Guide to Pain Management in Low-Resource Settings


part of CRPS, but is no prerequisite for diagnosis. Diag-


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part of CRPS, but is no prerequisite for diagnosis. Diag-
nosis and treatment are diffi
  cult and should be left to a 
specialist. Advanced CRPS may leave the patient with a 
permanently unusable extremity.
Rheumatoid arthritis
An autoimmune disease that causes chronic infl amma-
tion of the joints and the tissue around the joints, as 
well as other organs in the body. Autoimmune diseases 
occur when the body tissues are mistakenly attacked by 
the body’s own immune system. Th
  e immune system is 
a complex organization of cells and antibodies designed 
to “seek and destroy” invaders of the body, particularly 
infections. Patients with autoimmune diseases have an-
tibodies in their blood that target their own body tis-
sues, where they can be associated with infl ammation. 
Because it can aff ect multiple other organs of the body, 
rheumatoid arthritis is referred to as a systemic illness 
and is sometimes called rheumatoid disease. While 
rheumatoid arthritis is a chronic illness (meaning it can 
last for years), patients may experience long periods 
without symptoms. Pain management includes NSAIDs 
and opioids. Pain control should not be attempted with-
out controlling the infl ammation, otherwise joint de-
struction will continue.
Sciatica
Pain resulting from irritation of the sciatic nerve, 
typically felt from the low back to behind the thigh 
and radiating down below the knee. While sciatica 
can result from a herniated disk directly pressing on 
the nerve, any cause of irritation or inflammation of 
this nerve can reproduce the painful symptoms of 
sciatica. Diagnosis is by observation of symptoms, 
physical and nerve testing, and sometimes by X-ray 
or MRI if a herniated disk is suspected. Very often, 
physical examination and careful taking of the history 
will reveal that the pain is not radiating along typical 
dermatomes. Therefore, other pain etiologies than 
radicular compression have to be taken into account, 
such as facet-joint pain, sacroiliacal joint irritation, 
or myofascial pain.
Somatoform disorders
Th
 e somatoform disorders are a group of psychiat-
ric disorders that cause unexplained physical symp-
toms (somatoform disorder, hypochondriasis, pain 
disorder,and conversion disorder). Th
 e pathophysiol-
ogy of these complaints still remains unclear. A com-
mon main symptom of these disorders is that physical 
symptoms cannot be completely explained by means 
of a physiological process. Somatic disorders can be 
accompanied by defi ned physical illnesses, but they 
may not be adequately explained by these illnesses. 
Patients who suff er pain without an organic cause 
are often unable to cope with emotional stress; this is 
converted into physical stress factors. Th
 ese diff use 
stress factors can no longer be understood as a physi-
cal expression of an intrapsychic confl ict, but are non-
specifi c, vegetative stress factors (e.g., with agitation
shaking, and pain) as a result of emotional pressure 
experienced primarily physically. Various physical dis-
orders can result. Th
  e standard medical treatment is 
often limited. Th
 ese disorders should be considered 
early on in the evaluation of patients with unexplained 
symptoms to prevent unnecessary interventions and 
testing. Th
 e identifi cation of a life event that is impor-
tant enough to be taken as a cause of this disorder may 
prove helpful to “solve” the stress of this life event with 
behavioral interventions. Consequently, the somato-
form pain may diminish over time.
Spinal stenosis
Narrowing of the spaces in the spine, resulting in com-
pression of the nerve roots or spinal cord by bony spurs 
or soft tissues, such as disks, in the spinal canal. Stenosis 
occurs most often in the lumbar spine (in the low back) 
in patients older than 60 years, but it also occurs in the 
cervical spine (in the neck) and less often in the thoracic 
spine (in the upper back). Th
  e typical symptoms to ask 
when suspecting spinal stenosis are claudication (pain 
increases after a certain time of exercise without evi-
dence of peripheral artery disease) and pain relief with 
bending forward. If surgery is not possible, a few thera-
peutic options are left for analgesia, including epidural 
steroids, physiotherapy, opioids and NSAIDs, and fl ex-
ion-orthostasis. 

