Guide to Pain Management in Low-Resource Settings

References
[1]  Allman KG, Wilson I, editors. Oxford handbook of anaesthesia, 2nd ed. 
New York: Oxford University Press; 2006.
[2]  Amata AO, Samaroo LN, Monplaisir SN. Pain control after major sur-
gery. East Afr Med J 1999;76:269–71.
[3]  Matta JA, Cornett PM, Miyares RL, Abe K, Sahibzada N, Ahern GP. 
General anesthetics activate a nociceptive ion channel to enhance pain 
and infl ammation. Proc Natl Acad Sci USA 2008;105:8784–9.
[4]  Scott NB, Hodson M. Public perceptions of postoperative pain and its 
relief. Anaesthesia 1997;52:438–42.
[5]  Wheatley RG, Madej TH, Jackson IJ, Hunter D. Th
 e fi rst year’s experi-
ence of an acute pain service. Br J Anaesth 1991;67:353–9.
Websites
www.anaesthesia-az.com 
Anesthesia, pain, and intensive care management
www.postoppain.org  
Good site for pain management in ideal situations
www.nda.ox.ac.uk/wfsa 
Updates aimed at poorly resourced countries
www.who.int/medicines 
Drug policies and control, including essential drugs list

115
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
O. Aisuodionoe-Shadrach
Chapter 15
Acute Trauma and Preoperative Pain
When acute trauma occurs, the diagnosis and purposeful 
management of pain should be of paramount concern.
Case report
A 38-year-old man, John Bakor, is brought to the ac-
cident and emergency room after being knocked down 
by a small vehicle. He was transported in the back seat 
of a saloon car without any splint to his injured leg 
and had jolts of pain every time the car stopped on its 
bumpy ride to the hospital.
John is received by Dr Omoyemen, the attend-
ing resident, who after putting a full-length aluminium 
gully-splint to immobilize his left lower limb, asks for 
a helping hand to move him onto a hospital stretcher. 
Fracture immobilization on its own minimizes pain 
due to the fracture injury by limiting movement of the 
aff ected parts. A quick review reveals that John had 
sustained an open fracture with dislocation of the left 
ankle and has multiple skin bruises over his left fore-
arm and thigh. He is fully conscious, knows who he is, 
and is well oriented as to time and place. He is then 
checked for other injuries that he may have ignored as 
inconsequential or may be unaware of, such as other 
bruises or lacerations. Dr Omoyemen obtains a brief 
history of the nature of the accident and proceeds to 
specifi cally evaluate for secondary injuries such as 
blunt abdominal injuries, or chest wall or pelvic frac-
tures. Th
 e benefi t of this evaluation is to identify inju-
ries that may pose a potential danger to life besides the 
obvious left ankle injury.
Intravenous access is obtained for the admin-
istration of fl uids and/or medications, and Dr Omoy-
emen then performs a thorough evaluation of the pa-
tient’s pain using a standardized assessment tool, the 
verbal rating scale (VRS). John’s VRS = 7/10, suggesting 
that he is having acute severe pain. Th
  e doctor admin-
isters 50 mg of pethidine (meperidine) intramuscularly 
(i.m.) as a preliminary analgesic before the injury is 
formally reviewed and dressings are changed, and i.m. 
tetanus toxoid is administered to prevent tetanus.
After dressings are complete, adequate regular 
analgesia is commenced (pethidine 50 mg i.m., 6-hour-
ly). Finally, while John is awaiting formal orthopedic 
surgical review, his pain is reassessed regularly to deter-
mine the eff ectiveness of the analgesic regimen, which is 
also periodically reviewed as required.
Questions you should ask yourself 
and their probable answers
What is pain?
Acute pain results from tissue damage, which can be 
caused by an infection, injury, or the progression of a 
metabolic dysfunction or a degenerative condition. 
Acute pain tends to improve as the tissues heal and 
responds well to analgesics and other pain treatments. 
We know that pain is a subjective sensation, although 

