Guide to Pain Management in Low-Resource Settings

Practical consequences
Adequate counseling and emotional support should 
be integrated in the provision of health care for these 

342
Claudia Schulz-Gibbins
patients. Good communication and explanations 
about the existing possibilities of therapy and about 
the prognosis can reduce fears and helplessness, and 
enable patients to cope better with the disease and its 
accompanying challenges. Particularly in Kenya, reli-
gious support has been reported as being helpful.
What are the options in chronic 
noncancer pain?
In the context of chronic abdominal pain, which is quite 
often diffi
  cult for the patient to locate and come to 
terms with, often together with the threat of incurability 
and looming death. Commonly, the physician wonders, 
“Why is the patient coming now?” Possible reasons for 
the patient can be a fear of serious diseases after deaths 
in the family, psychological comorbidities, emotional 
distress because of sexual abuse, but also trouble with-
in the actual context of life and poor coping strategies, 
which may lead to an increase in the pain.
Practical consequences
Indicators of stress mentioned above should be looked 
for, which can aff ect the development and maintenance 
of pain. Th
  erapeutic interventions including a good ex-
planation of the disease, continuing psychological sup-
port, advice on balanced nutrition, and so on should be 
added over time.
How can we tackle                    
chronic headache?
Most headaches have no organic cause. Very often we 
fi nd interactions between headache and dysfunction-
al patterns of the muscles, such as increased tension, 
which can then, by itself, become a trigger for head-
ache. Social stress factors such as excessive demands at 
the workplace or poor coping strategies with stress, can 
make headaches intense and chronic.
Practical consequences
Important in the treatment of headache is describing to 
the patient that stress can lead to an increase in the in-
tensity and frequency of the headache. Th
  e most impor-
tant psychological interventions are education in coping 
skills and in the importance of stress management, and 
the reduction of hyperactivity with lessons in cognitive 
behavioral therapy, relaxation techniques, and so on.
What can we use for chronic      
back pain?
Chronic back pain, in most cases, is musculoskeletal in 
origin, accompanied by poor coping skills along with 
other “yellow fl ags.” A special problem in coping with 
back pain is the fact that sometimes no suffi
  cient expla-
nation can be given to the patient regarding the cause 
and origin of the pain. For example, a diagnosis of “non-
specifi c back pain” leads to an extreme uncertainty on 
the part of the patient, often leading to increased fear of 
serious pathology and the desire for repeated diagnos-
tic procedures. Often there is an iatrogenic component 
when repeated investigations are ordered—partly be-
cause the patient insists on it, and partly because the 
physician may be uncertain: “Is there a tumor or a seri-
ous disk prolapse causing the pain?” Th
  ere may be a re-
luctance “to miss something.”
Practical consequences
A comprehensive compilation of all available fi ndings, 
as well as discussion with colleagues about previous di-
agnosis and treatment, can be useful to get a complete 
picture about the patient. Th
  e patient should be advised 
against unnecessary and often very expensive invasive 
diagnostic procedures.
After considering all possible factors including 
psychiatric comorbidity or risks of chronifi cation,  a 
treatment plan can be developed. Good models on 
interactions, for example between depression and 
chronic pain, can help the patient to cope successfully 
with pain.
References
[1]  American Psychiatric Association. Diagnostic and statistical manual of 
mental disorders, 4th ed. Washington, DC: American Psychiatric Asso-
ciation; 1994.
[2]  Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathol-
ogy: research fi ndings and theoretical considerations. Psychosom Med 
2002;64:773–86.
[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.
[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, 
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-
tiple pains and mental disorders: results from the World Mental Health 
Surveys. Pain 2008;135:82–91.
[5]  Merskey H, Lau CL, Russell ES, Brooke RI, James M, Lappano S, 
Neilsen J, Tilsworth RH. Screening for psychiatric morbidity. Th
 e pat-
tern of psychological illness and premorbid characteristics in four 
chronic pain populations. Pain 1987;30:141–57.
[6]  Murray SA, Grant E, Grant A, Kendall M. Dying from cancer in devel-
oped and developing countries: lessons from two qualitative interview 
studies of patients and their carers. BMJ 2003;326:368.

