancient models for centuries. Pain had an important 
role. Th
  e Bible illustrates the need to withstand catas-
trophes and pain in the story of Job. Strength of faith is 
proved by Job’s humility toward God. Humility is still 
an ideal in Christian thought today. In the New Testa-
ment, Jesus Christ fi nishes his life on earth as a mar-
tyr hanging and dying at the cross. His suff ering marks 
the way to God. To bear suff ering in life is necessary to 
be absolved from sin. Th
  e message of pain is to show 
mankind the insuffi
  ciency of life on earth and the bril-
liance of being in heaven. Th
  us, whatever science may 
say about pain, an approach based only on a physiologi-
cal concept does not take into account the religious or 
spiritual meaning of pain.
Th
 e most important and radically mechanis-
tic scientifi c theory of pain in early modern age derives 
from the French philosopher René Descartes (1596–
1650). In his concept, the former assumption that pain 
was represented in the heart was relinquished. Th
 e 
brain took the place of the heart. In spite of (or because 
of ) its one-sidedness, Descartes’ theory opened the gate 
for neuroscience to explain the mechanisms of pain.
Th
  e question of how pain should be treated has 
led to diff erent answers over time. If supernatural pow-
ers had to be pleased to get rid of pain, certain magi-
cal rituals had to be performed. If scientifi cally invented 
remedies were not used or not available, ingredients 
from plants or animals had to be used to ease the pain. 
Especially, the knowledge that opium poppies have anal-
gesic eff ects was widespread in ancient societies such as 
Egypt. For a long time, opium was used in various prep-
arations, but its chemical constituents were not known. 

4
Wilfried Witte and Christoph Stein
Th
  e isolation of the opium alkaloid morphine was fi rst 
accomplished in 1803 by the German pharmacist Fried-
rich Wilhelm Sertürner (1783–1806). Th
 e industrial 
production of morphine began in Germany during the 
1820s, and in the United States in the 1830s. During the 
late 18th to the mid-19th century, the natural sciences 
took over the lead in Western medicine. Th
 is period 
marked the beginning of the age of pathophysiological 
pain theories, and scientifi c knowledge about pain in-
creased step by step.
Th
  e discovery of drugs and medical gases was 
a cornerstone of modern medicine because it allowed 
improvements in medical treatment. It was modern an-
esthesia in particular that promoted the development of 
surgery. General anesthesia using ether was introduced 
successfully in Boston on October 16, 1846, by the phy-
sician William Th
  omas Morton (1819–1868). Th
 e im-
portance of this discovery, not only for surgery but for 
the scientifi c understanding of pain in general, is under-
scored by the inscription on his tombstone: “Inventor 
and Revealer of Inhalation Anesthesia: Before Whom, in 
All Time, Surgery was Agony; By Whom, Pain in Sur-
gery was Averted and Annulled; Since Whom, Science 
has Control of Pain.” Th
  is statement suggested that pain 
would vanish from mankind just by applying anesthe-
sia. Surgery itself changed to procedures that were not 
necessarily connected with a high level of pain. Th
 us, 
the role of surgery changed. Surgeons had more time to 
perform operations, and patients were no longer forced 
to suff er pain at the hands of their surgeons.
Further innovations followed. One year later, 
in 1847, chloroform was used for the fi rst time for an-
esthesia in gynecology by the Scottish physician James 
Young Simpson (1811–1879). In Vienna, the physi-
cian Carl Koller (1857–1944) discovered the anesthetic 
properties of cocaine in 1884. At about the same time, 
during the last two decades of the 19th century, the U.S. 
neurologist James Leonard Corning (1855–1923) and 
the German surgeon August Bier (1861–1949) carried 
out trials of spinal anesthesia with cocaine solutions. 
Modern anesthesia enabled longer and more complex 
surgical procedures with more successful long-term 
outcomes. Th
  is advance promoted the general consen-
sus that the relief of somatic pain was good, but it was 
secondary to curative therapy: no pain treatment was 
possible without surgery! Th
  us, within the scope of an-
esthetic practice, pain management as a therapeutic 
goal did not exist at that time. Chronic pain was not a 
topic at all.
Th
 e fi rst decades of morphine use may be seen 
as a period of high expectations and optimism regard-
ing the ability to control pain. Th
 e fi rst drawback to 
this optimism was the discovery made in the Ameri-
can Civil War (1861–1865), when cases of morphine 
dependence and abuse appeared. As a consequence, 
restrictions on the distribution of opiates were begun. 
