APCA Beating - Pain 2nd Ed

African Palliative Care Association
Beating Pain 2nd Edition

Beating Pain A Pocketguide For Pain Management In Africa
EDITORS AND LIST OF CONTRIBUTORS

EDITORS
This guide has been edited by:
• Dr Julia Downing
• Mackuline Atieno
• Stephanie Debere
• Dr Faith Mwangi-Powell
• Dr. Henry Ddungu
• Fatia Kiyange
LIST OF CONTRIBUTORS
Contributors to this pocket guide are APCA staff and members. These include:
• Dr Renee Albertyn, Red Cross Children’s Hospital, Cape Town,

South Africa
• Dr Henry Ddungu, African Palliative Care Association, Kampala,
Uganda
• Dr Julia Downing, African Palliative Care Association, Kampala,
Uganda
• Dr Liz Gwyther, Hospice and Palliative Care Association of South
Africa, Cape Town, South Africa
• Dr Jack Jaqwe, Hospice Africa Uganda, Kampala, Uganda
• Dr Zipporah Merdin-Ali, Kenya Hospice and Palliative Care
Association, Nairobi, Kenya
• Dr Faith Mwangi-Powell, African Palliative Care Association,
Kampala, Uganda
• Dr Liz Namukwaya, Mulago Hospital Palliative Care Team, Kampala,
Uganda
• Lameck Thambo, Palliative Care Association of Malawi, Lilongwe,
Malawi.
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APCA is also grateful to the following people besides the editorial team for
reviewing the pocketguide and providing input to the editors: Rose Kiwanuka,
Dr Mhoira Leng, Dr Michelle Meiring, Patricia Ulaya, Dr Steve Williams, Dr
Henry Ddungu, Dr Andrew Fullem and Dr John Palen.
APCA also thanks all of its members and those on the advisory team for the
AIDSTAR project: Mackuline Atieno (APCA), Stephanie Debere (APCA), Dr
Henry Ddungu (APCA), Dr Julia Downing (APCA), Fatia Kiyange (APCA), Dr
Faith Mwangi-Powell (APCA), Richard A Powell (APCA), Kath Defillipi (South
Africa), Olivia Dix (UK), Eunice Garanganga (Zimbabwe), Carla Horne (South
Africa), Jennifer Hunt (Zimbabwe), Dr Ekie Kikule (Uganda), Joan Marston
(South Africa), Dr Michelle Meiring (South Africa), Dr Zipporah Merdin-Ali
(Kenya), Dr Jennifer Ssengooba (Uganda), Lameck Thambo (Malawi), Patricia
Ullaya (Zambia) and Dr Stephen Williams (Zimbabwe).
APCA thanks AIDSTAR-One and USAID for funding the development and
publication of this pocket guide.
ISBN 978 9970 204 01 4

2nd Edition @African Palliative Care Association (APCA) 2012
All rights are reserved, whether the whole or a part of the material is concerned, particularly
the rights to reproduce images or text, or to translate or reprint. Requests for permission to
reproduce text or images, or to translate APCA publications, or any other inquiries, should be
directed to APCA, PO Box 72518, Kampala, Uganda, Tel: +256 414 266251, Fax: +256 414 266217
email: [email protected]
This pocket guide was made possible by the support of the American people through the United
States Agency for International Development (USAID) and the AIDSTAR-One project. The
contents of this report are the sole responsibility of the African Palliative Care Association and do
not necessarily reflect the views of USAID or the United States Government.
APCA does not warrant that the information contained in this publication is complete and correct
and shall not be liable for any damages incurred as a result of its use. This pocket guide contains
information relating to general principles of pain management within Africa, which should not be
construed as specific instructions for individual patients. Some of the information may cite the use
of a particular medicine in a dosage, for an indication, or in a manner other than recommended.
Therefore the manufacturer’s literature should be consulted for complete prescribing information.
Clinical judgement should be exercised at all times.
3
PREFACE
Palliative care is distinguished from supportive care in progressive disease by
its clinical dimensions, specifically pain and symptom control. As defined by
the World Health Organization (WHO), palliative care is concerned with
the assessment and management of pain and symptoms among patient with
life limiting illnesses and it embraces physical, emotional and spiritual pain.
PEPFAR supports the WHO definition of palliative care and has included it as
a key component for all PEPFAR supported HIV care, treatment, and support
programs for persons and families with HIV disease in low resource settings.
With the huge burden of cancer and HIV disease among other life limiting
illnesses across Africa, there is a clear public health argument for the availability
of pain and symptom-relieving drugs to enhance quality of life for the millions
of people affected, to maximise clinical benefit from available treatments, and
to ensure freedom from unnecessary suffering. The majority of problems can
be controlled with adequate clinical knowledge and drug availability. To address
this gap in knowledge, the PEPFAR Care and Support Technical Working Group
funded the African Palliative Care Association in collaboration with AIDSTAR-
One to has develop a pocket guide for clinicians and prescribers. The purpose
of this guide, Beating Pain: A Pocketguide of Pain Management, is to strengthen
the knowledge of providers in areas of pain assessment, treatment, and
management. The guide provides common and HIV-related conditions and
approaches to addressing pain for pediatric and adult clients.
Beating Pain: A Pocket guide of Pain Management in Africa has been developed
for prescribers and dispensers at all levels of care provision working in Africa,
but with a main focus towards intermediary and specialist palliative care
providers. This second edition, was revised in 2012 to include important
updates that reflect current best practice. It is part of a series of pocketbooks
developed by the African Palliative Care Association (APCA) and can
be used independently or in conjunction with other books in the series,
such as A Handbook for Palliative Care in Africa. It is underpinned by the
philosophy of palliative care and aims to provide useful quick-reference tips
to assist practitioners to ‘beat pain’. The pocket guide is used in conjunction
with self-directed learning accessed through the APCA website www.
africanpalliativecare.org
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This pocket guide addresses the concept of ‘total pain’ and demonstrates an
integrated, multi-disciplinary approach to care covering psychological, social,
spiritual and physical pain. In taking this approach, however, PEPFAR and
APCA are aware that not all of the medications used for pain management are
available in all countries across Africa and that the names and formulations may
vary from country to country. For example, although strong opioids may not
be available, they have been included as they are essential medicines for the
management of pain. Pain in children is also an important issue and so children’s
needs are highlighted in separate section of this pocket, but its worth noting
that some of the general principles of pain management apply across all ages and
this will not be repeated.
It is worth mentioning that this pocket guide is not intended to cover

everything related to the assessment and management of pain. It contains
only essential information for the clinician, and further information about pain
assessment and management can be found in other more detailed texts, which
have been used as resources in compiling this pocket guide (see reference list).
Beating Pain is a vital part of caring for people with a life-threatening illness
and relief of pain is a human right. PEPFAR and APCA therefore hopes that
this pocket guide will provide prescribers and dispensers at all levels of care
provision working in Africa with useful tips that will help them beat pain for
patients across the region.
Dr. Faith Mwangi-Powell

Executive Director, APCA
Dr. Jon Kaplan – CDC, Atlanta

Co-Chair, PEPFAR Care and Support Technical Working Group
Dr. John Palen – USAID, Washington, D.C.

Co-Chair, PEPFAR Care and Support Technical Working Group
5
TABLE OF CONTENTS
1. Classification of pain Page 7

2.Pain assessment Page 19
3. Pharmacological methods of pain management Page 36
4. Morphine and other opioids Page 57
5. Non-pharmacological methods of pain management Page 68
6.Management of psychological, spiritual and cultural Pain Page 78
7. Special considerations for People with HIV/AIDS, the Elderly,
and those at the End-of-Life. Page 85
References Page 97
Appendices Page 100
1. The three pillars of pain treatment: management, assessment
and measurement Page 100
2.Possible interactions between ARVs and medicines used in the
management of pain Page 101
3. List of medicines used in this pocket guide (excluding ARVs) Page 104
List Of Acronyms Page 105
About Apca Page 107
About Aidstar-One Page 108
6
CHAPTER 1:
CLASSIFICATION OF PAIN
Pain is an unpleasant sensory and emotional

experience associated with actual or potential
tissue damage, or described in terms of such
damage.
(IASP, 1994)
A. Principles
• Pain, although unpleasant, is essential for survival as it tells us when
something is wrong.
• Pain is an important physiologic response to stimuli that have the
potential to cause damage.
• Understanding the physiology and classification of pain will help in the
assessment and management of pain, i.e. determining the type of pain
helps to determine its treatment.
• Stimuli that activate the nociceptors (i.e. receptors preferentially
sensitive to a noxious stimulus or to a stimulus which would become
noxious if prolonged) is perceived as pain.
• Pain is influenced by many different factors and therefore total pain
encompasses physical, psychological, cultural, social and spiritual
factors.
• Psychological factors are as important in dealing with pain as the
physical cause of the pain.
• Pain can be caused by a disease (e.g. cancer), its consequences
(e.g. opportunistic infections), treatment (e.g. chemotherapy) or
concurrent disorders (e.g. arthritis).
• Children (including newborns) suffer pain as much as adults.