Appendix: Glossary
371
Spondylolisthesis
Forward movement of one of the vertebrae of the spine 
in relation to an adjacent vertebra, most often at the 
level of L5/S1. Simple “functional” X-ray (lateral view 
in full extension and full fl exion of the spine) may dem-
onstrate spondylolisthesis. Only a major forward move-
ment (>25–50% of the vertebral length) is an indication 
for surgery.
Substance P
Substance P is a member of the tachykinin family of 
neuropeptides that is expressed in sensory neurons. 
It works as a stimulatory neurotransmitter or neuro-
modulator when it is released centrally, and as a proin-
fl ammatory mediator when it is released peripherally. 
It activates the neurokinin-1 receptor, a major factor in 
central sensitization.
Withdrawal syndrome
Th
  e abrupt cessation of a repeatedly or continuously ad-
ministered opioid agonist, or the administration of an 
antagonist, typically results in withdrawal syndrome. 
Signs and symptoms include sweating, tachycardia, hy-
pertension, diarrhea, hyperventilation, and hyperrefl ex-
ia. See also the entry on “Dependence”.
Tolerance
Tolerance is the need for progressively increasing doses 
of an agonist to maintain the same eff ect (e.g., analge-
sia). In chronic pain, the need for increasing doses of 
opioids can be due to alterations in receptor functioning 
(e.g., coupling to G proteins, second messengers) and/
or to increasing painful stimulation (e.g., by a growing 
tumor), among other reasons. Tolerance is fortunately 
not common in patients who have opioid-sensitive pain. 
In patients seeking opioid treatment for mood stabiliza-
tion, tolerance is frequent. Th
  erefore, in patients with 
nonmalignant pain and nonprogressing disease, the re-
peated need for dose escalation (typically every 4 to 8 
weeks, when tolerance to the sedating and euphoric 
eff ects of opioids develops) should be a warning sign 
for “inadequate” opioid use, and the opioid medication 
should be gradually discontinued.
Trigeminal neuralgia
A disorder of the trigeminal nerve in its root area (e.g., 
secondary trigeminal neuralgia due to malignant masses 
in the cerebellar region) or due to pulsatile compres-
sion by the cerebellar artery that causes brief attacks 
of severe pain in the lips, cheeks, gums, or chin on one 
side of the face. Only a symptom complex including 
attack-like pain of less than 2 minutes, no neurological 
defi cits, absent or minor chronic pain, and typical trig-
ger factors should be diagnosed as trigeminal neural-
gia. Carbamazepine is still considered to be the drug of 
fi rst choice. If drug therapy fails, trigeminal neuralgia 
is one of the few pain syndromes where surgery is in-
dicated (Janetta surgery).
World Health Organization
An agency of the United Nations established in 1948 
to further international cooperation in improving 
health conditions. Although the World Health Or-
ganization (WHO) inherited specifi c tasks relating 
to epidemic control, quarantine measures, and drug 
standardization from the Health Organization of the 
League of Nations (which was set up in 1923) and 
from the International Offi
  ce of Public Health at Par-
is (established in 1909), the WHO was given a broad 
mandate under its constitution to promote the attain-
ment of “the highest possible level of health” by all 
people. WHO defi nes health positively as “a state of 
complete physical, mental, and social well-being and 
not merely the absence of disease or infi rmity.”  Th
 e 
cancer pain management recommendations of the 
WHO (the analgesic ladder) have had a major eff ect on 
the rate of opioid prescriptions to patients with cancer 
and HIV-related pain, mainly in countries belonging to 
the Organization for Economic Co-operation and De-
velopment (OECD). Unfortunately, Eastern European 
countries and many low-resource countries continue 
to have only very restricted opioid delivery rates to 
cancer patients, which should be considered a health 
emergency. Th
  e Pain and Policy Study Group of the 
WHO is investing a lot of eff ort to infl uence this situ-
ation by advising government authorities and health 
care workers on legislative, educational, and treat-
ment changes necessary to be able to provide adequate 
amounts of opioids to patients in need. For further in-
formation see their website for a lot of relevant facts 
regarding opioids in most countries of the world.