Psychological Pearls in Pain Management
343
[7]  Norman SB, Stein MB, Dimsdale JE, Hoyt DB. Pain in the aftermath of 
trauma is a risk factor for posttraumatic stress disorder. Psychol Med 
2008; 38:533–42.
[8]  Tang NK, Crane C. Suicidality in chronic pain: a review of the preva-
lence, risk factors and psychological links. Psychol Med 2006:36:575–
86.
[9]  Tsang A, Von Korff , M, Lee S, Alonso J, Karam E, Angermeyer MC, 
Borges GL, Bromet EJ, de Girolamo G, de Graaf R, Gureje O, Lepine 
JP, Haro JM, Levinson D, Oakley Browne MA, Posada-Villa J, Seedat S, 
Watanabe M. Common chronic pain conditions in developed and de-
veloping countries: gender and age diff erences and co morbidity with 
depression-anxiety disorders. J Pain 2008;9:883–91.
Websites
www. immpact.org (Initiative on Methods, Measurement, and Pain Assess-
ment in Clinical Trials)

345
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 47
Insights from Clinical Physiology
Rolf-Detlef Treede
Insights on acute pain
Aside from alleviating suffering, one of the major 
aims of postoperative pain management is to facili-
tate and speed up recovery, reestablish mobility, and 
ultimately favor a rapid discharge. One of the funda-
mental mechanisms in the nociceptive system is in-
terfering with these aims is called central sensitiza-
tion. Sensitization is a basic learning mechanism that 
describes an increased neural response when stimuli 
of constant intensity are simply repeated. (Its coun-
terpart, habituation, a decrease in response upon re-
petitive stimulation, is less prominent in the nocicep-
tive system). In central sensitization, the increased 
neural response is due to enhanced efficacy of the 
synaptic connections within the nociceptive system. 
Central sensitization mostly enhances pain to me-
chanical stimuli, whereas peripheral sensitization al-
most exclusively increases heat pain sensitivity. This 
makes central sensitization highly relevant in the 
postoperative setting.
When sensitization occurs in the nociceptive sys-
tem, the patient perceives more pain in response to 
relatively mild stimuli such as moving around in bed 
or coughing. As a consequence, the patient will move 
less and breathe less deeply, in order to titrate the pain 
down to a tolerable level. Fortunately, eff ective  pain 
treatment (e.g., with opioids or local anesthesia) also 
reduces central sensitization.
Practical consequences
Ask each patient about movement-evoked pain, and 
treat with eff ective, multimodal analgesics.
Insights on cancer pain
One of the most painful conditions in a patient with 
advanced cancer is bone metastasis. Th
 is well-known 
clinical reality is in confl ict with traditional basic sci-
ence teaching: according to standard textbooks, only 
the periosteum is innervated, but not the bone itself. 
If this were true, only large bone metastases that ex-
tend into the periosteum should be painful. But ex-
perience teaches otherwise: fortunately, painful bone 
metastases usually have not yet destroyed the com-
pacta. Th
  us, when they are treated causally by radia-
tion or chemotherapy, the stability of the bone is still 
preserved. It is also well known that aspiration of 
bone marrow is very painful, in spite of local anesthe-
sia of the periosteum.
Th
  us, the bone’s interior structures are densely in-
nervated by nociceptive aff erents, probably very similar 
to the innervation of teeth. Only recently have anato-
mists been able to demonstrate nociceptive nerve fi bres 
within the bone using the marker CGRP (calcitonin 
gene-related peptide), where they appear to have con-
tacts with both the bone trabecula and the osteoclasts. 
Physiologically, there is also some recent evidence that 