Th
  e negative view of morphine use was enhanced by 
experiences in Asia, where an extensive trade in opium 
and morphine for nonmedical purposes was already 
established during the 19th century. Th
  erefore, at the 
beginning of the 20th century, societal anxiety regard-
ing the use of morphine became strong and developed 
into opiophobia (i.e., the fear of using opioids), which 
was a major step backwards for pain management in 
the following decades.
Wars stimulated pain research because soldiers 
returned home with complex pain syndromes, which 
posed insurmountable problems for the available ther-
apeutic repertoire. Following his experience after 1915 
during the First World War, the French surgeon René 
Leriche (1879–1955) began to concentrate on “pain 
surgery,” mainly addressing the autonomic nervous 
system. Leriche applied methods of regional anesthe-
sia (infi ltration with procaine, sympathetic ganglionic 
blockade) as well as surgery, particularly periarterial 
sympathectomy. He not only rejected the idea of pain 
as a necessary evil but also criticized the reductionist 
scientifi c approach to experimental pain as a purely 
neuroscientifi c phenomenon. He viewed chronic pain 
as a disease in its own right (“douleur-maladie”), not 
just as a symptom of disease.
Regional anesthesia was the mainstay of pain 
therapy applied by the French surgeon Victor Pauchet 
(1869–1936). Already, before his experiences in the 
war, he had authored the fi rst edition of his textbook 
L’Anesthésie Régionale in 1912. Th
 rough Louis Gas-
ton Labat (1876–1934), a physician from Paris who 
later practiced in the United States, his wisdom be-
came known in the New World and was an important 
stimulus for the dissemination of regional anesthesia in 
the United States between the two World Wars. In the 
1920s, the notion that regional anesthesia could be used 
not only for surgery but also for chronic pain spread 
throughout the United States.
After the Second World War these ideas 
were taken up by John Joseph Bonica (1914–1994), 
who had emigrated with his parents from Sicily to 
the United States at the age of 11 years. As an army 

History, Defi nitions, and Contemporary Viewpoints
5
surgeon entrusted with the responsibility of giv-
ing anesthesia, he realized that the care of wounded 
soldiers was inadequate. Th
  e patients were left alone 
with their pain after surgery. Bonica observed that 
pain frequently became chronic and that many of these 
patients fell prey to alcohol abuse or depressive disor-
ders. Bonica’s answer to this problem, which also af-
fected other pain patients, was to establish pain clinics 
where physicians of diff erent disciplines, psycholo-
gists, and other therapists worked together in teams to 
understand the complexity of chronic pain and treat it 
adequately. Anesthesiology remained Bonica’s special-
ty. Only a few pain clinics existed in the United States 
when he published the fi rst edition of his textbook 
Pain Management in 1953. Th
  is landmark may be re-
garded as the date of birth of a new medical discipline.
Nevertheless, it took many years before a 
broader audience became interested in pain therapy. In 
the year 1973, to make this topic more popular, Bonica 
founded the International Association for the Study of 
Pain (IASP). In the following years, national chapters of 
the IASP were founded around the globe. In 1979, IASP 
coined the important defi nition of pain as “an unpleas-
ant sensory and emotional experience associated with 
actual or potential tissue damage or described in terms 
of such damage,” which is still valid. Th
 is defi nition was 
important because for the fi rst time it implied that pain 
is not always a consequence of tissue damage but may 
occur without it. Western science then began to realize 
that “somatic” factors (tissue damage) cannot be sepa-
rated from “psychological” factors (learning, memory, 
the soul, and aff ective processes). Together with the rec-
ognition of social infl uences on pain perception, these 
factors form the core of the modern biopsychosocial 
concept of pain.
During the 20th century multiple pain theo-
ries were conceived. Th
  e most important theory—to 
which Bonica also subscribed—came from the Ca-
nadian psychologist Ronald Melzack (1929–) and 
the British physiologist Patrick D. Wall (1925–2001). 
Th
  eir theory was published in 1965 and is known as 
the “gate control theory.” Th
 e term “gate” was sup-
posed to describe spinal cord mechanisms regulating 
the transmission of pain impulses between the periph-
ery and the brain. Th
  is theory was important because 
it no longer regarded the central nervous system as a 
simple passive medium for transmission of nerve sig-
nals. It implied that the nervous system was also “ac-
tively” altering transmission of nerve impulses. How-
ever, the “gate control theory” emphasized a strictly 
neurophysiological view of pain, ignoring psychologi-
cal factors and cultural infl uences.