116
O. Aisuodionoe-Shadrach
several assessment tools have been designed to objec-
tively measure it. Pain has multiple dimensions with 
several descriptions of its qualities, and its perception 
can be subjectively modifi ed by past experiences.
Acute pain leads to a stress response consist-
ing of increased blood pressure and heart rate, systemic 
vascular resistance, impaired immune function, and al-
tered release of pituitary, neuroendocrine, and other 
hormones. Th
  is response could limit recovery from sur-
gery or injury. Adequate relief or prevention of pain fol-
lowing orthopedic surgery has been shown to improve 
clinical outcomes, increase the likelihood of a return to 
preinjury activity levels, and prevent the development of 
chronic pain. Undertreatment of acute pain can lead to 
increased sensitivity to pain on subsequent occasions.
Furthermore, the sources of pain in acute trau-
ma and preoperative settings are mostly of deep somatic 
and visceral origin, as may occur in road traffi
  c  acci-
dents, falls, gunshot wounds, or acute appendicitis. Pain 
in the acute trauma and preoperative settings is usually 
caused by a combination of various stimuli: mechanical, 
thermal, and chemical. Th
  ese stimuli cause the release 
of nociceptive substances, e.g., histamine, bradykinin, 
serotonin, and substance P, which activate pain recep-
tors (nociceptors) to initiate pain signals.
How should pain be assessed?
Because of its complex subjectivity, pain is diffi
  cult  to 
quantify, making an accurate assessment problematic. 
However, a number of assessment tools have been de-
veloped and standardized to identify the type of pain, 
quantify the intensity of pain, and evaluate the eff ect 
and measure the psychological impact of the pain a pa-
tient is experiencing.
A pain scale may be either one-dimensional or mul-
tidimensional. In the acute trauma/preoperative setting, 
where the cause of pain is obvious and pain is expected 
to resolve more or less promptly, one-dimensional scales 
are recommended. Examples include the following:
•  Numeric rating scale (NRS), in which the patient 
rates pain from 0 to 10 in increasing order of in-
tensity
•  Visual analogue scale (VAS), in which the patient 
marks the severity of pain on a line
•  Verbal rating scale (VRS)
•  Illustrative scales such as the Faces Pain Scale, 
 
which consists of drawings of facial expressions. 
Th
  is type of scale is useful in children, the cogni-
tively impaired, and persons with language barriers.
Although the multidimensional pain scale was 
developed for pain research, it can be adapted for use in 
the clinic. An adapted version of the Brief Pain Invento-
ry questions patients about pain location, intensity as it 
varies over time, past treatments, and the eff ect of pain 
on the patient’s mood, physical function, and ability to 
function in various life roles.
Is there an obligation to manage pain in the 
acute trauma and preoperative setting?
Th
  e commitment to manage a patient’s pain and relieve 
suff ering is the cornerstone of a health professional’s ob-
ligation. Th
 e benefi ts to the patient include shortened 
hospital stay, early mobilization, and reduced hospital-
ization cost.
Pain is not merely a clinical symptom but evi-
dence of an underlying pathology. In the acute trauma 
and preoperative setting, there is a temptation to over-
look pain and its specifi c management, while all eff orts 
are geared toward treating the underlying pathology. Th
 e 
challenge is to help the health professional realize that the 
management of both symptoms (pain) and underlying 
pathology (acute appendicitis) should go hand in hand. 
Using the WHO analgesic ladder, a rational systematic 
approach to pain management in the acute trauma and 
preoperative setting can be developed and implemented.
Is pain an important issue to the patient who is 
in the acute trauma/preoperative setting?
Yes. Freedom from pain can be considered a human 
right. As fanciful as that may seem, it must be empha-
sized that pain is a natural accompaniment of acute 
injury to tissues and is to be expected in the setting of 
acute trauma. In such a scenario, the goal of the physi-
cian is to ensure that the patient’s pain is tolerable.
In a study conducted at an accident and emer-
gency room department of a university hospital in sub-
Saharan Africa, 77% of patients who had preoperative 
analgesia considered the analgesic dosage inadequate, 
and 93% of those patients blamed this inadequacy of 
pain relief on inadequate analgesic prescription by their 
doctors. Th
  e 77% of patients who had preoperative an-
algesia admitted they would have preferred a lot more 
than what they were given.
What should the attitude of the attending 
physician be regarding the specifi c 
management of pain in this scenario?
Concern. Often, paying attention to adequate analgesic 
coverage for this category of patients is overlooked in 