346
Rolf-Detlef Treede
the spinal cord receives nociceptive input from within 
the bone.
Practical consequences
Tissue damage restricted to the bone marrow can be 
a source of intense nociceptive input. Hence, patients 
with pain in such conditions do need treatment. How-
ever, treatment here does not necessarily have to be by 
analgesics; instead, radiation or chemotherapy may ac-
tually eliminate the cause of this pain.
Insights on neuropathic pain
Th
  ere has been a long-standing debate on how to de-
fi ne “neuropathic pain.” Th
  e concept, however, is quite 
simple: consider the nociceptive system as the body’s 
alarm system. Pain is perceived when this system rings 
an alarm. As with any other alarm system, there are two 
possible ways the alarm can be activated: (a) it is a true 
alarm signaling an actual event; (b) it is a false alarm, 
caused by a defect in the alarm system. Th
  e usual pain 
after tissue damage is a case of true alarm by the noci-
ceptive system. In case of neuropathic pain, it is a false 
alarm caused by some kind of damage to the nocicep-
tive system.
Practical consequences
If a patient reports pain in a part of the body that is not 
damaged, consider neuropathic pain as a possibility. To 
verify this clinical hypothesis, evidence should be sought 
to demonstrate the underlying damage to the nocicep-
tive system. Th
  e patient’s history may reveal a possible 
etiology such as diabetes, peripheral nerve damage, HIV, 
or previous shingles. Th
  e sensory examination is of ut-
most importance: the distribution of pain and the dis-
tribution of negative or positive sensory signs should 
closely match. Sensory testing must include either a 
painful test stimulus such as pinprick, or a thermal stim-
ulus such as contact with a cold object (thermoreceptive 
pathways are very similar to nociceptive pathways and 
hence are an excellent surrogate). To be able to diagnose 
neuropathic pain correctly, pain specialists need to have 
some level of neurological training.
Insights on chronic pain
Migraine is a frequent headache syndrome that has 
a major impact on quality of life. In spite of major re-
search, its pathophysiology is still not fully understood. 
In the aura phase, many patients are hypersensitive to 
external stimuli such as light, sound, smell, or touch. 
Th
  is increased sensitivity appears to be related to a de-
fi ciency in habituation. For example, evoked cerebral 
potential studies have shown that the normal response 
decrement upon repetitive application of visual stimuli 
is absent in migraine suff erers. More recently, such defi -
cits have also been shown for pain habituation, by using 
laser-evoked potentials (here an infrared laser applies 
very brief heat pulses of a few milliseconds’ duration). 
Th
  ere is some evidence that defi cits in pain habituation 
occur in other chronic pain conditions as well, such as 
in cardiac syndrome X.
Practical consequences
Currently none, but in the future it may be possible to al-
leviate chronic pain conditions by treatment modalities 
that enhance habituation without being directly analgesic.
Insights on pain in                     
infants and children
Skin innervation occurs at about 7–15 weeks’ gesta-
tion, and simple refl ex arcs appear as early as 8 weeks. 
Th
  alamocortical connections are established much later 
(from week 20 onwards), and EEG signals and somato-
sensory evoked potentials start to be present at week 
29–30. Th
  ese electrical brain signals suggest that con-
scious perceptions such as pain may be present before 
birth. However, the nervous system is immature at birth 
and undergoes substantial changes postnatally. Immedi-
ately after birth, cutaneous withdrawal refl exes are lively 
and occur with very low threshold, such as mild touch 
by a pointed object. GABAergic synapses are excitato-
ry at early developmental stages and become inhibito-
ry only with maturation. After birth, refl exes decrease, 
whereas cortical stimulus responses increase (detect-
able by near-infrared spectroscopy, for example). My-
elination in peripheral nerves is complete within about 
1 year, but it takes 5–8 years in the central nervous 
system. As soon as a child is able to understand verbal 
instructions, faces pain scales can be used in a similar 
fashion as visual analogue scales in adults.
Practical consequences
It is diffi
  cult to judge the level of pain and discomfort 
in infants due to their strong refl ex responses that may 
or may not run parallel to conscious perception. To 
be on the safe side, adequate anesthesia and analgesia 

Clinical Physiology Pearls
347
are considered the standard of care at all ages. Special 
regimens apply, and most medications are being used 
off -label.
Insights on pain in                            
old age and dementia
Pain thresholds and pain-evoked brain potentials have 
been studied in healthy volunteers up to the age of 100 
years. Pain thresholds and evoked potential latencies 
slightly increase and evoked potential amplitudes de-
crease at ages above 80 years. In many cases, however, 
verbal communication skills may deteriorate in old age, 
with large individual variations. In this situation, pain 
assessment becomes diffi
  cult. For demented people, 
special observer-based scales have been developed 
and validated to allow assessment of pain and suff er-
ing in this vulnerable group. Th
  ere is some evidence 
that the placebo eff ect is less effi
  cacious in demented 
people. Decline in liver and kidney function, on the 
other hand, makes dosage adjustments necessary for 
many medications.
Practical consequences
Many people maintain normal functions of their no-
ciceptive system way into old age. When dementia is 
present, pain assessment relies increasingly on the ob-
servation of pain-related behavior. It is currently as-
sumed that the level of pain in demented patients is un-
derestimated substantially.