Medical ethnology examines cultural infl u-
ences on perception and expression of pain. Th
 e most 
important early study was published in 1952 and was 
fi nanced by the U.S. Public Health Service. On the 
basis of about 100 interviews with veterans of both 
World Wars and the Korean War, who were accommo-
dated in a Veterans’ Hospital in the Bronx, New York 
City, the investigators examined how diff erent cultural 
backgrounds infl uence pain perception. Th
 e  veter-
ans were diff erentiated into those of Italian, Irish, or 
Jewish origin—besides the group of the “Old Ameri-
cans,” comprising U.S.-born Whites, mostly Protestant 
Christians. One result of this investigation was that 
the “Old Americans” presented the strongest stoicism 
in the experience of pain, while their attitude towards 
pain was characterized as “future-oriented anxiety.” 
According to the interpretation of the investigators, 
this anxiety demonstrated an attempt to be conscious 
about one’s own health. Th
  e more a Jew or Italian or 
Irish immigrant was assimilated into the American 
way of life, the more their behavior and attitudes were 
similar to those of the “Old Americans.” However, pain 
was still seen merely as a symptom, and non-Western 
cultures were not a focus of interest.
It took about another three decades to change 
this situation. During the 1990s, studies demonstrated 
that diff erent attitudes and beliefs in diff erent  ethnic 
groups around the world play a role in the variation of 
intensity, duration, and subjective perception of pain. As 
a consequence, health workers have to realize that pa-
tients with (chronic) pain value therapists who recog-
nize their cultural and religious beliefs.
Another important aspect that attracted inter-
est was the relief of pain in patients with advanced dis-
ease. It was the nurse, social worker, and later physi-
cian Cicely Saunders (1918–2005) who developed the 
“Total Pain” concept. Chronic pain in advanced disease 
totally changes everyday life and challenges the will to 
live. Th
  is problem is continuously present, so Saunders 
drew the conclusion that “constant pain needs con-
stant control.” According to this concept, pain cannot 
be separated from the personality and environment of 
a patient with advanced and fatal illness. Th
 e founda-
tion of St. Christopher’s Hospice in London, England, 
in 1967 by Saunders may be seen as the starting point 
of palliative medicine. It refl ects a change of interest in 

6
Wilfried Witte and Christoph Stein
medicine from acute (infectious) diseases to cancer and 
other chronic diseases in the fi rst half of the 20th cen-
tury. Th
  e term “palliative care” (or palliative therapy) 
comes from the Latin word “pallium” (cover, coat) and 
is supposed to alleviate the last phase of life if curative 
therapy is no longer possible. Palliative care is, a priori, 
designed to concentrate on quality of life. It has roots in 
non-Christian societies, but it is mainly regarded to be 
in the tradition of medieval hospices. However, the his-
torical background of the hospices was not the same in 
every European country, and neither was the meaning 
of the word “pallium”; sometimes it was used by healers 
to disguise their inability to treat patients curatively.
Palliative care became even more important 
when another totally unexpected pandemic occurred 
in the mid-1980s—HIV/AIDS. Particularly in Africa, 
this new “plague” rapidly developed into an enormous 
health problem that could no longer be ignored. Cancer 
and neuropathic pain play important roles in patients 
with HIV/AIDS. Th
 e development of palliative medi-
cine in Africa began in Zimbabwe in 1979, followed 
by South Africa in 1982, Kenya in 1989, and Uganda 
in 1993. Th
  e institutions in Uganda became models in 
the 1990s, based on the initiative of the physician Anne 
Marriman (1935-), who spent a major part of her life in 
Asia and Africa. Uganda provided a favorable environ-
ment for her project “Hospice Africa Uganda” because 
at the time Uganda was the only African country whose 
government declared “palliative care for AIDS and can-
cer victims” a priority within its “National Health Plan.” 
Th
  e rate of curative cancer treatment in Uganda is low, 
as in most economically disadvantaged countries. Th
 is 
situation makes problems associated with cancer and 
AIDS all the more urgent.
