Introduction to pain

Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for
individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is
the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the
Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these
materials, or for any errors or omissions. Last updated on January 12, 2015
Objectives

By the end of the session, learners should be able to:

1. Define the term pain
2. Name the common opioid analgesics
3. Understand that the World Health Organization considers morphine to be
an essential medicine
4. Describe the disparity in access to morphine by country income level
5. Give key advantages of morphine relative to other pain medicines
6. Describe challenges that limit access to morphine
7. Understand why pain treatment is important
8. Name the simple treatment algorithm that relieves pain in 80-90% of people
9. Challenge some common myths about pain treatment

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Pain

• Pain is an unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or
described in terms of such damage
• Pain is a subjective experience. The experience varies from
person to person and from time to time
– Pain is whatever the experiencing person says it is, existing
wherever he says it does

Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. (1979). Pain, 6(3),
3
249.; McCaffery, (1968)
Total pain: how patients experience pain

PHYSICAL

PSYCHOLOGICAL TOTAL PAIN Social

SPIRITUAL

• Patients experience pain on several levels and effective treatment requires a

holistic assessment
• This training program focuses on physical pain

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Who suffers from pain?

• Pain is prevalent in almost all medical specialties including

general practice, palliative care, oncology, internal medicine,
haematology, and surgery
• Patients who are affected include people who have cancer,
HIV, sickle-cell disease, those who have surgery or accidents,
and potentially other patients
• Approximately 80% of people with advanced cancer and 50%
of people with advanced HIV experience moderate or severe
pain

Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines.
World Health Organization (2011); Foley et al. Pain Control for People with Cancer and AIDS (2006) 5
Opioid analgesics for pain relief

• Analgesics are medicines that relieve pain

• Opioids are medicines that are derived from opium poppy plants or synthetic
formulations that act in the same way
– Weak opioids
• Codeine
• Tramadol
• Dihydrocodeine
– Strong opioids
• Morphine
• Fentanyl
• Oxycodone
• Hydrocodone
• Buprenorphine
• Methadone

Beating Pain, 2nd Ed. APCA (2012) 6

World Health Organization

• Opioid analgesics, including morphine, are considered

essential medicines by the World Health Organization
• Strong opioid analgesics are the only treatment for moderate
or severe pain recommended in World Health Organization
guidelines
• No suitable alternatives have been found

Ensuring balance in national policies on controlled substances: guidance for availability and accessibility of controlled medicines.
World Health Organization (2011) 7
Disparity in access to opioids

Opioids are on almost all national essential medicines lists, but

access to them is severely limited in most low and middle-
income countries, where 85% of the world’s population
consumes just 7% of the medicinal opioids
Low and middle-income High-income
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Population Medicinal opioids

Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2018
2)
 Number of deaths with untreated pain (2012)

Deaths with
untreated pain

The lowest treatment coverage rates are:

• South Asia: 9%
• Sub-Saharan Africa: 20%

Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (2019
2)
Access to morphine differs according to
country income level

Maximum coverage rate for deaths in pain from HIV or cancer

based on national consumption of opioid analgesics:
• High-income countries: 100%
• Middle-income countries: 62%
• Low-income countries: 19%

People in lower income countries are significantly less likely to

get pain treatment than people in higher-income countries

Treat the Pain: based on data from the International Narcotics Control Board and WHO Cause of Death data (201
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2)
Opioid analgesics for pain relief

Opioids are the foundation of pain management for moderate or

severe pain
• No organ toxicity, even at high doses and after prolonged use
• Side effects diminish over time
• Potential harmful side effects are avoidable when opioids are
used correctly

IASP: Treatment of pain in low-resource settings (2010) 11

Morphine advantages

• Most effective treatment for severe pain

• Safe (if used according to guidelines)
• Effective
• Plentiful
• Inexpensive
• Easy-to-use

Beating Pain, 2nd Ed. APCA (2012) 12

Challenges that limit access to morphine

Although morphine is inexpensive people lack access due to:

