Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction 
 
The World Health Organization estimates 
that 5.5 billion people do not have access to 
treatments for moderate to severe pain. The majority 
of these people live in low- and middle-income 
countries. As the availability of surgical services 
increases in these settings, the need for treatments for 
moderate to severe perioperative pain will also 
increase. The barriers to improving access to 
treatment for pain are numerous and include low 
prioritization of pain relief by both the patient and the 
healthcare provider, lack of understanding regarding 
therapies, misconceptions about opioid addiction, 
lack of reliable supply chains for analgesics, and lack 
of understanding regarding the physical, social and 
emotional harms of poorly controlled pain.  
Despite these obstacles, it has been shown 
that improvements in pain management are possible, 
even in low-resource settings. In recent years there 
has been growth in both research and advocacy 
related to pain management in austere settings. 
However, without access to pain management 
education these efforts will be wasted. Essential Pain 
Management (EPM) is one example of a step toward 
improving access to education in pain management. 
EPM was developed in 2010 as a short course (one 
to two days) to be delivered to healthcare providers 
of different cadres to equip these providers with the 
necessary tools to recognize, assess and treat pain, 
especially in low-resource settings. This course has 
now been translated into seven languages and 
delivered in over 60 countries worldwide. Today an 
on-line version exists and is freely available at 
https://www.anzca.edu.au/safety-advocacy/global-
health/essential-pain-management. 
The harms of poorly controlled pain, 
including 
perioperative 
pain, 
are 
numerous. 
Uncontrolled pain leads to activation of the 
sympathetic nervous system which can lead to 
hypertension and myocardial stress. Chest wall and 
abdominal pain can lead to shallow breathing 
causing atelectasis. Patients who are in severe pain 
will be less likely to ambulate, increasing the risk of 
thrombotic complications. Severe pain will also lead 
to disturbances in sleep patterns and poor appetite. 
At a more personal level, pain is closely linked to 
depressed mood and social stress. All of these 
complications inevitably lead to increased duration 
of hospitalization and increased cost of healthcare.  
Finally, there is a growing body of evidence 
that suggests that poorly controlled surgical pain can 
lead to the development of chronic pain (pain at the 
site of incision which continues for greater than three 
months). For all of these reasons and many more, we 
believe that recognizing, assessing and treating 
perioperative pain is of great importance in the 
surgical care of patients in any setting.  
 
Pathophysiology 
 
The International Association for the Study 
of Pain defines pain as “an unpleasant sensory and 
emotional experience associated with actual or 
potential tissue damage, or described in terms of such 
damage.” 
This 
definition 
highlights 
several 
important points. First, the pain pathways are 
intricately linked to the cortical emotional centers of 
the brain. Pain can contribute to anxiety and 
depression which can, in turn, worsen pain. Second, 
tissue damage does not need to be obvious for a 
patient to be suffering from pain. Pain is a subjective 
experience, and it is never the job of the healthcare 
provider (surgeon, nurse, anesthetist) to assume that 
a patient is or is not in pain.  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The pain pathway. From “Essential Pain Management” 
https://www.anzca.edu.au/safety-advocacy/global-
health/essential-pain-management Used with permission. 
 
The pain pathways are illustrated above. Pain 
begins with the activation of nociceptors by a 
noxious stimulus (e.g., a surgical incision). This 
triggers the transmission of pain impulses through A 
delta and C sensory nerve fibers to the dorsal horn of 
the spinal cord, the first relay center. These impulses 
are then relayed to the opposite side of the spinal cord 
and travel cephalad to the thalamus, the second relay 
center. From the thalamus, signals are transmitted to 
numerous areas of the brain (including the limbic 
system) where the “perception of pain” occurs. At 
the same time, descending pathways modulate 
ongoing pain signals as a negative feedback loop.  
 
Nociception vs. Pain. From “Essential Pain Management” 
https://www.anzca.edu.au/safety-advocacy/global-
health/essential-pain-management Used with permission. 
 
One point which is often ignored is the fact 
that nociception and perception of pain are not 
identical. Nociception is the pathway by which 
signals travel from the site of injury to the brain. Pain 
is what is perceived by the patient and is influenced 
by 
many 
factors 
including 
cultural, 
social, 
psychological, and religious factors (see the figure 
above.) This again highlights the importance of 
asking patients to describe their pain, rather than 
assuming the patient is or is not having pain based on 
what injury or surgery they have undergone.  
What we will emphasize in the final section 
of this chapter (“Treatment of Pain”) is that this 
pain pathway can be interrupted at each level by both 
pharmacological 
and 
non-pharmacological 
interventions. Combining these therapies will allow 
us to create a “multi-modal analgesic plan” to 
optimize the pain control of our patients thus 
reducing their risk of complications linked to 
uncontrolled pain and reduce their suffering. 
 