Broad acceptance of chronic pain manage-
ment in the 20th century required the leadership of 
the World Health Organization (WHO), stimulated 
by Jan Stjernswärd from Sweden (1936–). In 1982, 
Stjernswärd invited a number of pain experts, includ-
ing Bonica, to Milan, Italy, to develop measures for 
the integration of pain management into common 
knowledge and medical practice. Cancer was cho-
sen as a starting point. At that time, the experts were 
concerned about the increasing gap between success-
ful pain research, on the one hand, and decreasing 
availability of opioids to patients, especially cancer 
patients, on the other. A second meeting took place 
in Geneva in 1984. As a result, the brochure “Cancer 
Pain Relief ” was published in 1986. In distributing this 
brochure, the WHO fi lled the gap by “forcing” health 
care systems to use opioids according to the now 
widely known three-step “analgesic ladder.” Th
 e suc-
cess of this initiative was, unfortunately, not the same 
in diff erent regions of the world. While opioid avail-
ability and opioid consumption multiplied in the An-
glo-American and Western European countries, other 
regions of the world observed only minor increases or 
even falling numbers of opioid prescriptions. It must 
be added, though, that in the Anglo-American and 
Western European sphere, facilitated access to opioids 
has promoted an uncritical extension of opioid use to 
noncancer pain patients as well. Th
  is use might be jus-
tifi ed in cases of neuropathic or chronic infl ammatory 
pain, but it should be regarded as a misapplication in 
most other noncancer pain syndromes. Opioids should 
not be used as a panacea (one remedy working for all), 
and current practice in some countries might threaten 
opioid availability in the future if health care authori-
ties decide to intervene and restrict opioid use even 
more than today.
In conclusion, the understanding of pain as a 
major health care problem has come a long way. From 
the old days, when pain often was regarded as an un-
avoidable part of life, which humans could only par-
tially infl uence because of its presumed supernatural 
etiology, a physiological concept has developed, where 
pain control is now possible. In the last few decades 
the “natural science” concept has been revised and ex-
tended by the acceptance of psychosocial and ethno-
cultural infl uencing factors. Although basic research 
has helped to uncover the complex mechanisms of 
pain and facilitated the development of new strategies 
to treat pain, the age-old opioids are still the mainstay 
of pain management for acute pain, cancer pain, and 
neuropathic pain. While the understanding and treat-
ment of other chronic noncancer pain syndromes are 
still demanding, cancer pain, acute pain, and neuro-
pathic pain may be relieved in a large number of pa-
tients with easy treatment algorithms and “simple” 
opioid and nonopioid analgesics. Th
  erefore, the future 
of pain management in both high- and low-resource 
environments will depend on access to opioids and on 
the integration of palliative care as a priority in health 
care systems. Pain Management in Low-Resource Set-
tings intends to contribute to this goal in settings 
where the poor fi nancing of health care systems high-
lights the importance of pain management in pallia-
tive care.

History, Defi nitions, and Contemporary Viewpoints
7
References
[1]  Bates, MS, Edwards WT, Anderson KO. Ethnocultural infl uences  on 
variation in chronic pain perception. Pain 1993;52:101–12.
[2]  Brennan F, Carr DB, Cousins M. Pain management: a fundamental hu-
man right. Pain Med 2007;105:205–21.
[3]  El Ansary M, Steigerwald I, Esser S. Egypt: over 5000 years of pain 
management—cultural and historic aspects. Pain Pract 2003;3:84–7.
[4]  Eriksen J, Sjøgren P, Bruera E. Critical issues on opioids in chronic non-
cancer pain: an epidemiological study. Pain 2006;125:172–9.
[5]  Jagwe J, Merriman A. Uganda: Delivering analgesia in rural Africa: 
opioid availability and nurse prescribing. J Pain Symptom Manage 
2007;33:547–51.
[6]  Karenberg A, Leitz C. Headache in magical and medical papyri of An-
cient Egypt. Cephalgia 2001;21:545–50.
[7]  Loeser JD, Treede RD. Th
  e Kyoto protocol of IASP basic pain terminol-
ogy. Pain 2008;137:473–7.
[8]  Meldrum ML. A capsule history of pain management. JAMA 
2008;290:2470–5.
[9]  Merskey H. Some features of the history of the idea of pain. Pain 
1980;9:3–8.
