Newsletter Aug 2011: Pain Management in Low and Middle Income Countries (LMIC) Just Put Up With It?
Over the last couple of years we
have had the privilege of travelling to and working in a number of
resource-poor countries exploring pain attitudes, knowledge and treatment options. In this article, we will present our
perspective on pain in these countries and give an overview of a pain
management course we have developed, which uses a framework we have called RAT (Recognise, Assess, Treat).
The physiological processes of acute
nociception from the periphery to the brain are the same in all humans,
irrespective of where they live. The causes of pain are varied:
- Pain from multi-trauma following a motor vehicle
crash (an increasing drain on medical services in many countries).
- Postoperative pain following a laparotomy for a
perforated duodenal ulcer.
- Lumbar spine pain from a pathological vertebral
fracture in a woman with carcinoma of the cervix.
- The first dressing change in a 3-year-old child
following extensive burns from a cooking fire.
- Labour pain in a teenager struggling through her
Apart from the humanitarian
aspects of treating acute pain and decreasing the stress response, the benefits
of early mobilisation, ability to self care and quicker hospital discharge
would seem to be of value in resource poor countries.
Cancer is a common cause of
chronic or acute on chronic pain in LMIC.
According to the WHO, a disproportionately high number of new cases
occur in the developing world with 80% being incurable at the time of
diagnosis. Extrapolating from
Australian data, it is probable that at least 75 percent of these cases will
experience moderate to severe pain during the course of their illness. This is a very strong argument for the
development of palliative care services, including effective pain management.
On the surface, it appears that
many people in LMIC accept pain as an unavoidable part of life. Patients may have little or no
knowledge that certain treatments are available. Nursing and medical staff, for a variety of reasons, may not
offer treatment, reinforcing patient and societal low expectations about pain
Stoicism appears to reign supreme,
and individuals appear never to complain because there seems to be no point. It
is often difficult to tease out the role that cultural factors play in the way
patients express their pain – pain and suffering may be seen as a test of
faith, while some societies will be fatalistic about pain.
Doctors’ and nurses’ attitudes
and knowledge about pain seem to suggest that pain is a symptom of a disease
process that they either can or cannot do something about, rather than a
symptom that can be treated. For example, there is still a strong belief that
treating acute abdominal pain will obscure the diagnosis; therefore the pain is
frequently left untreated (1).
There has been significant effort
by the WHO to prevent cancer and address cancer pain treatment. There have also been huge international
efforts to prevent and treat HIV/AIDS and this has had some spin-off benefits
for palliative care and pain management of other terminal diseases.
Morphine was included on the
WHO’s Essential Medicines List back in 1977. Then, in a major advance for cancer pain management, the WHO
introduced the Three Step Analgesic Ladder in 1986. Unfortunately however, there are still many places in the
world where oral morphine is not available. This is despite its vital role in the treatment of cancer
pain, its low cost and ease of preparation. A number of organisations have campaigned for the global
availability of morphine and a good overview of some of the issues relating to
the unavailability of morphine was recently published in the BMJ (2).
Staff knowledge and attitudes are
important factors when it comes to recognising pain and treating it
effectively. We strongly believe
that education plays a vital role in improving pain management and we appear to
be lagging in our efforts to provide effective pain management to our global
Consequently we developed a one-day
workshop called Essential Pain
Management (EPM) with initial funding from the Australian and New Zealand
College of Anaesthetists (ANZCA).
The course emphasises low cost management strategies and how quality of
life can often be markedly improved with very simple treatments. Delivery of
the course in the Western Pacific Islands, Papua New Guinea, Mongolia and
recently Tanzania has been generously supported by the IASP, WFSA and private
The EPM course structure is
modelled on the successful Primary Trauma Care (PTC) course. It comprises a one
day (8 hour) interactive course and a half-day (4 hours) teach-the-teacher
course for “local champions” identified during the initial one-day course. Identification of local enthusiasts to
continue the educational programme is an essential component of the model – it
encourages local ownership of issues and promotes a culture of continuing
education and teamwork.
EPM is principally designed for
medical and nursing staff, but can be easily modified for other groups of
healthcare workers such as pharmacists and nurse aides. The workshop is highly interactive and
comprises a series of short lectures, brainstorming sessions and case
discussions. Morning topics
include the classification of pain, basic physiology and pharmacology which
includes time on non-drug treatments, reasons to treat pain, and pain
management barriers. Most of the
afternoon is devoted to a series of case discussions illustrating different
pain problems, followed by a brainstorming session looking at ways to overcome
ABC (Airway, Breathing,
Circulation) has proved very successful as a teaching tool in trauma and
resuscitation. In EPM, we have
coined our own acronym, RAT,
standing for Recognize, Assess, Treat.
This simple framework has proved very popular with course participants and
provides a good structure (along with subheadings) for the case
The four-hour instructor workshop
is also highly interactive and covers relevant teaching principles and
practical issues relating to the running of an EPM workshop.
Participant feedback about EPM
has been very positive. One
measure of success of the workshop will be whether the course is taken up by
local health workers. Since running two workshops in Papua New Guinea in April
2010, several EPM workshops have since been organised and taught by local
instructors and the course has also been incorporated into the undergraduate
EPM is in its infancy but we hope
it will prove to be an important tool for improving pain knowledge and practice
in developing countries.
Please contact either one of us
if you are interested in more information about the course.
J Emerg Med 2009;2:211-215
PERTH Western Australia
CHRISTCHURCH New Zealand