Acute Trauma and Preoperative Pain
117
favor of getting them prepared as quickly as possible for 
surgery. Adequate analgesia facilitates the evaluation and 
subsequent treatment of the underlying injury or disease.
What is the attitude of the patient to pain?
Except when the cause is very obvious, as in the case of 
a fractured limb, the patient does not know the diagno-
sis, but only knows the symptoms—pain. Often, pain 
management is poor.
When or how soon should active     
management of pain be instituted in the acute 
trauma/preoperative setting?
Immediately after diagnosis, the principles of eff ec-
tive management of acute pain should be adopted and 
pain control instituted immediately (Fig. 1). Th
  e goals of 
treatment are to relieve pain as quickly as possible and 
prevent any adverse physical and psychological respons-
es to acute pain.
Th
  e general principles of acute pain relief 
include the following:
•  Analgesic selection is based on the pathophysi-
ological mechanism of pain and its severity.
•  Both opioid and nonopioid analgesics are highly 
eff ective for nociceptive pain.
•  Nonopioid agents are preferred for mild pain.
•  Opioids may be required for moderate to se-
vere pain.
•  Combined treatment with opioids and nonopi-
oids is often appropriate, and nonopioids may be 
employed to reduce the opioid dose requirement.
•  Nonpharmacological treatments may be helpful 
but should not preclude drug treatment.
What are the principles of eff ective               
acute pain management ?
•  Unrelieved pain may have negative physical and 
psychological consequences.
•  Aggressive pain prevention and control before, 
during, and after surgery and medical procedures 
does result in both short- and long-term benefi ts.
•  Successful evaluation and management of pain 
is partly dependent on a positive relationship be-
tween the patient and his or her relatives on the 
one hand, and the doctor and nurses on the other.
•  Patients should be actively involved in pain evalu-
ation and control.
•  Pain control must be evaluated and reevaluated at 
specifi c regular intervals.
•  Attending physicians and nurses must have a 
high index of suspicion for pain.
•  Total elimination of all pain is not practically 
attainable.
Fig. 1. An algorithm of the management of pain in the acute trauma/perioperative setting.
Mild pain
VAS=1-3/10
IM/IV Pentazocine
IM/IV NSAID’s
Cold/Hot compresses
Tolerable pain
Tolerable pain
Yes
Yes
No
No
Cold/Hot compresses
IM/IV Tramadol
IM/IV Pethidine
Moderate pain
VAS=4-6/10
Re-evaluate
Re-evaluate
Proceed
to planned
definitive
Rx
Proceed
to planned
definitive
Rx
Severe pain
VAS=7-10/10
Proceed to planned
definitive treatment
IV/IM Morphine
IV/IM Fentanyl

118
O. Aisuodionoe-Shadrach
What specifi c roles should the doctors and 
nurses play in ensuring that patients in this 
scenario are pain-free?
Th
  e clinicians should proceed to quantify the patient’s 
degree of pain using the following methodical ap-
proaches:
•  A brief oral pain history documented at the time 
of admission.
•  A measurement of the patient’s pain using a self-
reporting instrument, e.g., VAS or VRS.
• Th
  e use of behavioral observation as an adjunct 
to the self-report instruments.
•  Monitoring of the patient’s vital signs (although 
this is not a specifi c or sensitive test for pain).
Th
 ese procedures should be repeated at peri-
odic intervals by the attending health professional with 
a view to assessing the effi
  cacy of the analgesic regimen. 
Further measures include ensuring good patient posi-
tioning with the use of pillows and blankets in addition 
to the application of hot or cold compresses as needed.
Pearls of wisdom
•  Avoid misconceptions and recognize culturally 
determined beliefs about pain.
•  Always remember that pain cannot be ignored.
•  Don’t believe that the ability to tolerate pain is a 
measure of “manhood.”
• Th
  e truth is that pain is not meant to be tolerated.
•  It may not be practical to expect patients in the 
acute trauma/preoperative setting to be absolute-
ly pain-free.
•  However, pain can be reduced to tolerable levels 
by using widely available techniques.
•  Develop an algorithm for the management of 
pain in the acute trauma/perioperative setting, as 
shown in Fig. 1.
References
[1]  Aisuodionoe-Shadrach IO, Olapade-Olaopa EO, Soyanwo OA. Preop-
erative analgesia in emergency surgical care in Ibadan. Tropical Doctor 
2006;36:35–6.
[2]  Reuben SS, Ekman EF. Th
 e eff ect of initiating a preventive multi-
modal analgesic regimen on long-term patient outcomes for outpa-
tient anterior cruciate ligament reconstruction surgery. Anesth Analg 
2007;105:228–32.
[3]  Reuben SS, Buvanendran A. Preventing the development of chronic 
pain after orthopedic surgery with preventive multimodal analgesic 
techniques. J Bone Joint Surg 2007;89:1343–58.
Websites
Pain: current understanding of assessment, management, and treatments. 
(2001). National Pharmaceutical Council and Joint Commission on Accredi-
tation of Healthcare Organizations. 
Available at: http://www.npcnow.org/resources/PDFs/painmonograph.pdf