[10]  Stolberg M. “Cura palliativa”: Begriff  und Diskussion der palliativen 
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9
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
Olaitan A Soyannwo
Chapter 2
Obstacles to Pain Management in Low-Resource Settings
Why is eff ective pain management 
diffi
  cult to achieve in low-resource 
countries?
Low-income and middle-income economies of the 
world are sometimes referred to as developing coun-
tries, although there are wide diff erences in their eco-
nomic and development status, politics, population, and 
culture. Poverty is, however, a common factor in the 
health situation of low-resource countries, and it is the 
main determinant of disease, since most of the popu-
lation lives on less than US$1 a day (below the “bread-
line”). Malnutrition, infections, and parasitic diseases 
are prevalent, with high rates of morbidity and mortal-
ity, especially in rural areas and among pregnant wom-
en and children. Most countries therefore defi ne  and 
implement an “essential health package” (EHP), which is 
a minimum package of cost-eff ective public health and 
clinical interventions provided for dealing with major 
sources of disease burden.
Th
 ese health priorities were addressed in the 
2000 United Nations Millennium Development Goals 
(MDG), which emphasized the eradication of poverty 
and hunger, universal primary education, gender equal-
ity, reduction of child mortality, improvement of ma-
ternal health, combating HIV/AIDS, malaria, and other 
major diseases, environmental sustainability, and global 
partnership for development. Although communicable 
diseases are the emphasis, a transition in the epidemiology 
of diseases even in poor countries is now noticeable as 
noncommunicable diseases, injuries, and violence are as 
important as communicable diseases as causes of death 
and disability. Many of these conditions have accompa-
nying pain (acute and chronic), which is inadequately ad-
dressed and treated. While there is consensus that stron-
ger health systems are key to achieving improved health 
outcomes, there is less agreement on how to strengthen 
them. In countries where the average income is below the 
“breadline,” there is little priority specifi cally for pain is-
sues as most people concentrate on working to earn an 
income regardless of any pain problem.
Is pain management a problem      
in resource-poor countries?
Pain is the most common problem that makes patients 
visit a health care practitioner in low-resource coun-
tries. In a WHO study, persistent pain was a commonly 
reported
 
health problem among primary care patients 
and was consistently
 
associated with psychological ill-
ness. Both acute and chronic cancer and noncancer 
pains are undertreated, and analgesics may not even be 
available in rural hospitals.
How do patients handle               
their pain problems?
Usually, the fi rst attempt at pain management in these 
patients is the use of home remedies, including herbal 

10
Olaitan A Soyannwo
and over-the-counter (OTC) medications. Th
  ese can be 
simple analgesics, herbal preparations, or complementa-
ry drugs. Self-prescription and recommendations from 
nonmedical practitioners (friends, relatives, other pa-
tients, patent medicine vendors, and traditional medi-
cal practitioners) are common. Such recommendations 
may be eff ective for simple, uncomplicated pain, but 
when pain is severe or persistent, patients then go to 
the hospital as a last resort. In the hospital setting, most 
pain problems are treated by general medical practi-
tioners, family physicians, or fi rst-line specialists such 
as orthopedic surgeons, neurologists, and oncologists. 
Pain management specialists and dedicated pain clinics 
or acute pain teams are few and sometimes nonexistent 
in many resource-poor countries. Th
 us, although re-
lief of pain is part of the fundamental right to the high-
est attainable standard of health, this aim is diffi
  cult to 
achieve in low-resource countries, where most of the 
population lives in rural areas. Frequently, health care is 
delivered by a network of small clinics—some without 
doctors or essential analgesics. Even when doctors are 
available, for example for surgery, patients expect pain 
as an inevitable part of surgical intervention, and de-
spite the high incidence of reported pain, may still rate 
“pain relief ” as satisfactory.
Why is it diffi
  cult to provide 
eff ective pain management?
Lack of knowledge
Inadequate knowledge among health care profession-
als in low-resource countries is one of the major ob-
stacles to eff ective pain management. Comprehensive 
pain assessment and multimodal treatment approach-
es are poorly understood since pain is mostly taught 
as a symptom of disease rather than an experience 
with physical, psychosocial, and other dimensions. 
Lack of training and myths may lead to unreasonable 
fears of side eff ects of opioid analgesics and errone-
ous beliefs about the risk of addiction, even in cancer 
patients. Patients may also have a poor understanding 
of their own medical problems, and may expect pain, 
which they think has to be endured as an inevitable