• Inadequate training or lack of knowledge of healthcare
providers
• Cultural misperceptions about pain
• Lack of appropriate government policies or guidelines
• Legal and regulatory restrictions
• Weak procurement systems
• Disproportionate concern about diversion, addiction, and abuse
• Practices meant to prevent abuse of morphine that result in
limited access for those in need of pain relief
IASP: Treatment of pain in low-resource settings (2010) 13
Advantages of pain treatment

In low-resource countries, pain is the most common indication

for visiting a health care practitioner
Pain treatment:
• Improves compliance to curative treatment
• Extends survival for some patients
• Improves quality of life
• Improves patient – physician relationship
• Reduces unnecessary prolonged admission

IASP: Treatment of pain in low-resource settings (2010); Temel et al- NEJM (2010) 14
How to treat pain?

• The World Health Organization has developed a simple

algorithm, or model for pain treatment: the WHO Analgesic
Ladder
– Incorporates non-opioid and opioid pain relievers
– Extremely effective for patients with acute pain, cancer pain,
and neuropathic pain (nerve pain)
• 80-90% of people are effectively treated
IASP: Treatment of pain in low-resource settings (2010); http://www.who.int/cancer/palliative/painladder/en/
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Dispelling some myths

• Myth: Children don’t feel pain

– There is no evidence that neonates or young children feel
less pain than adults
• Myth: Moderate or severe pain is uncommon
– Approximately 50% of people with advanced HIV and 80%
of people with advanced cancer will experience moderate
or severe pain
– Other causes of pain include surgery, trauma, burns,
myocardial infarction, sickle cell disease, and childbirth

IASP: Treatment of pain in low-resource settings (2010); Children’s Palliative Care in Africa; Ensuring balance in national policies
on controlled substances: guidance for availability and accessibility of controlled medicines. World Health Organization (2011);
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Foley et al. Pain Control for People with Cancer and AIDS (2006)
Dispelling some myths

• Myth: Opioids are dangerous

According to the World Health Organization:
– “Opioid analgesics, if prescribed in accordance with
established dosage regimens, are known to be safe and
there is no need to fear accidental death or dependence.”
– “A systematic review of research papers concludes that
only 0.43% of patients with no previous history of
substance abuse treated with opioid analgesics to relieve
pain abused their medication and only 0.05% developed
dependence syndrome.”

World Health Organization: Ensuring Balance in National Policies on Controlled Substances: 2011
17
Dispelling some myths

• Myth: Pain relief is not affordable

– Locally produced oral morphine solution costs just
3-12/25 birr per dose in Ethiopia and 5.00 USD per week in
Nigeria
– Tablets or injectable opioids also not a such expensive
• Myth: Morphine is only appropriate for patients at the end of
life
– Morphine allows many patients who are not dying, but are
limited by pain, to live a more active life
– Pain treatment should be determined by the level and
type of pain, not the stage of disease
Treat the Pain Costing Data, 2014. 18
Take home messages

The advent of the WHO analgesic ladder means that all health
care providers can provide effective, high-quality pain treatment
• Pain assessment and treatment should be integrated into
service delivery in all departments
• Specialists in palliative care or anesthesiology can be called on
for complex cases
• Patients should be informed about pain and pain relief
measures

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Upcoming pain sessions in the series

• Mechanism of pain
• Pain assessment
• Treatment with the WHO Analgesic Ladder
• Use of adjuvants or co-analgesia
• Pain emergencies and incident and breakthrough pain

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References

• African Palliative Care Association. Beating Pain: a pocketguide for pain management in
Africa, 2nd Ed. [Internet]. 2012. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf

• African Palliative Care Association. Using opioids to manage pain: a pocket guide for health
professionals in Africa [Internet]. 2010. Available from:
http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf

• Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from:
http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in-Africa-
Full-Text.pdf

• Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet].

2010. Available from:
http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/FreeBooks/
Guide_to_Pain_Management_in_Low-Resource_Settings.pdf

• The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory
Palliative Care Course for Healthcare Professionals. 2013.

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