Recognition and Assessment of Pain 
 
Pain is what the patient says it is. You cannot 
predict with any accuracy the amount of pain a 
patient is experiencing by the appearance on their 
face or by any other external factor. The only way to 
recognize pain is to ask the patient, “Are you having 
pain?” This simple question and your response to the 
answer, will ultimately determine their level of 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
suffering and will also greatly impact your 
relationship with that patient. It is natural to pay 
attention to pain when it is our own, or even that of 
our loved one. However, we often forget that every 
patient 
we 
are 
treating 
is 
someone’s 
mother/father/sister/brother/son/daughter. And so, 
we should care about their pain, as we would care 
about the pain of someone we love. 
In many parts of the world pain is considered 
the fifth vital sign and is assessed every time a 
patient’s heart rate, blood pressure and respiratory 
rate are recorded. While this may be difficult to 
achieve in certain settings, especially those with very 
low nurse-to-patient ratios, it is reasonable and 
attainable to assess and record a patient’s pain level 
at least daily during their hospitalization.  
 
 
The 
Visual 
Analogue 
Scale. 
From 
“Essential 
Pain 
Management” 
https://www.anzca.edu.au/safety-
advocacy/global-health/essential-pain-management Used with 
permission 
 
 
 
The Wong-Baker FACES Pain Rating Scale. From “Essential 
Pain 
Management” 
https://www.anzca.edu.au/safety-
advocacy/global-health/essential-pain-management Used with 
permission 
 
 
There are many tools which can be used to 
assess the severity of pain but the two most widely 
used are the visual analogue scale) and the Wong-
Baker FACES Pain Rating Scale. Most adult and 
even adolescent patients who are verbal can report a 
pain score between zero to ten with one or both of 
these scales. The utility of these scales is that their 
results will both direct treatment, as we will see in 
the following section of this chapter, and allow you 
to assess the effectiveness of an intervention when 
this score is re-evaluated post-treatment. A reported 
score of 0-3 is considered mild pain, a score of 4-6 
moderate pain, and a score of 7-10 severe pain. 
While these tools are useful for verbal 
patients, they are obviously of little value in 
assessing the pain of infants and young children. 
Other tools have been developed for these 
populations including the Neonatal Infant Pain Scale 
(NIPS) and the Faces, Legs, Activity, Cry, 
Consolability (FLACC) scale. These tools can easily 
be found on the internet.  
Most patients during the perioperative period 
will be suffering from acute nociceptive pain. 
However, it is important to assess whether there is a 
neuropathic component (that caused by damage to 
the sensory nervous system) or whether acute pain is 
occurring in the setting of chronic pain (that which 
lasts longer than 3 months). Treatment for these will 
vary.  
 
 
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Treatment of Pain 
As stated in the previous section, an 
appropriate treatment of pain depends on an 
assessment to guide that treatment. The most useful 
and widely used tool for guiding treatment of 
perioperative pain is the World Health Organization 
Analgesic Ladder (Above) According to this ladder 
most patients with mild pain (pain score of 3 or less) 
can have their pain adequately controlled with simple 
analgesics (e.g., paracetamol and/or non-steroidal 
anti-inflammatories.) A patient with moderate pain 
(pain score of 4-6) will likely need a mild opioid 
(e.g., codeine or tramadol) in addition to simple 
analgesics. For these patients it is strongly 
recommended to continue the simple analgesics in 
conjunction with the mild opioid, as these 
medications will have a synergistic effect and 
provide better pain control than with the mild opioid 
alone. 
Finally, patients with severe pain (pain score 
of 7 or higher) will very likely need a strong opioid 
such as morphine. Again, it is recommended that 
these patients continue to receive simple analgesics 
in conjunction with morphine to control their pain. 
Although there is much concern over the use of 
morphine in many parts of Sub-Saharan Africa, 
morphine can be used safely and effectively when the 
side effects and contraindications are understood and 
when appropriate dosing and frequency are used (see 
below.) 
 