Younger children experience higher levels. Fear of treatment may
prevent them expressing pain.
• Repeated painful procedures may cause children increased anxiety
and pain perception.
8
B. Physiology of pain
• Pain pathways involve the peripheral nervous system and central
nervous system.
• The sensation of pain is made up of an initial fast, sharp pain and a
later slow, dull, long-lasting pain and this is due to the difference in the
speed of the nerve impulses in the different nerve-fibre types.
• When cellular damage occurs, a number of chemical substances are
produced or released which influence the degree of nerve activity and
therefore the intensity of the pain sensation.
• Pain from internal organs is perceived at a location that is not the
source of the pain i.e. referred pain.
• Chronic pain can result in an altered perception to pain, leading
to increased sensitivity or abnormal sensations such as burning or
numbness.
C. Types of pain
• Pain can be classified according to:
Duration
Underlying mechanism
Situation.
• Different types of pain respond differently to different types of
analgesia; hence the importance for clinicians to determine the type
of pain that a patient is experiencing in order to prescribe the most
appropriate analgesia.
• Patients with life-threatening illnesses will often have both nociceptive
(i.e. transmitted by an undamaged nervous system and is usually
opioid-responsive) and neuropathic pain (i.e. transmitted by a
damaged nervous system, and which is usually only partially opioid-
sensitive), and many will also have more than one cause of pain
• A definition of pain terms can be found in Table 1.
9
Table 1: Definition of pain terms
Pain that begins suddenly and is usually sharp in quality and serves as a
Acute pain
warning of disease or a threat to the body
Allodynia Pain caused by a stimulus which does not normally provoke pain
Absence of pain in response to stimulation which would normally be

Analgesia
painful
A transitory exacerbation of pain that occurs on a background of

Breakthrough pain
otherwise stable and controlled pain
A syndrome of sustained burning pain, allodynia and hyperpathia after a
traumatic nerve lesion, often combined with vasomotor dysfunction and
Causalgia
later trophic changes. Preferred terminology is Complex Regional Pain
Syndrome type II.
Pain associated with a lesion in the central nervous system (brain and
Central pain
spinal cord)
Pain that persists despite the fact that the injury has healed. Pain signals
Chronic pain remain active in the nervous system for weeks, months, or years.
Chronic pain results from a chronic pathologic process
An unpleasant abnormal sensation which can be either spontaneous or

Dysaesthesia
provoked
Hyperaesthesia An increased sensitivity to stimulation
Hyperalgesia An increased response to a stimulus that is normally painful
A painful syndrome characterized by an increased reaction to a

Hyperpathia
stimulus, especially a repetitive stimulus, and an increased threshold
Occurs only in certain circumstances, such as after a particular

movement or on standing: it should be regarded as chronic pain but,
Incident pain
as it is intermittent, it is better managed with local measures where
possible
10
Neuralgia Pain in the distribution of a nerve
Neuropathy A disturbance of function or pathological change in a nerve
Pain which is transmitted by a damaged nervous system, and which is

Neuropathic pain
usually only partially opioid-sensitive
A receptor preferentially sensitive to a noxious stimulus or to a

Nociceptor
stimulus which would become noxious if prolonged
Pain which is transmitted by an undamaged nervous system and is

Nociceptive pain
usually opioid-responsive
An unpleasant sensory and emotional experience associated with

Pain
actual or potential tissue damage or described in terms of such damage
Pain threshold The least experience of pain which a subject can recognize
Pain tolerance level The greatest level of pain which a subject is prepared to tolerate
Pain related to procedures /interventions: this is especially important in

Procedural pain children with chronic illnesses (HIV and malignancies) and is an important
cause of anxiety in children that can be prevented
Sympathetically Caused by damage to sympathetic nerves – a part of the autonomic

nervous system that serves to accelerate the heart rate, constrict blood
mediated pain
vessels, and raise blood pressure.
Total Pain Encompasses physical, psychological, cultural, social and spiritual pain
11
1.Classification according to Duration

Acute pain
• Is usually due to a definable acute injury or illness

• Has a definite onset and its duration is limited and predictable
• Is accompanied by anxiety and clinical signs of sympathetic over-
activity
• It is almost invariably the first step in the development of chronic
pain.
Treatment is directed at the acute illness or injury causing pain, with the short-
term use of analgesics.
Chronic pain
• R esults from a chronic pathological process;

• Has a gradual or ill-defined onset, continues unabated and may
become progressively more severe; persists longer than the expected
healing time for the injury or illness in question;
• Often leads to the patient appearing depressed or withdrawn and
possibly being labelled as ‘not looking like somebody in pain’;
• Offers no protective benefits, serves no purpose and has detrimental
effects causing changes at the level of the nervous system as well as
psychological burden.
Treatment is directed at the underlying disease where possible, along with

regular use of analgesics to relieve pain and prevent recurrence as well as
psychological supportive care.
12
2.According to underlying mechanism

Nociceptive
Nociceptive pain is produced by stimulation of specific sensory receptors

in the viscera and somatic structures (although the nerves are intact). Its
characteristics are:
Nociceptive
Visceral Somatic
Capsular Bowel Cardiac Bone Soft tissue

(liver)
Source: Watson et al, 2009, p226.

Reprinted with permission
• Somatic pain: superficial (cutaneous) in skin, subcutaneous tissue or

mucous membranes: sharp and well localised pain, deep muscles,
tendons, joints: more diffuse and dull;
• Visceral pain from organs: dull and poorly localised - the sensation
of pain may be referred to a cutaneous site, often associated with
autonomic responses (e.g. sweating, nausea).
13
Neuropathic
Produced by damage to the central or peripheral nervous system. (the nerves

are abnormal). Characteristics:
Neuropathic
Nerve Nerve injury

compression
Sympathetically
Peripheral Central
maintained
Source: Watson et al, 2009, p227.

Reprinted with permission
• Burning pain (dysaesthesia)

• Shooting pain (lancinating);
• Aching sensation relieved by pressure applied to the affected area
• Increased sensitivity to a pain stimulus (hyperalgesia) or to a stimulus
that is not normally painful (allodynia)
• Neuropathic pain is a clinical description (not a diagnosis), which
requires a demonstrable lesion, or a disease that satisfies established
neurological diagnostic criteria.
3. According to situation
• B reakthrough pain – a transitory exacerbation of pain that occurs
on a background of otherwise controlled pain.
• Incident pain – occurs only in certain circumstances (e.g. after a
particular movement).
• Procedural pain – related to procedures or interventions.
14
D. Other factors
• P ain is influenced by psychological factors as well as spiritual issues
and social circumstance; these factors can increase or decrease pain
sensation.
• The concept of total pain reminds us we need to holistically assess
and manage chronic pain.
• The IASP definition of pain draws attention to the emotional
component of the pain experience.
• Pain is often expressed in emotional terms such as ‘agonising’, ‘cruel’,
‘terrible’ etc.
• Integrated multi-disciplinary teams need to be involved in the
management of chronic pain. This should include collecting
information about traditional medicines and over the counter
medicines, as well as other medicines used to treat specific
conditions, such as HIV.
• Holistic support for a patient with chronic pain can have a profound
effect on the patient’s quality of life and may focus on addressing
feelings of helplessness and on building resilience.
• Women experience pain differently from men as a result of
biological, psychological and social factors; men and women also
respond differently to pharmacological and non-pharmacological pain
management.
• Women in Africa are more likely to suffer pain than men and this may
be because:
They are more likely to be under-treated for their pain.
They have higher levels of anxiety than men and this
exacerbates pain.
If they have HIV, they have unique pain syndromes of
a gynaecological nature that are specifically related to
opportunistic infections.
Moreover, HIV-positive women are often young with babies
and young children and the children may also have HIV, and
this adds emotional, social and spiritual suffering to their pain.
15
1.Psychological factors
• Pain is influenced by psychological factors as it affects the human

consciousness.
• Psychological factors are just as important in managing pain as the
• Psychological pain related to chronic pain often shows itself as
depression or anxiety.
• Distress associated with chronic pain may present as anger,
frustration, hopelessness, denial, grief, sadness or withdrawal.
• Avoiding activities and social contact affects the patient themselves
and leads to less activity, more social isolation and a focus on the
pain – leading to a vicious circle of pain – lack of activity – fear –
depression – more pain.
• It has been shown that negative feelings, such as rejection or loss,
create neuronal stimulation patterns similar to those created by
noxious stimuli.
2.Spiritual factors
• S piritual and existential distress may manifest themselves in physical

problems and are an important source of clinical suffering that can
aggravate and even cause pain.
• Spiritual pain may or may not have a religious component and often
reflects the patient’s questioning of the meaning of life generally, and
that of their own lives in particular.
• Hopelessness and despair make pain difficult to bear, and a sense of
peace and strength from faith will help to make pain easier to live
with.
• Spiritual pain may:
prompt in the patient a re-evaluation of their life
lead to the recovery of values and beliefs
be a transition point along their journey towards greater self-
understanding.
• Recognition and support for spiritual issues is an integral part of pain
assessment and management.
16
3.Cultural factors
• C ultural factors play a major role in how we view health and illness
and therefore pain.
• A sensitive approach to culture, ethnicity and language will prevent
the aggravation of pain and help reduce emotional distress.
• Many cultures believe in ‘supernatural’ powers that can cause pain,
hence pain may not be managed.
• Different cultures respond differently to pain and it is important to
recognise the different behaviours such as shouting and crying, or
being stoical.
• How we see the family and community respond to pain will affect
how we as individuals respond to pain.
• Language may also be a challenge, with the patient being unable to
communicate effectively with the health professional and visa versa.
4.Social factors
• U nresolved social factors can aggravate pain, and management of such