Document Outline

  • Front Matter: Guide to Pain Management in Low-Resource Settings
  • Basics
    • Chapter 1: History, Definitions, and Contemporary Viewpoints
    • Chapter 2: Obstacles to Pain Management in Low-Resource Settings
    • Chapter 3: Physiology of Pain
    • Chapter 4: Psychological Factors in Chronic Pain
    • Chapter 5: Ethnocultural and Sex Influences in Pain
    • Chapter 6: Pharmacology of Analgesics (Excluding Opioids)
    • Chapter 7: Opioids in Pain Medicine
    • Chapter 8: Principles of Palliative Care
    • Chapter 9: Complementary Therapies for Pain Management
  •  Physical and Psychological Patient Evaluation
    • Chapter 10: Pain History and Pain Assessment
    • Chapter 11: Physical Examination: Neurology
    • Chapter 12: Physical Examination:  Orthopedics
    • Chapter 13: Psychological Evaluation of the Patient with Chronic Pain
  • Management of Acute Pain
    • Chapter 14: Pain Management after Major Surgery
    • Chapter 15: Acute Trauma and Preoperative Pain
    • Chapter 16: Pain Management in Ambulatory/Day Surgery
    • Chapter 17: Pharmacological Management of Pain in Obstetrics
  • Management of Cancer Pain
    • Chapter 18: Abdominal Cancer, Constipation, and Anorexia
    • Chapter 19: Osseous Metastasis with Incident Pain
    • Chapter 20: Lung Cancer with Plexopathy
    • Chapter 21: Lung Cancer with Breathing Problems
    • Chapter 22: Hematologic Cancer with Nausea and Vomiting
  • Management of Neuropathic Pain
    • Chapter 23: Painful Diabetic Neuropathy
    • Chapter 24: Management of Postherpetic Neuralgia
    • Chapter 25: Central Neuropathic Pain
    • Chapter 26: The Management of Pain in Adults and Children Living with HIV/AIDS
  • Management of Chronic Noncancer Pain
    • Chapter 27: Chronic Nonspecific Back Pain
    • Chapter 28: Headache
    • Chapter 29: Rheumatic Pain
  • Difficult Therapeutic Situations and Techniques
    • Chapter 30: Dysmenorrhea, Pelvic Pain, and Endometriosis
    • Chapter 31: Pain Management Considerations in Pregnancy and Breastfeeding
    • Chapter 32: Pain in Sickle Cell Disease
    • Chapter 33: Complex Regional Pain Syndrome
    • Chapter 34: Pain Management in Children
    • Chapter 35: Pain in Old Age and Dementia
    • Chapter 36: Breakthrough Pain, the Pain Emergency, and Incident Pain
    • Chapter 37: Pain Management in the Intensive Care Unit
    • Chapter 38: Diagnostic and Prognostic Nerve Blocks
    • Chapter 39: Post-Dural Puncture Headache
    • Chapter 40: Cytoreductive Radiation Therapy
    • Chapter 41: The Role of Acupuncture in Pain Management
  • Planning and Organizing Pain Management
    • Chapter 42: Setting Up a Pain Management Program
    • Chapter 43: Resources for Ensuring Opioid Availability
    • Chapter 44: Setting up Guidelines for Local Requirements
  • Pearls of Wisdom
    • Chapter 45: Techniques for Commonly Used Nerve Blocks
    • Chapter 46: Psychological Principles in Pain Management
    • Chapter 47: Insights from Clinical Physiology
    • Chapter 48: Herbal and Other Supplements
    • Chapter 49: Profiles, Doses, and Side Effects of Drugs Used in Pain Management
  • Appendix: Glossary

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