Morphine 
The World Health Organization Analgesic Ladder: World Health Organization and “Essential Pain Management” 
https://www.anzca.edu.au/safety-advocacy/global-health/essential-pain-management Used with permission 
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Morphine 
is 
on 
the 
World 
Health 
Organization’s list of essential medications, both in 
oral and intravenous form. It is widely available in 
both high and low-resource settings. However, in 
many hospitals it is rarely used. There is a great deal 
of fear surrounding the use of morphine, especially 
with regards to its risk of addiction and side effects. 
Regarding addiction, there is more than sufficient 
evidence available that giving morphine to a patient 
in pain does not lead to addiction. Addiction occurs 
when patients take morphine for purposes that it is 
not indicated for, either to manage pain chronically 
or for recreational use. For patients with acute severe 
pain, however, morphine is most certainly indicated 
and it can be given safely if one is aware of the 
appropriate dosing and understands how to monitor 
for side effects. 
For most patients with severe pain, a starting 
dose of intravenous morphine between 0.05 mg/kg 
and 0.2 mg/kg is appropriate, depending on their 
level of pain. This dose should be given every 3 to 4 
hours for patients who continue to be in severe pain. 
If patients can take oral medications, oral morphine 
(syrup or tabs) may be more appropriate and has 
certain advantages, including slower onset and 
offset, lower cost, and the elimination of the need for 
an intravenous line to administer. The dose of oral 
morphine needs to be doubled or tripled compared to 
intravenous dosing due to its first-pass hepatic 
metabolism which rapidly reduces the active amount 
in the bloodstream. For example, a patient requiring 
5 mg of intravenous morphine every 4 hours, may 
need 15 mg of oral morphine every 4 hours.  
We discourage the use of intramuscular 
morphine for a variety of reasons. Although there is 
a popular idea that the effect will last longer if the 
medication is given intramuscular, this is not true. In 
addition, the absorption of intramuscular injections 
is variable with some patients receiving much less 
than the total amount absorbed into the bloodstream. 
Finally, intramuscular injections are painful for the 
patient. Therefore, our preference would be to 
administer oral morphine if possible. For patient who 
cannot tolerate orals, intravenous morphine should 
be given. Intramuscular morphine should only be 
used as a last resort for patients in severe pain who 
cannot take orals and for whom an IV is not possible. 
Anesthetists around the world commonly add 
intrathecal morphine to their spinal anesthetic which 
can provide analgesia for up to 24 hours after the 
surgery. For most adult patients a dose of 0.15 mg 
administered intrathecally will provide potent 
analgesia 
with 
minimal 
risk 
of 
respiratory 
depression. Doses of 0.15 to 0.3 mg are associated 
with a slightly higher risk of this complication, 
whereas a dose greater than 0.3 mg poses a high risk 
of respiratory depression and should be avoided.  
Morphine in any form should be used with 
caution in certain patients. Those patients include: 
● Infants less than 6 months old 
● Patients with renal failure 
● Elderly patients 
● Patients who are hemodynamically unstable 
● Patients with known or suspected obstructive 
sleep apnea 
 
Patients who receive morphine should ideally be 
monitored for signs of respiratory depression such as 
respiratory rate less than 8/minute, hypoxia (SpO2 < 
90%) or decreased level of consciousness. For 
intravenous morphine, patients should be monitored 
every 5 minutes for 20 minutes, then every hour. For 
patients receiving oral or intrathecal morphine, 
monitoring the patient every hour is sufficient. If 
signs of respiratory depression, arrest or inability to 
arouse the patient occur, naloxone can be given as 
the antidote. The dose of naloxone is 0.08 – 0.12 mg 
intravenously every 3 minutes until the patient’s 
condition improves. For patients in respiratory arrest, 
a full dose of 0.4 mg can be given. 
 
Other analgesics 
 
There are numerous other analgesics which 
can be found in the appendix to this chapter. 
Intravenous fentanyl is often used intraoperatively 
during a standard anesthetic. A dose of 1 – 3 mcg/kg 
IV is a good starting point, but larger doses may be 
required for patients expected to experience severe 
postoperative pain. Ketamine is also a potent 
analgesic in addition to its anesthetic properties. 
Recent studies have shown that small doses (0.5 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
mg/kg) given intravenously toward the start of the 
procedure can significantly reduce post-operative 
pain scores. Dexamethasone in doses of 0.1 mg/kg 
IV or greater may also confer some analgesic effect. 
Additional 
analgesics 
including 
gabapentin, 
intravenous lidocaine, dexmedetomidine, clonidine 
and others may be useful when used pre or intra-
operatively but are outside the scope of this chapter.  
One point that should be emphasized is that 
the use of local anesthetics, either as a spinal 
anesthetic, peripheral nerve block, or local 
infiltration at the site of incision, can have a 
significant beneficial impact on postoperative pain 
scores. The authors would like to encourage all 
surgeons to consider the use of local anesthetics for 
each intervention, whenever possible. However, 
these too can lead to complications, the most deadly 
being local anesthetic systemic toxicity (LAST). 
This can usually be avoided by careful aspiration 
before each injection as well as by remembering the 
toxic dose of each local anesthetic. For lidocaine, a 
dose of up to 4.5 mg/kg plain lidocaine and a dose of 
up to 7 mg/kg lidocaine mixed with adrenaline is 
within the acceptable range and poses little risk of 
LAST. For bupivacaine a dose of 2.5 mg/kg is 
acceptable. Recall that a 1% solution will have a 
concentration of 10mg/mL. 
 
Conclusions 
 
As stated in the introduction, pain control is 
an important part of perioperative care and 
adequately controlling pain is possible even in low-
resource settings. The most effective strategy is to 
create an analgesic plan BEFORE incision for every 
patient that incorporates one or more analgesics 
according to the expected severity and duration of 
pain. Using these strategies will improve the physical 
and emotional well-being of patients experiencing 
perioperative pain. 
 
Gregory Sund, MD 
AIC Kijabe Hospital  
Kenya 
 
Matthew Kines, MD 
AIC Kijabe Hospital 
Kenya 
 
April 2022 
 
 
Note: All Tables in following Appendix are from “Essential 
Pain 
Management” 
https://www.anzca.edu.au/safety-
advocacy/global-health/essential-pain-management Used with 
permission 
 
 
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
 
 
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pain Management 
Gregory Sund, Matthew Kynes 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