issues can facilitate pain control.
• Factors influencing pain may include the lack of aids for daily living, the
lack of accessibility to community and local resources and services,
along with financial and legal issues.
17
E. Management of pain
• T he management of pain is based on the type and cause of the
pain; the approach needs to be holistic. It is important to treat the
underlying cause of the pain if it is treatable (e.g. an opportunistic
infection).
• The aims of pain management are:
Prompt relief of pain
Prevention of recurrence.
• In the management of pain, the goals are for the patient to be
pain free at night, at rest during the day, and then pain free during
movement. It is important to discourage the acceptance of pain by
health care workers as well as the patient and their family.
• Both pharmacological and non-pharmacological methods should be
used to manage pain.
• Pain can be managed across a range of settings, including the home. It
is only in severe cases where an individual may need to be hospitalised
in order to get their pain under control.
F. Be aware …
• E ach person is different and will experience pain in a different way.
• The concept of ‘total’ pain is important but is often neglected, with
emphasis only being put on physical pain.
• The experience of pain is a complex one and it is important to believe
the patient – just because you may not find a physical cause for the
pain does not mean that the patient is not experiencing pain.
• Pain not reported does not mean pain not experienced – you need to
ask the patient.
• Psychological interventions are an integral component of the
management of pain.
References:
• I nternational Association for the Study of Pain (IASP) Task Force on
Taxonomy (1994). Classification of Chronic Pain, 2nd Edition. Seattle:
IASP Press. Available at www.iasp-pain.org.
• Mersky H and Bogduk N (1994). Classification of Chronic Pain, 2nd
edition. Seattle: ASP Press.
18
CHAPTER 2:
PAIN ASSESSMENT
I think that the simplest and probably the

best definition of pain is what the patient says
hurts. I think that they may be expressing
a very multi-faceted thing.They may have
physical, psychological, family, social and
spiritual things all wound up in this one whole
experience. But I think we should believe
people and once you believe somebody you
can begin to understand, and perhaps tease
out the various elements that are making up
the pain.
(Dame Cicely Saunders)

A. Principles
Assessment
• P ain can be both a disease and a symptom, and should be carefully

assessed.
• Pain can develop and change rapidly in a person therefore the
importance of initial and routine assessments which can be compared
with subsequent assessments.
• The assessment and management of pain is best considered as an
essential component of the broad therapeutic approach known
as palliative care. Proper pain assessment using appropriate
measurement tools, and subsequent treatment can keep the pain
experience to a minimum.
Measurement
• P ain intensity should be carefully measured based on a thorough

assessment.
• It is impossible to measure pure pain! What is measured in the name
of pain is a composite of pain, anxiety, fear and discomfort from the
perspective and experience of that particular individual.
• Initial measurements are necessary to compare subsequent pain
scores against which to evaluate treatment efficacy.
Management
• P ain should be carefully managed based on thorough assessment and

measurement.
• Pain management depends largely on a comprehensive assessment
of the patient, the disease, and the pain experience. Included in pain
assessment are all factors that could influence the pain experience.
• Pain is not only treatable, but may also be preventable. It is always
better to prevent pain than to treat pain once it has occurred.
• The treatment of pain rests on three pillars: pain assessment, pain
measurement and pain management (see Appendix 1).
20
• Remember the golden rule with children: don’t wait for the child to
indicate pain – they might not be able to do so (being either too sick
or too sore, or not having the energy).
• The basic principles of pain control are the same for everyone.
• There are some unique features about the very young that need to be
considered.
• Children feel pain and there is no evidence to suggest that it is less
intense than in adults.
• No child should be withheld from accessing adequate and safe
analgesia because of insufficient understanding of pain control in
children.Use non-pharmacological methods regularly in children.
B. Goals of assessing and measuring pain

• Goals of pain assessment(Portenoy, 2011)
To understand the experience of the patient and the
underlying holistic factors and pathophysiology contributing
to the pain
To prevent the onset of detrimental effects (both
psychological and physical) as a result of untreated pain.
• To characterize the multiple dimensions of the pain
Intensity
Temporal features: onset, course, daily fluctuation, and
breakthrough pains
Location and radiation
Quality
Provocative or relieving factors
To characterise the effect of pain on quality-of-life domains
– effect on physical functional well being; effect on mood and
related aspects of psychological wellbeing; effect on sleep,
mood, and sexual function
• Goals of measuring pain
To determine the presence, intensity and duration of pain
To determine the location of pain
To determine treatment efficacy.
21
Right Left Right
• A ssessment should not be confused with measurement, where a

score is indicative of pain intensity and treatment efficacy.
• All findings or relevant information should be clearly documented.
Of particular interest would be information obtained during initial
assessment, pain scores, intervention and intervention efficacy.
• Clear and precise notes should be kept in a place easily accessible to
other health professionals involved in caring for the patient.
• Several pain assessment and measurement tools are available, e.g.
body diagrams to document the site of pain; and pain rating scales
to follow the patient’s pain and the effect of treatment (useful in
managing difficult pain).
22
C. Barriers to pain assessment and measurement

• A number of barriers exist, not only for pain management but also for
pain assessment and measurement.
• An awareness of existing barriers in a setting could eliminate the
impact on the assessment and measurement process.
• The most important barriers are:
Lack of age-appropriate and validated pain-measurement
tools
Lack of training on the use and implementation of pain
measurement tools
Lack of knowledge on how to interpret a pain score once
obtained
Lack of knowledge on how to differentiate between pain,
anxiety, and emotional issues such as fear, depression and
discomfort
Lack of skill in applying information obtained during
assessment to the process of measurement and management
Lack of an open attitude where the patient is listened to and
their experience is validated.
23
D. Pain assessment
Principles:
• P ain is subjective; therefore encourage the patient to report about

their pain.
• An impeccable assessment is a principle of the WHO definition of
palliative care.
• Undertaking a comprehensive clinical assessment is vital for effective
pain management.
Standard assessment guideline:
• A
standard assessment guideline for pain is important in order to be
able to see change over time.
Pain assessment through:
• D ata collection and interviews should be conducted in a relaxed,

comfortable atmosphere.
• Collect information on medical and previous pain-management
history:
Information on previous medical history should include:
type of drug and dosage used, effectiveness of previous drug
regime, time to onset, duration of relief and return to pain,
and current medication used, including all any medicines used
to treat specific conditions (such as ART).
Review all medical records to evaluate previous pain episodes
and management attempts.
Ensure that information is collected about traditional
medicines and other over-the-counter medicines, as well as
those prescribed.
Include a review on the previous pharmacological approach
as well as the efficacy of, reaction to and possible adverse
reaction to, drugs previously used in the treatment of pain.
• Determine and evaluate all factors that exacerbate or alleviate pain
is done by careful questioning of the patient. This information is
particularly key to the treatment success of the particular individual
24
• T he PQRST pneumonic offers valuable guidelines for questions to

help assess and measure pain:
Precipitating and relieving factors: What makes your pain
better/worse?
Quality of pain (e.g. burning, stabbing, throbbing, aching,
stinging): How would you describe your pain? What does
it feel like? Ask (where possible) the patient to describe
their pain for you. The choice of words in this description is
important – for example, words such as ‘shooting’, ‘burning’,
‘dull’ or ‘aching’ could refer to neuropathic pain, which will
require a specific type of drug intervention.
Radiation of pain: Is the pain in one place or does it move
around your body?
Site and severity of pain: Where is your pain? (use a body
chart) How bad is it? (use a Visual Analogue Scale).
Timing and previous treatment for pain: How often do you
get the pain? Are you pain free at night or on movement? Are
you on any pain treatment or have you been in the past? Does
it help?
• Determine the location of pain or the body area involved by looking
out for signs of ‘guarding’. (Any attempt that prevents you from
touching a specific body area can be considered as ‘guarding’.)
• It is important to correctly classify pain as neuropathic or nociceptive,
as this will partly determine the drugs needed for treatment.
• Ask (where possible) the patient to describe their pain for you.
The choice of words in this description is important – for example,
words such as ‘shooting’, ‘burning’, ‘dull’ or ‘aching’ could refer
to neuropathic pain, which will require a specific type of drug
intervention.
• Ask too what the pain means to that person.
• Be sensitive to the secondary effects of pain:
Inability to sleep, changes in appetite, lost of interest in the
environment, fear, anxiety or increased agitation.
Parameters such as activities, social interaction and work/
school attendance, which should be considered when
assessing chronic pain.
• Include behavioural factors associated with pain and anxiety: crying,
facial display of anxiety, fear, tenseness, and withdrawal.
• Pain assessment may also involve relevant investigations such as x-rays
but these should be used sparingly after taking a careful history from
the patient and their family.
25
Pain assessment in children
• T he body position often reflects pain: Observe the way in which

the patient walks, holds their body or moves, and the way the
body is positioned when lying down. This is particularly important
in young children and those unable to verbalise their pain.
• Note: a sleeping child, a very quiet child, even a child that is
playing is not necessarily pain free – movement might be painful,
or the child might be too sick or too tired to move.
• It is important to include, where possible, parents or caregivers
in the assessment of pain in children.
• Children may not report pain for several reasons, including their
being:
Frightened of talking to doctors
Frightened of finding out they are sick
Unwilling to disappoint or bother their carers
Unwilling to receive an injection
Unwilling to return to or delay discharge from hospital
Unwilling the side effects of medication for pain.
• Health professionals should always ask parents/carers whether
they have observed that their child is in pain.
• Therefore it is useful to:
Question the child and their parent
Use a pain rating scale (see fold-in on page)
Evaluate behaviour and physiological changes.
26
E: Pain measurement
• Pain measurement is complicated and requires:
Use of tested, verified and validated tools for pain
management
Knowledge on the correct use of the measurement tool
Understanding of the scoring process
The ability to correctly interpret a score
• Obtaining an initial score is vitally important:
For comparison with other scores after intervention
To determine treatment efficacy
• Ideally, carry out pain measurements at regular intervals – either six
or four measurements per week.
• Remember that most measurement instruments do not acknowledge
the presence of anxiety and can therefore produce false high or false
low scores. The behavioural indicators of anxiety are more or less the
same as for pain, and it is possible to measure anxiety instead of pain.
• There are a number of different measurement tools available both for
adults and children, and a sample list of recommended tools for adults
and children is given in the next pages.
Guidelines for selecting a measurement tool
• S hould be age appropriate.