349
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
Joel Gagnier
Chapter 48
Herbal and Other Supplements
What is the defi nition                        
of natural health products?
Natural health products include vitamins, minerals, 
herbal medicines, homeopathics and other naturally de-
rived substances (e.g., glucosamine, bee pollen) to pre-
vent or treat various health conditions.
In the developing world, it would be advis-
able to consult local elders or healers to determine lo-
cal plants or foods that may be used. You should get 
instructions on how to use them safely. Traditional 
knowledge from a respected elder, healer, or tribal chief 
may be reliable information. Always think about the 
risk/benefi t ratio, since natural health products might 
contain “unnatural” ingredients, such as heavy metals or 
other contaminants. Th
  erefore, the use of natural health 
products depends on mutual trust between the care-
giver and the healer, since there are few evidence-based 
data and standardized products available.
It is advisable to seek cooperation between the 
“offi
  cial” and “unoffi
  cial” medical sector, both to broad-
en therapeutic options and to avoid counterproduc-
tive interactions. Some initiatives have undertaken this 
task. For example, in 1998 a task force was set up by the 
Ministry of Health in Ghana to identify the credible Na-
tional Healer Associations. Six such healer associations 
were identifi ed.  Th
 ese associations came together to 
form the nucleus of the Ghana Federation of Traditional 
Medicine Practitioners’ Associations (GHAFTRAM). 
Other activities followed, including international con-
ferences and research exchanges.
What supplements are                   
best for acute pain?
Surgical procedures and acute trauma may be ad-
dressed by several natural health products. For exam-
ple, the homeopathic remedies Arnica and Hypericum 
may be useful prior to and after surgery. Arnica is par-
ticularly useful for decreasing pain, bruising discolor-
ation, and discomfort in the patient. Homeopathic Hy-
pericum is very useful to heal incisions and eliminate 
pain. Th
  ese remedies can be given orally at 200C po-
tencies every 2–4 hours on the day prior to surgery and 
after surgery until the incision is healed. For acute trau-
ma to muscles, ligaments, and tendons, topical creams 
or ointments containing Harpagophytum procumbens 
(Devil’s claw), Capsicum frutescens (cayenne), homeo-
pathic Arnica, or methylsulfonylmethane (MSM) may 
be applied 3–4 times per day on the aff ected site as 
long as the skin is intact.
What supplements are best             
for neuropathic pain?
Peripheral neuralgias, if caused by malnutrition, may 
be treated by supplementation with vitamins. Vitamins 
E, B
1
, B
3
, B
6
, and B
12
 are essential for adequate nerve 

350
Joel Gagnier
function. A diet with regular fruit and vegetable intake 
would include these vitamins, or alternatively a simple 
multivitamin mineral formula would be suffi
  cient.  In 
patients with diabetic neuropathy, besides adequately 
controlling blood sugar, vitamin B
6
 at 150 mg or vitamin 
E at 800 IU per day may be eff ective. Th
 ese supplements 
may be used together. A simple dietary intervention to 
aid in blood sugar control is the regular consumption of 
beans and legumes.
What supplements are                   
best for chronic pain?
Chronic unspecifi ed back pain may be treated with oral 
Harpagophytum procumbens (Devil’s claw) at 2000–
3000 mg per day, delivering 50–100 mg of the active 
constituent harpagoside; oral willow bark (Salix alba, 
Salix daphnoides, or  Salix purpurea) at 1200 mg per 
day, delivering 120–240 mg of the active constituent 
salicin; or topical capsicum cream. Dysmenorrhea may 
be treated with oral calcium at 1000–1500 mg per day, 
magnesium at 300–400 mg per day, vitamin B6 at 100 
mg per day, vitamin E at 400–800 IU per day, or Vitex 
agnus-castus  (chaste berry) at 20–40 mg per day. For 
migraine headaches the following are eff ective: vitamin 
B
2
 400 mg per day, Tanacetum parthenium (feverfew) 
100 mg per day, magnesium 500 mg per day, or Petasites 
hybridus (Butterbur) 150 mg per day. Th
  ese can be used 
individually or in combination. Rheumatic pain in the 
form of osteoarthritis (OA) may be successfully treated 
with oral glucosamine sulfate at 1500 mg per day to-
gether with oral chondroitin sulfate at 1200 mg per day; 
oral unsaponifi able fractions of avocado and soybean 
oils at 300 mg per day; oral Harpagophytum procum-
bens (Devil’s claw) 2400 mg per day; and topical creams 
containing a combination of camphor, glucosamine 
sulfate, and chondroitin sulfate. Mild to moderate OA 
may respond to a treatment starting with glucosamine 
sulfate (1500 mg/day) and chondroitin sulfate (1200 mg 
per day) for 4–6 weeks, and if there is a limited eff ect 
adding oral unsaponifi able fractions of avocado and soy-
bean oils and Devil’s claw. Rheumatoid arthritis may be 
treated with oral borage seed oil at 1–1.5 grams per day, 
oral fi sh oil providing eicosapentaenoic acid (EPA) and 
docosahexanoic acid (DHA) at 2 grams/day, oral vita-
min E at 800 IU per day, or oral Tripterygium wilfordii 
(thunder god vine) at 200–600 mg per day.