119
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
Chapter 16
Pain Management in Ambulatory/Day Surgery
Case report
John, a 5-year-old boy, had an orchidopexy done un-
der general anesthesia. Th
 e perioperative period was 
uneventful, and the child (accompanied by his moth-
er) was discharged home, fully awake and comfortable 
about 5 hours after the procedure with a prescription 
of oral paracetamol (acetaminophen). Problems began 
later that night when the child woke up complaining of 
signifi cant pain around the operation site. Th
 e mother 
gave him the prescribed analgesic, but the pain per-
sisted, and the child had now become inconsolable and 
unable to go back to sleep, keeping the parents and the 
other siblings awake.
Th
  is sort of scenario is unfortunately very com-
mon and causes unnecessary pain, distress, and suff er-
ing, not only to the patient but often to the whole house-
hold. Th
  e good news is that this type of situation is easily 
preventable or at least eff ectively treatable in most cases 
by applying simple and safe methods of pain relief.
For our illustrative case above, an example of a 
typical pharmacological analgesia therapy can be as fol-
lows. Paracetamol and/or a nonsteroidal anti-infl am-
matory drug (NSAID) is given orally as a premedication 
about 1 hour before surgery or as a suppository after in-
duction of anesthesia. A caudal block or a fi eld block or 
local infi ltration with bupivacaine or ropivacaine local 
anesthetic is administered after induction of anesthe-
sia. Postoperatively, oral paracetamol and/or an NSAID 
should be given at regular intervals for the fi rst 48 hours, 
and oral tramadol or codeine ordered as required (rescue 
analgesia) for unrelieved moderate to severe pain.
Why is analgesia for minor   
surgical procedures a topic      
worth reading about ?
In this section, I will explain why pain may be a com-
mon and signifi cant problem in seemingly minor sur-
gical procedures and how such pain can be eff ectively 
managed.  Postoperative pain should be considered a 
complication of surgery with signifi cant adverse eff ects, 
and every eff ort should therefore be made to avoid or 
minimize it. It is obvious that there are various options 
for providing eff ective and safe analgesia after minor 
surgical procedures. Satisfactory analgesia should be 
feasible for every patient, irrespective of geographical 
location or level of resources.
What is minor surgery?
Surgery is commonly classifi ed as major or minor de-
pending on the seriousness of the illness, the parts of 
the body aff ected, the complexity of the operation, and 
the expected recovery time. Minor surgical procedures 
now constitute the majority of procedures carried out 
in health care facilities because of greater awareness and 
Andrew Amata

120
Andrew Amata
earlier presentation of patients, and the increasing avail-
ability and accessibility of health care resources. Gen-
erally, more than half or even two-thirds of all surgical 
cases in health care facilities are usually considered mi-
nor and are often done as “same-day” or “day-case” or as 
“outpatient” or “ambulatory” surgery, where the patient 
comes into the health care facility, has the procedure 
done, and goes home the same day. Th
  is trend has been 
increasing recently and is mainly driven by economic 
factors, patients’ preferences, improved anesthetic and 
surgical techniques, and the increasing availability of 
minimally invasive surgical procedures.
What is the prevalence of pain after 
minor surgery?
Th
 e general assumption is that minor surgery is as-
sociated with less pain than major surgery. One of the 
criteria for selection for outpatient surgery is that pain 
should be minimal or easily treatable. However, it may 
be diffi
  cult to accurately predict pain intensity in a par-
ticular individual as some seemingly minor surgery 
may elicit moderate to severe pain for various reasons, 
including interindividual variability in pain perception 
and response. For the same type of surgical procedure, 
two similar individuals may perceive and experience 
pain very diff erently, and even for the same individual, 
the intensity of pain of a procedure may vary with time 
and activity. Several studies have shown that more than 
50% of children and a similar proportion of adults who 
undergo outpatient surgery experience clinically signifi -
cant pain after discharge.
What factors lead to poor pain 
control after minor surgery?
Contributory factors to poor postoperative pain control 
in minor surgery include:
• Th
  e assumption that minor surgery is associated 
with little or no pain, so that little or no analge-
sics are given in the postoperative period.
• Th
 e pressures of current ambulatory surgical 
practices, which emphasize rapid recovery and 
return to “street fi tness” and early discharge, re-
sulting in anesthesia care givers and surgeons 
avoiding or minimizing the perioperative use of 
potent and longer-lasting analgesics and sedatives 
that may delay recovery and discharge.
•  The fear among health care providers of the 
respiratory depressant and sedative effects of 
opioid drugs outside of immediate supervised 
medical care.
•  The presumption that patients or guardians 
may be ignorant of the risks of medications and 
may abuse them, with significant consequences 
at home.
•  Legislative and restrictive policies in some re-
gions that make it diffi
  cult to have access to po-
tent analgesics.