• Should have tested psychometric properties of validity and reliability.
• Should be able to measure different pain levels.
• Should be easy to use – many measurement tools are complicated
and time consuming and not recommended in all situations.
• Should be able to produce an easily understandable score.
• Should have clear instruction on application and interpretation.
• Note: Many pain measurement tools are available but few are tested
and validated for use in Africa.
27
Suggested tools for pain measurement in adults
Numerical rating scale
• T
he health worker asks the patient to rate their pain intensity on a
numerical scale that usually ranges from 0 (indicating ‘No pain’) to 10
(indicating the ‘Worst pain imaginable’).(it is easier from 0-5)
0-10 Numeric pain intensity Scale
0 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
pain pain pain
• A
variation of this scale is a verbal-descriptor scale, which includes
descriptors of pain such as ‘Mild pain’, ‘Mild-to-Moderate pain’.
‘Moderate pain’ etc.
The hand scale
• T
he hand scale ranges from a clenched hand (which represents ‘No
hurt’) to five extended digits (which represents ‘Hurts worst’), with
each extended digit indicating increasing levels of pain. Note: it
is important to explain this to the patient as a closed fist could be
interpreted as worst possible pain in some cultures.
0 1 2 3 4 5
no hurt hurts little hurts little hurts even hurts whole hurts
bit more more more worst
28
How to use a pain measurement instrument
1. Select the right instrument.

2. Learn the basics of the instrument: how to use it, how to score and
how to translate the score.
3. Decide on the interval of measurement.
4. Document all relevant information obtained during the process of
assessment.
5. Do the first measurement as soon as possible after admission or after
referral.
6. Based on the numerical score, decide on the severity of pain. A lower
score normally indicates less pain or the presence of anxiety. This
needs to be documented. It is sometimes useful to do more than one
baseline score. It is, for example, difficult to score pain in a severely ill
patient, a patient who is unconscious or one who is not responding.
Here, scoring needs to be done more than once. If a patient is
restrained and cannot move, and movement is a parameter, exclude
movement from the scale and, if necessary, subtract the score total
involved with movement from the end score.
7. Use the WHO analgesic ladder to introduce treatment
(see Chapter 4).
8. Wait the recommended time for administered medicine to produce
analgesia: 30–60 minutes is standard.
9. Score the patient again.
10. Compare the second score against the initial score.
11. If the numerical value is equal to or more than the first, the approach
to treatment was unsuccessful. Either go the next step of the WHO
analgesic ladder, or decrease the medicine interval, or increase the
dose. Ensure that anxiety is ruled out and treated.
12. Introduce the chosen second approach to pain management.
13. Score the patient again. If there is no improvement in the score when
compared with the initial score, pain is not being adequately treated
so go up one step on the WHO analgesic ladder. If the pain score is
less than the initial score, pain is being adequately treated and pain
tolerance has been achieved.
14. Document all relevant information.
29
Suggested tools for pain measurement in infants and children
• P ain measurement in infants and children is more complicated

than in adults – there are a variety of tools available.
• Choose instrument to measure pain giving consideration to a
child’s level of development and introduce instrument prior to
painful procedure.
• Numerical Rating scale can be used in older children.In
neonates, behaviour is the best way to assess pain – the
Neonatal Infant Pain Scale (NIPS) addresses facial expression,
crying, behaviour patterns, arms, legs and state of arousal.
• Some suggested tools for Infants and children less than three
years of age include NIPS, FLACC and TVP (see below for the
last two listed).
• Suggested tools for older children include FLACC, the Faces
Scale (see also below) and the Visual Analogue Scale.
• Self-report pain measurement tools can be used in children from
the age of four – the higher the score the more pain, anxiety or
discomfort is present.
30
FLACC Scale for use in children less than three years of age or older
non-verbal children.
• Use it like an Apgar score, evaluating each item and arriving at a total
score out of 10 (see layout below).
DATE/TIME
Face
0 – No particular expression or smile
1 – Occasional grimace or frown, withdrawn, disinterested
2 – Frequent to constant quivering chin, clenched jaw
Legs
0 – Normal position or relaxed
1 – Uneasy, restless, tense
2 – Kicking, or legs drawn up
Activity
0 – Lying quietly, normal position, moves easily
1 – Squirming, shifting back and forth, tense
2 – Arched, rigid, jerking
Cry
0 – No cry (awake or asleep)
1 – Moans or whimpers, occasional complaint
2 – Crying steadily, screams or sobs, frequent complaints
Consolability
0 – Content, relaxed
1 – Reassured by occasional touching, hugging or being talked to, distractible
2 – Difficult to console, comfort
TOTAL SCORE

(Pediatric Nursing by Merkel S et al. Copyright 1997 by JANNETTI PUBLICATIONS
INC.. Reproduced with permission of Jannetti Publications Inc. in the format Textbook
via Copyright Clearance Center.)
The FLACC is a behavioural scale for scoring pain in young children.

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C)
Consolability is scored from 0-2, which results in a total score between zero
and ten.
31
The 10-point Touch Visual Pain (TVP) Scale for assessing pain and
symptoms through touch and observation
Tactile and visual score Present
1. Toes bent down or upwards and tense under soles, ankles tightly crossed
2. Knees tightly together or tightly crossed
3. One leg protecting nappy area
4. Thoracic or and irregular breathing, and / or mouth breathing and / or intercostal

muscles and / or nasal flaring and / or crackles
5. Heart rate increased and / or iregular
6. Arms tight against body or guarding or crossed over face, chest or stomach
7. Fists (not or difficult to open with finger)
8. Neck asymmetrically positioned on shoulders, should pulled up
9. Head asymmetrical
10. Facial tension (fearful or painful expression; tense mouth, eyes tense or anxious,
distressed look
(Used with permission. Copyright: Dr Renee Albertyn, School of Child and Adolescent health,
University of Cape Town, South Africa)
• T he 10-point TVP Scale uses touch and observation to assess not

only a child’s pain but also any anxiety or discomfort that may be
experienced.
• It was developed in Africa.
• It is based on signs of pain and anxiety that can be observed, including
an asymmetrical head, verbalisations of pain, facial tension, clenched
hands, crossed legs, shallow breathing, and an increased or irregular
heartbeat.
32
The faces scale for pain assessment in children
00 1 2 33 4 55
no hurt hurts little hurts little hurts even hurts whole hurts
bit more more more worst
(Used with permission; Copyright: 2001, International Association for the Study of Pain)
• T his scale comprises six cartoon faces, with expressions ranging from
a broad smile representing ‘no hurt’ to a very sad face representing
‘hurts worst’.
• Ensure that the child is adequately trained in how to use the tool.
In particular, make sure the child is rating their pain and not their
emotion.
• Experiences have ranged with regards to the use of the faces scale in
Africa, with many children preferring the hand scale.
• The faces scale can also be used by adults if preferred.
33
F: Be aware …
• E ach patient is an individual and will react to pain differently. An
individual or personal pain plan for each patient is therefore essential.
• Differentiate between pain and anxiety by eliminating aspects that
could have contributed to the onset of pain:
Aspects of dosing – for instance, the time of last dose of
analgesics given, a particular dose of analgesics, combinations
of analgesics, the interval of drug administration (six-, four- or
two-hourly)
The possible recent subjection to painful procedures – such
as venipunctures, physiotherapy or wound dressings – that
could have contributed to a lessened pain tolerance
Drug tolerance, withdrawal, over-sedation or side effects.
• Pain is an individual experience. Patients might react differently to the
same pain stimulus.
• Avoid downloading measurement tools from the internet or journals
if they do not have clear instructions on how to implement them.
These methods could be methodologically and/or conceptually
flawed. Most, if not all of the available instruments were designed in
mono/dual cultural or language settings and might therefore not be
applicable for use in African countries.
• The pharmacological management of pain is not entirely determined
by the numerical value obtained in the pain score. The numerical
value serves only to indicate the presence and severity of pain, and to
act as an indicator to use when evaluating drug efficacy and as a way
to tell if treatment is successful.
• Any management plan must be discussed and explained to the patient
and their family.
34
References:
• B
aker CM and Wong DL (1987). ‘QUEST: A process of pain
assessment in children’, Orthopaedic Nursing 6: 11–21.
• Merkel S, Voepel-Lewis T, Shayevitz JR, Malviya S (1997). ‘The

FLACC: A behavioural scale for scoring postoperative pain in young
children’ in Pediatric Nursing 23: 293–97.
• P
owell RA, Downing J, Harding R, Mwangi-Powell F and Connor S on
behalf of the APCA M&E Group (2007). ‘Development of the APCA
African Palliative Outcome Scale’ in Journal of Pain and Symptom
Management 33: 229–32.
• H
icks CL, von Baeyer CL, Spafford P, van Korlaar I and Goodenough
B (2001). ‘The faces Pain Scale – Revised: Towards a common metric
in pediatric pain measurement’ in Pain 93: 173–83.
• M
erkel S, Voepel-Lewis T, Shayevitz JR, and Malviya S (1997). ‘The
FLACC: A behavioral scale for scoring postoperative pain in young
children’ in Pediatric Nursing 23(3): 293–7.
35
CHAPTER 3:
PHARMACOLOGICAL
METHODS OF PAIN
MANAGEMENT
The right dose of an analgesic is the

dose that relieves pain without causing
unmanageable side-effects. Some
individuals may simply require regular
paracetamol, while others may need oral
morphine.
(Watson et al., 2009)

A. Principles
• R elieve pain as fast as possible and prevent its return.
• Control pain while treating the underlying cause(s) (e.g. infection).
• Determine the pathophysiology of the pain to determine the most
suitable treatment (e.g. nociceptive vs neuropathic).
• Continually re-evaluate pain and its response to treatment.
• Correct use of analgesic medicines will relieve pain in most
patients and should be based on the following principles:
By the mouth/appropriate route: use the oral route
whenever possible.
By the clock: administer analgesics according to a regular
schedule rather than according to an as-needed schedule.
The interval is determined by the pharmacokinetics of
each medicine.
By the ladder: use the WHO analgesic ladder (see section
B below). If after giving the optimum dose an analgesic
does not control pain, move up the ladder; do not move
sideways in the same efficacy group.
Individualized treatment: the right dose is the one that
relieves the pain. Titrate the dose upwards until pain is
relieved or undesirable effects prevent further escalation.
Check to see that patient and carers understand.
Use of adjuvant drugs alongside analgesics.
• The choice of analgesic drugs is based on the severity, type
and (sometimes) cause of pain. Possible side effects should be
discussed with patients and/or their care givers prior to starting
drugs and again during follow-up visits.
• Affordability and accessibility are important factors in the choice
of analgesics. First step in determining drug use is if it is on the
essential medicines list and if not the cost to patients.
• A key component of safety and efficacy is to ensure that patients
and their carers understand the use of the medicines they are
taking and that those medicines are reviewed regularly.
37
• The basic principles of pain control are the same for everyone.
• There are some unique features about the very young that need to
be considered.
• Children feel pain and there is no evidence to suggest that it is less
intense than in adults.
• No child should be withheld adequate and safe analgesia because of
insufficient knowledge.
• Possible side effects should be discussed with care givers
(particularly for children) prior to starting drugs and again during
follow-up visits.
• Use non-pharmacological methods regularly in children.
• Factors to be considered in planning pain control for children
include:
Developmental age – children will express their pain
differently according to their development stage, and
management techniques will also vary (see Table 6 below)
The physical status of the child
Parents’/ care provider’s level of education
Availability of resources.
• There are specific pain-related syndromes in HIV and cancer in
children and these are discussed later in this chapter.
38
B. Pain management using the WHO analgesic ladder
Pain persisting
or increasing Strong opioid
+/- nonopioid
Pain persisting +/- adjuvants
or increasing
Weak opioid
+/- nonopioid Step 3
+/- adjuvants Severe Pain
Step 2
Nonopioid Moderate Pain
+/- adjuvants
Step 1
Mild Pain
The WHO Three-Step Analgesic Ladder

Step 1 Non-opioid (e.g., paracetamol, aspirin) ± adjuvant (e.g., antidepressant).
If pain is not controlled by Step 1 analgesics, move to Step 2 by adding a weak
opioid.
Step 2 Opioid for mild to moderate pain (e.g. codeine) ± non-opioid ±

adjuvant.If an opioid for mild to moderate pain has been used to a maximum
dose and the patient still has pain, then move to Step 3 by changing to a strong
opioid.
Step 3 Strong opioid (e.g., morphine) ± non-opioid ± adjuvant.

(Source:WHO 1996, reprinted with permission)
39
• The WHO analgesic ladder provides a framework for the

pharmacological management of pain.
• Start patients on Step 1 analgesics for mild pain; if these are
ineffective, change to a Step 2 analgesic, then to Step 3 as required.
• If Step 1 or 2 analgesics don’t work, don’t switch to another analgesic
at the same level: move up a step.
• The choice of analgesic depends on the severity, site and type of pain.
• If a patient presents with moderate/severe pain, then they can be
given a Step 2 or Step 3 analgesic straight away, depending on the
severity of the pain and the availability of analgesics.
• A combination of a non-opioid and an opioid drug is effective (they
have different modes of action). Don’t combine weak with strong
opioids.
• Other medications for managing pain (adjuvants) can be combined
with Step 1, 2 and 3 analgesics.
• In most sub-Saharan Africa countries Step 2 analgesics are rather
expensive and in this case a low dose of Step 3 analgesics may be used.
There should be at least one analgesic for each step of the ladder on
the Essential Medicines List for each country.
• If the oral route isn’t possible, use alternative methods, including
rectal, intravenous, nasogastric tube, transdermal and subcutaneous.
• The majority of patients can have their pain controlled in the home
care / outpatient setting using the WHO analgesic ladder as a guide;
only in very severe cases may they need to be an inpatient.
40
Mild pain – Step 1
Paracetamol
• A dult dose: 500mg–1g po 6hrly; max daily dose 4g

• Note: Hepatotoxicity can occur if more than the maximum dose is
given per day. Paracetamol can be combined with a Non-Steroidal
Anti-Inflammatory Drug (NSAID).
Ibuprofen (NSAID)
• A dult dose: 400mg po 6–8 hrly (max dose 1.2g per day);
• Give with food and avoid in asthmatic patients.
• Caution: can cause serious side effects, e.g. gastro-intestinal (GI)
bleeding or renal toxicity. If GI symptoms occur, stop and give H2
reception antagonist, e.g. Ranitidine.
Diclofenac (NSAID)
• A dult dose: 50mg po 8 hrly (max daily dose 150mg);

• Give with food and avoid in asthmatic patients.
Moderate pain – Step 2 (weak opioids)

(see chapter 4: Morphine and Other Opioids)
Codeine
• T he commonest weak opioid, codeine can be combined with a Step

1 analgesic. If pain relief is not achieved on the ceiling dose (max dose
240mg per day), move to strong opioids.
• Adult dose: 30–60mg po 4 hrly (max daily dose 240mg).
• Note: codeine is often combined with Step 1 analgesics; give laxatives
to avoid constipation unless patient has diarrhoea.
Tramadol
• A dult dose: 50–100mg po 4–6hrly.

• Note: start with a regular small dose and increase if no response
(dose limit: 400mg/day). Use with caution in epileptic cases, especially
if the patient is on other drugs that lower the seizure threshold.
Tramadol may be costly.
41
Severe pain – Step 3 (strong opioids)

Morphine
Starting dose (p.o)
• M orphine is the ‘gold standard’ against which other opioid analgesics

are measured.
• When used correctly, patients don’t become dependent, tolerance is
uncommon and respiratory depression doesn’t usually occur.
• The equianalgesic doses for other opioids can be found in Chapter 4.
• The correct morphine dose is the one that gives pain relief: there is
no ‘ceiling’ or maximum dose – the right dose is the one that controls
the patient’s pain without side effects; Need to increase the dose
gradually.
• Starting dose: 2.5–20mg po 4 hrly depending on age, previous use of
opiates, etc. Patients changing from regular administration of a Step 2
opioid should start on morphine 10 mg po 4hrly.
Patients changing from regular administration of a Step 2
opioid (e.g. codeine phosphate 30mg q4h) should start on
morphine 10 mg po 4hrly.
If the patient is cachexic or has not progressed onto Step 2
analgesics, start morphine at 5mg po 4hrly.
Start frail/elderly patients on morphine at 2.5mg po 6–8hrly,
due to the likelihood of impaired renal function.
42
Titrating oral Morphine into other formulations
• T itrate the regular dose of morphine over several days until the
patient is pain free. Either add the total daily dose and the total
breakthrough dose given in 24 hours and divide by six to get the new
4hrly dose, or give 30–50% increments, e.g. 5–10–15mg etc., given as
4hrly doses. Increments of less than 30% are ineffective.
• If the patient cannot swallow, use other routes, e.g. rectal,
subcutaneous, buccal, intravenous, or administer via an alternative
enteral route such as a gastrostomy tube.
• The ratio of morphine PO:SC is 2:1, e.g. 10mg oral morphine is 5mg
SC morphine.
• The ratio of morphine PO:IV is 2–3:1, e.g. 30mg oral morphine is
10mg IV morphine
• Morphine is available in immediate and slow-release oral formulations
(see Appendix 4). Use slow-release morphine once pain is controlled,
dividing the total 24-hour dose into two to get the twice-daily dosage.
There are several options for maintenance, e.g.:
Continue with 4hrly immediate-release morphine (syrup
morphine)
Change to 12hrly modified-release morphine (MST)
Change to 24hrly modified-release morphine where available
Change to fentanyl patch (72 hours’ duration of action) where
available
Change to other strong opioids where available.
• Fentanyl patches where they exist can be started as soon as pain is
under control via morphine and you know the amount of analgesia
the patient needs in 24 hours. Don’t use fentanyl for acute or
uncontrolled pain.
Alternative routes of administration, equivalent dosages
• uccal
B
• Rectal
• Subcutaneous
• IV
43
Maintenance issues
• Dealing with breakthrough pain (defined as a transient flare-up of

pain superimposed on an otherwise stable pain pattern in patients
treated with opioids)
‘Breakthrough’ or ‘rescue’ doses of morphine can be given as
often as required (ideally the same as the 4hrly dose). Keep
a record of each rescue dose. The dose of morphine for
breakthrough pain is equivalent to the 4hrly morphine dose.
Breakthrough pain due to end-of-dose failure may promptly
respond to increasing the dose of basal medication or
decreasing the interval between doses.
• Pain relief to allow sleep
If needed, give a double dose of morphine at night to allow
pain-free sleep.
Cautions
Never use slow-release opioids as rescue medication.

A patient should never be prescribed more than one
modified-release opioid at a time.
Dealing with side effects
• E xplain common opioid side effects to patients (e.g. constipation,

drowsiness, nausea, etc.) and prevent such complications wherever
possible (see Chapter 4). Patients on a stable morphine dose should
not be sedated and if sedation occurs reduce the dose and consider
adjuvants.
• Patients on modified-release opioids should always have available
an immediate-release opioid (usually morphine) for episodes of
breakthrough pain.
• If the cause of pain has been treated and morphine needs to be
stopped, reduce the dose gradually to avoid withdrawal symptoms
(sweating, nausea, agitation).
44
Mild pain – Step 1
Paracetamol
• Children under 1 year: 10–15mg/kg po 6–8 hrly; 1–5 years:
10–15mg/kg po 6–8 hourly; 5–12 years: 250-500mg po 6–8
hrly; max daily dose 75mg/kg
• Step 1 drug of choice in children.
Ibuprofen (NSAID)
• In children, dose is 5mg/kg po 6–8 hrly (max 30mg/kg/day in
3–4 divided doses);
Diclofenac (NSAID)
• Children 6 months to 12 years: 2–3mg/kg po per 24 hrs in 2
or 3 doses.
Moderate pain – Step 2 (weak opioids)

• There is evidence to emphasize the exceptional role of

opioids, against non-opioids, for pain control in children with
life-limiting conditions.
• There is still debate on whether weak opioids (such as
tramadol and codeine) should be regularly used in children
with pain and whether opioid therapy should be initiated with
a very low dose of a strong opioid (Zernikow, Michel, Craig,
& Anderson, 2009).
Codeine
• Children over 6 months 0.5–1mg/kg po 6 hrly.
• Infants – safety and efficacy is not established.2-6 years –
1-1.5mg/kg/day divided 4-6 hourly intervals; not to exceed
30mg/day).
• 6-12 years old, same as for the 2-6 year old but not to exceed
60mg/day.
45
Tramadol
• Safety and efficacy in children < 16 years is not established.
• 16 years or older, 50-100mg PO q4-6hr; not to exceed 400mg/
day.
Severe pain – Step 3 (strong opioids)

Morphine
1. Starting dose (p.o)

• For children: opioid-naive infants <6 months, starting dose
0.02mg/kg po 4hrly. Opioid-naive infants >6 months, starting
dose 0.04mg/kg po 4hrly.
2. Titrating oral Morphine into other formulations

• The smallest fentanyl patch, for use in children, is 12mcgm
(corresponds to a total daily dose of 45mg of oral morphine).
3. Dealing with side effects

• Urinary retention and pruritis are side effects that are more
common in children than adults.
46
C. Adjuvant analgesics
• A lthough their primary purpose is not analgesia, these medications
relieve pain through other mechanisms.
• They are particularly useful in pain that is only partially sensitive to
opioids – for instance, neuropathic and bone pain, smooth or skeletal
muscle spasms, or pain related to anxiety.
• Use adjuvants alone or in conjunction with Step 1, 2 and 3 analgesics.
Antidepressants
• U se for neuropathic pain, presenting primarily as burning or

dysaesthesia. For example:
Amitriptyline dose: adult 10–75mg at night. Start with a low
dose and slowly increase as needed. Can also be given in a
dose of 0.5–2mg/kg at night.
• Side-effects include dry mouth and drowsiness.
• Use with caution in the elderly and those with cardiac disease.
Anticonvulsants
• Use for neuropathic pain. For example:

Clonazepam. Adults: 0.5mg to 2mg once daily
Carbamazepine. Adults: start at 100mg twice a day, and can
be increased up to 800mg twice a day.
Sodium valporate. Adults: 200mg–1.2g per day.
Note: Use Phenytoin and Carbemazepine with caution
because of the rapid metabolism of other drugs metabolised
in the liver and therefore potential drug interactions.
• Side effects: drowsiness, ataxia or blurring of vision.
• It is important to check for drug interactions when anticonvulsants
are given alongside other drugs.
Antispasmodics
• U se antispasmodics for muscle spasm, e.g. colicky abdominal pain or

renal colic. For instance:
• Hyoscine butylbromide (Buscopan). Adult: start at 10mg three times
per day; can be increased to 40mg three times per day.
• Note: antispasmodics can cause nausea, dry mouth or constipation.
47
Muscle relaxants / anxiolytics
• U se these drugs for skeletal muscle spasm and anxiety-related pain –

for example:
• Diazepam. Adult: 5mg orally two or three times per day.
• Side effects: can cause drowsiness and ataxia.
Corticosteriods
• U se corticosteroids for bone pain, neuropathic pain, headache due

to raised intracranial pressure, and pain associated with oedema and
inflammation. For example:
Dexamethasone. Adult: 2–4mg per day for most situations
apart from raised intracranial pressure, nerve compression
and spinal cord compression. For raised intracranial
pressure, start at 24mg per day and reduce by 2mg daily
to the lowest effective maintenance dose. For pain from
nerve compression, 8mg is often used; and for spinal cord
compression, 16mg is usually the starting dose.
If Dexamethasone is not available, then adults can
also be given Prednisolone. A conversion rate of 4mg
Dexamethasone to 30mg Prednisolone can be used.
• Note: in advanced disease, a corticosteroid may improve appetite,
decrease nausea and malaise, and improve quality of life.
• Side effects include neuropsychiatric syndromes, gastrointestinal
disturbances and immunosuppression.
Biphosphonates
• A ppear to have a role in managing metastatic bone pain refractory

• to conventional analgesic management and/or where oncological
or orthopaedic intervention is delayed or inappropriate
(Mannix et al., 2000).
• Commonly used – pamidronate 60-90mg slow iv infusion given every
after 4 weeks.
• Serious side effects including osteonecrosis of the jaw, although
rare, have been associated with bisphosphonate therapy
(Beke & Pecherstorfer, 2008). Use these drugs for intractable
metastatic bone pain. For instance, for adults Pamidronate 90mg
can be used intravenously every four weeks.
• Side effects are fever and flu-like weakness.
48
Adjuvant analgesics
Antidepressants
• Use for neuropathic pain, presenting primarily as burning or
dysaesthesia. For example:
Amitriptyline dose: Children 2–12 years: 0.2–0.5 mg/kg
PO at night; children 12–18 years: 10–25mg po at night.
Anticonvulsants
Carbamazepine. Children: 2.5–10mg/kg po 12 hrly;
Increase gradually to avoid side effects.
Sodium valporate. Children: 7.5–20mg/kg po 12 hrly.
Gabapentin. Children 2–12 years 10mg/kg on day 1, twice
per day on day 2, three times per day on day 3; maintain
at 10–20mg/kg 8hrly. Children 12–18 years: 300mg on day
1, 300mg twice a day on day 2, 300mg three times /day on
day 3; maintain at 300mg twice or three times.
Note: use Phenytoin in the absence of these drugs: 100mg two or

three times per day (2.5–10mg/kg po 12hrly in children).
Antispasmodics
• Use antispasmodics for muscle spasm, e.g. colicky abdominal pain
or renal colic. For instance:
• Hyoscine butylbromide (Buscopan). Children 1month to 2 years:
0.5mg/kg po 8hrly. Children 2 – 5 years: 5mg po 8hrly. Children
6 – 12 years: 10mg po 8hrly.
Muscle relaxants / anxiolytics

• Use these drugs for skeletal muscle spasm and anxiety-related
pain – for example:
• Diazepam. Children1 – 6 years: 1mg/day in two or three divided
doses. Children 6 – 14 years: 2 – 10mg/day in two or three divided
doses.
Corticosteriods
• Use corticosteroids for bone pain, neuropathic pain, headache
due to raised intracranial pressure, and pain associated with
oedema and inflammation. For example:
Dexamethasone.
Prednisolone can be used for children: 1–2mg/kg po daily.
49
D. Be aware ...
• ain is often inadequately treated.
P
• Failure to assess pain levels and type causes poor pain control.
• A person with longstanding pain may not show the usual signs of pain.
• Never use slow-release opioids as rescue medication.
• It is important to assess the patient for side effects to medication at
every clinical interaction.
• Significant percentages of adults and children cannot metabolise
codeine, so it may be ineffective.
50
Specific considerations for pain management in children
• C hildren tend to receive less analgesia than adults, and the drugs
are often discontinued sooner.
• The uncalled for fear by health workers, of possible respiratory
depression and addiction to opioids, prevents children from
receiving adequate pain control. It should be known that opioids
can be safely used in children as it is in adults. Where possible,
medications should be given by mouth. The subcutaneous or
rectal routes can be an alternative if the child is unable to take
medication orally, but Intramuscular medications should be
avoided.
• Pain in children with HIV and AIDS is a multi-factorial,
biologically complex problem associated with diminished quality
of life and increased mortality.
• HIV-infected children with pain are five times more likely to die
than children without.
• Children with pain have lower CD4 percentages and more
severe immunosuppression than those without.
• It is perceptible that children do not receive adequate pain relief
as might be required.
• Children younger than six months are more sensitive to possible
opioid-induced respiratory depression, so there is need of a
lower starting dose.
• There is a belief that children do not feel pain, and this is based
on a lack of understanding and the fear of using narcotics in
children.
• Pain is subjective, and the response to pain is individual and
modified through social learning and experience; therefore an
individual’s early experience of pain plays an important part in
shaping their response in later life.
• Not all children can ask for analgesia and so it is important to try
and anticipate pain in children.
• There are some physiological differences between adults and
children, especially in neonates and small infants, that can cause
problems.
• The child’s parent or carer needs to be trained to give pain
medication properly.
51
• Children may express pain in different ways – for instance:

Infants – may exhibit body rigidity or thrashing, may cry
intensely, may draw knees to chest, or be irritable.
Toddlers – may be verbally aggressive, cry intensely,
withdraw, guard painful parts of the body, or be unable
to sleep.
Young children – may verbalise intensity of pain, see
pain as punishment, thrash about with arms and legs, be
uncooperative, cling to carer or be unable to sleep.
School-age children – may verbalise pain, be influenced
by cultural beliefs, experience nightmares, have muscular
rigidity or be unable to sleep.
Adolescents – may localise and verbalise pain, deny pain
in the presence of peers, show changes in sleep patterns,
be influenced by cultural beliefs, exhibit muscle tension,
regress or be unable to sleep.
52
Table 2: Pain expressions and management techniques in children
Develop- Management techniques;

Pain expression
mental age pain measurement tools
• Parent/carer interviews needed • U tilise parents and staff to

to assist with pain assessment comfort and hold child
• May become restless, cling or • Holding, rocking, use of
whine dummy, rattles, soothing
• May cry, pull sore limb away or music etc
Infant
protect painful area (guarding) • 0 –3 months: no procedure in
0–1 year
• Grimace on face, may sleep more crib
or increase activity frantically • 3 –12 months: use treatment
• May become still and stop crying room, use breast sucking, use
if in severe pain (a sleeping baby sucrose or a dummy
or one lying very still is not
necessarily pain free) Scales: NIPS, FLACC, TVP
• G et parents to support, hold

child
• W hining and listlessness may
• Holding/rocking , singing
equal discomfort
songs, distraction, stories,
Toddler • Tugging, less weight on limb or
bubbles, toys
1–3 years not using a part of the body may
• Use treatment room for all
each mean discomfort
procedures
• Resistance during painful
• Reward after treatment
procedures
Scales: NIPS, FLACC
• G et parent to support child

• Rehearsal before painful
• C hanges occurring in regular procedure
sleeping and eating patterns • Squeeze hand, use counting
• Showing fear of pain or reciting the ABC, story
Pre-school
• Acting according to previously telling, bubbles, noisy toys,
3–6 years
documented pain-coping relaxation techniques
behaviours • Use treatment room for all
• Changes in behaviour and procedures
movement • Reward after procedure
Scales: Faces, VAS
53
Develop- Management techniques;

Pain expression
mental age pain measurement tools
• G et parents to support child

• A cting according to previously • Distraction with noise or
documented pain-coping songs
behaviours • Breathing techniques, muscle
• Changes in eating and activity relaxation techniques, self-
School age level talk
6–12 years • Boys are more stoic when asked • 6 –8 years: use treatment
about pain, whereas girls might room
require more attention • 8+ years: give child a choice
• Can tell the location of pain in of where they want to have
terms of body part involved procedure done
• May answer questions gradually
Scales: Faces, VAS
• G ive child the choice of

• M ay be hesitant to express
whether parent should
feelings
be present during painful
• May ignore pain signals
procedure
• May regress
• Teach relaxation techniques
• Able to identify site, location,
Adolesc-ents 13+ • Use music, massage, breathing
intensity and duration of pain
techniques and blowing
• May talk freely about pain if
• Give choice of treatment
friends and family are not present
room or bed for procedures
• Might ask questions re treatment,
outcome and origin of disease
Scales: Faces, VAS, pain diaries
54
Pain during medical procedures
• C ontrol of procedural pain is important in children as health

workers often have to perform painful procedures on children.
• The principles for managing procedural pain in children include
the following:
Ask whether the child really needs the procedure.
Prepare first.
Get the child and family involved, explaining what is going
to happen.
Encourage the parent/carer present to be helpful and
supportive.
Carry out the procedure in a child-friendly manner.
Use both pharmacological and non-pharmacological
interventions to manage pain.
After the procedure, compliment the child on how well
they have done.
If they are available, use topical analgesics, e.g. EMLA
cream or local anaesthetic agents.
If anxiety rather than pain is the problem, sedate using a
benzodiazepine (e.g. midazolam).
If pain is a significant problem, use opioid analgesics in
advance so that it has time to attain maximum effect.
55
References:
• B
ritish National Formulary (2008). London: BMJ Group and RPS
Publishing.
• L avy V, Bond C and Wooldridge R (2007). Palliative Care Toolkit:

Improving care from the roots up in resource-limited settings.
London: Help the Hospices and WPCA.
• T
wycross R and Wilcock (2007). Palliative Care Formulary, 3rd
edition.
• W
orld Health Organization (1998). Cancer pain relief and palliative
care in children. Geneva, Switzerland: World Health Organisation.
• B
eke, D., & Pecherstorfer, M. (2008). [Bisphosphonates and
osteonecrosis of the jaw--an increasing challenge in palliative care].
[Case Reports]. Wien Med Wochenschr, 158(23-24), 702-706. doi:
10.1007/s10354-008-0630-z
• C
araceni, A., Martini, C., Zecca, E., Portenoy, R. K., Ashby, M. A.,
Hawson, G.,. . . Lutz, L. (2004). Breakthrough pain characteristics
and syndromes in patients with cancer pain. An international survey.
Palliat Med, 18(3), 177-183.
• J adad, A. R., & Browman, G. P. (1995). The WHO analgesic ladder

for cancer pain management. Stepping up the quality of its evaluation.
[Research Support, Non-U.S. Gov’tReview]. JAMA, 274(23), 1870-
1873.
• K
amei, J. (1996). Role of opioidergic and serotonergic mechanisms in
cough and antitussives. [Review]. Pulm Pharmacol, 9(5-6), 349-356.
• M
annix, K., Ahmedzai, S. H., Anderson, H., Bennett, M., Lloyd-
Williams, M., & Wilcock, A. (2000). Using bisphosphonates to control
the pain of bone metastases: evidence-based guidelines for palliative
care. [Review]. Palliat Med, 14(6), 455-461.
• S taritz, M. (1988). Pharmacology of the sphincter of Oddi. [Review].

Endoscopy, 20 Suppl 1, 171-174. doi: 10.1055/s-2007-1018170
56
CHAPTER 4:
MORPHINE AND OTHER OPIOIDS
We really see the impact of pain relief on

people’s lives. Around 95 per cent of new
patients arrive in severe pain. We give them
morphine immediately, then wait 10–15
minutes before examining them. Sometimes
you can even see them smile. … Morphine
should be available to all patients with
terminal illnesses.
(Peter Mikajjo, Hospice Africa Uganda,
personal statement)
A. Principles
• O ne of the common reasons for poor pain control is inadequate
administration of opioids.
• Opioid analgesics are safe and effective for managing pain.
• There are many myths about the use of opioids, which need to be
dispelled.
• Clinicians need to have a good working knowledge of the
pharmacology of opioid medication and an understanding of their use,
together with information to debunk surrounding myths. Clinicians
should also have a good working knowledge of the side effects of
opioids and how to manage them.
• Oral morphine is the gold standard by which other opioids are
judged. It is cheap and easy to use.
• Good pain control can be achieved through the use of morphine and
adjuvant medication in most cases.
• Often, morphine is associated with ‘terminal care’ and ‘the end of life’.
However, it can be used at any stage of an illness to control pain and
can be withdrawn if the patient no longer needs it.
• The use of the WHO analgesic ladder (see Chapter 3) guides us to
use a non-opioid such as paracetamol (Acetaminophen) and adjuvant
for mild pain; a weak opioid with a non-opioid and adjuvant for
moderate pain; and a strong opioid with a non-opioid and adjuvant for
severe pain.
• Judging which step of the analgesic ladder a patient should be on
requires ‘impeccable assessment’ of pain and the recognition that if a
patient on a weak opioid at maximum dose is still experiencing pain,
the medication needs to be changed to a strong opioid.
B. Opioid analgesics
Codeine phosphate (methylmorphine)
• I t is a weak opioid used for mild to moderate pain.

• There is not sufficient evidence to promote codeine in preference to
other opioids.
• It has analgesic, anti-tussive properties; antitussive effect is not
mediated via the opioid receptors (Kamei, 1996).
• It is much less potent than morphine and binds relatively weakly to µ
receptors.
58
• T he analgesic effect of codeine is due to codeine being converted to

morphine in the body.
• Codeine is not usually available on its own but is usually combined
with paracetamol for treating pain.
• It is important to check the strength of codeine in combination
medications because these preparations often contain 8 or 10mg of
codeine per tablet, which is sub-therapeutic in managing pain.
• Approximately 10% of caucasians are unable to convert codeine
to morphine. Not many studies have been carried out to ascertain
the situation among the negroid race. Younger children have
inadequate amounts of enzyme to convert codeine to morphine.
The recommended efficacious dose of codeine has been found to
be associated with adverse side effects which could be avoided if
a low dose of equianalgesic dose of morphine was used. Palliative
care experts thus suggest that there is less use for codeine in this
population. Low- dose morphine should be used instead.
Tramadol
• T ramadol is a weak opioid used for mild to moderate pain.

• It bridges Step 2 and Step 3 analgesia.
• The majority of cancer patients on Tramadol for pain relief need to
change to morphine as their disease progresses.
• Tramadol lowers the seizure threshold and should be used with
caution with other drugs that lower seizure threshold and in patients
with epilepsy.
• May be preferable to other opioids in the management of pain due to
pancreatitis because of its relaxant effect on the sphincter of Oddi
(Staritz, 1988).
Morphine
• M orphine is a strong opioid used for moderate to severe pain.

• It is a naturally occurring alkaloid of opium derived from the poppy
flower.
• Most of the strong opioids are pharmacologically similar to morphine.
• Morphine is inexpensive. In African countries that include opioids in
their Essential Medicine List, morphine is often the only strong (Step
3) opioid available for pain management.
59
• M orphine elixir (oral liquid morphine) is very easily prepared from

morphine sulphate powder into different strengths and proportions
as might be required..
• Morphine may also be available in slow-release form and by injection.
• In palliative care, parenteral morphine may be used as a continuous
subcutaneous infusion via a syringe driver.
• Morphine is metabolised in the liver.
• Morphine solution has a rapid effect on pain relief, with peak plasma
concentrations within 1 hour and an elimination half-life of 2–4 hours.
This means that for good control of chronic pain, morphine solution
must be administered 4hrly.
• Immediate-release morphine is recommended for titration of the
morphine dose in order to achieve pain control regardless of whether
slow-release morphine or another opioid (such as Fentanyl) is used
when the patient’s pain control is established.
• Morphine is the ‘gold standard’ opioid against which other opioids are
measured and is the only strong opioid available in many parts of the
developing world.
• The ‘potency’ of an opioid describes the response to a particular dose
of the drug, and the so-called ‘equianalgesic’ dose of other opioids is
defined with reference to 10 mg of morphine (see Table 2 below).
Table 3: equianalgesic doses of opioid compared with 10mg of IM/sc

morphine for adults
Dose equianalgesic to 10mg morphine administered by

intramuscular (IM) injection or subcutaneous (sc) infusion
Drug
IM/sc po (by mouth)
Morphine 10mg 20mg

Bupremorphine 0.4mg 0.8mg
Codeine 130mg 200mg
100µg/hr = 2–4 mg/hr of IV
Fentanyl
morphine
Hydromorphone 1.5mg 7.5mg
Methadone 10mg 20mg
Oxycodone 15mg 30mg
Tramadol 100mg 120mg
60
Methadone
• I t has a complex pharmacology and a wide range of pharmacological

effects.
• Methadone has unusual pharmacokinetic properties that contribute
to unintentional toxicity.
• Its use in management of pain is still limited to a few specialists.
• No evidence that methadone is superior to morphine as an analgesic.
• Methadone is a synthetic opioid.
• Use of methadone needs to be carefully monitored as it remains
in the body for longer and so drug accumulation may occur when
methadone is initiated or the dosage is increased.
• It takes approximately a week for a steady state to be achieved.
• Methadone is also useful in the management of neuropathic pain.
• It can be used in renal failure as its metabolism and excretion are
unchanged in renal failure.
• Methadone is also used in drug rehabilitation as a substitute for
heroin.
• If methadone is available for use as an analgesic, there are guidelines
to follow when converting a patient from morphine to methadone.
Fentanyl
• F entanyl is a strong opioid for chronic pain.

• It is lipophilic and so is taken up by fatty tissue and has a long half-life.
• It is less constipating than morphine.
• Fentanyl is available in transdermal formulations, the most common
of which comprises a drug reservoir separated from the skin by a
membrane that controls the rate of delivery of the medication to the
skin surface.
• When the fentanyl patch is applied to the skin, the serum
concentration of fentanyl rises gradually, reaches a steady state after
12–24 hrs and stays constant for some time before reducing.
• The skin patches are changed every 72 hrs to achieve a constant
serum concentration of fentanyl.
• Therefore it is not appropriate to use fentanyl for titration of the
opioid dose and it is more practical to use morphine solution to
establish the required dose of opioid and then to convert to fentanyl
patches. The patient should have morphine solution available for
breakthrough pain.
61
• I n patients with fever, the absorption of fentanyl is increased because

of increased skin permeability, and patients with fever should be
monitored for opioid side effects.
• In changing from morphine to fentanyl, it is important to follow the
manufacturer’s guide to equivalent dose.
• Calculate the dose and opioid of choice based on fentanyl 25mcg
patch (equivalent to approximately 100 mg of oral morphine in 24
hours or 20mg oral hydromorphone in 24 hours) and reduce the
oral dose by 50% or more. There is incomplete cross-tolerance and
caution must be used when switching to oral medication since some
of the fentanyl may still be present.
• Initial dose: convert from an oral morphine dose according to Table 3
(simplified to match available preparations).
Table 4: Fentanyl-to-morphine conversion doses in Adults
24hrly oral
4hrly oral morphine fentanyl patch size
dose (mg) morphine dose (mcg/hr)
(mg)
5–20 30–130 25
25–35 140–220 50
40–50 230–310 75
55–65 320–400 100
• D oses should always be titrated to the individual patient’s

requirements.
• Always have a breakthrough dose available as dosing may be
underestimated.
• Half-life after removal of the patch is 13-25 hours.
• Fentanyl is useful for patients with renal failure as it does not have
active metabolites.
• Fentanyl is less constipating than morphine and is suitable for use in
patients with swallowing difficulties if they have stable pain.
• If a patient is nearing the terminal phase and is on transdermal
fentanyl, keep the patch in place and give breakthrough doses via
another route if needed.
• Do not use in patients who need rapid pain control.
• Major side effect is respiratory depression – dose dependent.
62
Some practicalities with administration of opiods:

Morphine
• Patients converting from 4hrly immediate-release morphine will

require continued regular morphine until peak plasma levels of
fentanyl are reached, i.e. the first 12 to 24 hours.
• Patients converting from 12hrly modified-release morphine should
apply the patch at the same time as taking the final 12hrly tablet.
• Patients converting from 24hrly modified-release morphine should
apply the patch 12 hours after taking the final 24hrly morphine
capsule.
• An immediate-release opioid preparation (equivalent to a 4hrly
morphine dose) should always be available for breakthrough pain.
• The patient should be warned that they may experience more
breakthrough pain than usual in the first three days.
Fentanyl transdermal (TD) patch
• The dose of fentanyl patch should not be changed within the first two
days of the first application or of any change in dose.
• Replace the patches at the same time of day every three days.
• Titrate the dose upwards in 25mcg/hr steps with any required
increase.
• Vary the site of application with each change of the patch.
• Apply to a clean, dry, undamaged, non hairy, flat area of skin.
Prophylactic laxatives
• Constipation is a common side effect of opioids; you should always

give a laxative when you prescribe oipioids (unless the indication for
opioids is to control diarrhoea.
• Laxatives should be reduced up to 50% and then titrated to need.
Pethidine
• P ethidine is not suitable for patients with chronic pain.

• It has a faster onset of action and a shorter duration of action than
morphine and needs more frequent dosing: every 2–3hrs.
• Pethidine is metabolised to norpethidine which has side effects
inducing central nervous system excitability including mood changes,
tremors, myoclonus (sudden jerking of the limbs) and convulsions.
63
C. The pharmacokinetics and side effects of opioids

Side effects
There are several side effects of morphine and these include:

Constipation – therefore always give with a laxative (e.g.
bisacodyl 5mg at night, increasing to 15 mg if needed) unless
the patient has diarrhoea.
Nausea and vomiting – if this occurs, give metoclopromide
10mg 8hrly, or haloperidol 1.5mg once a day.
Drowsiness – which may occur in the first few days. If it does
not improve after about three days, reduce on the dose of
morphine.
Itching – less common, but if it occurs give chlorpheniramine.
• Hepatic and renal impairment is not a contraindication for the use
of opioids but care is required in these circumstances because of the
risk of accumulation of medication or active metabolites. Increase the
interval between doses so that the morphine is given 6- , 8- or even
12-hourly.
• Interactions with other medicines:
The sedative effects of morphine may add to those of
anxiolytics, neuroleptics and antidepressants.
The constipating effects of morphine may be exacerbated by
anticholinergic medication.
Pethidine should not be used in palliative care but in
particular is contraindicated in conjunction with monoamine
oxidase inhibitors because of serious adverse reactions of
hyperpyrexia, convulsions and death.
There may be interactions with some of the medicines used in
HIV and AIDS – see Chapter 8 for more information.
• Toxicity:
Signs of morphine toxicity include;
-- Drowsiness that does not improve
-- Confusion
-- Hallucinations
-- Myoclonus
-- Respiratory depression (slow breathing-rate) – seldom
seen with oral morphine dosing
-- Pinpoint pupils.
64
If you are concerned that the patient is becoming toxic,

reduce the dose by 50% and consider giving parenteral fluids
to increase excretion. In severe cases, stop the morphine and
give Naloxone, an opioid antagonist. Haloperidol 1.5–5mg at
night may help with any hallucinations or confusion caused by
the morphine.
• In older patients:
The pharmacokinetics is altered by the ageing process,
and older people respond well to lower doses of opioid
analgesics.
Reducing the dose or lengthening the time between doses
minimises the risk of serious adverse effects in older patients.
D. Myths about morphine that may limit its use

• T here is much ignorance surrounding the use of morphine and as a
result patients suffer unnecessarily.
• Physical dependence:
Physical dependence is a normal physiological response to
chronic opioid therapy, which causes withdrawal symptoms if
the medication is suddenly stopped – it also occurs with many
other medications and not just opioids.
Physical dependence does not prevent withdrawal of the
medication if the pain has been relieved by other means,
provided that patients are weaned from the drug slowly.
• Respiratory depression:
This is not common if morphine doses are titrated against
pain, because pain is a physiological antagonist to respiratory
depression.
Respiratory depression does not occur if the right drug is
given, at the right time, by the right route.
In palliative care, low doses can safely be used in patients with
end-stage chronic obstructive pulmonary disease (COPD),
lung cancer and in patients with sever dyspnoea.
• Tolerance:
The need for increasing doses of morphine is uncommon and
is related to disease progression. Reassure the patients that
there is adequate scope to treat more severe pain if it occurs.
Concern about tolerance is not a reason for ‘saving up’ the
use of opioids until the terminal phase.
There is no maximum dose of morphine.
65
• Addiction:
There is a need to differentiate addiction from physical
dependence, which is a normal physiological response to
chronic opioid use and results in withdrawal symptoms if the
drugs are suddenly withdrawn.
Addiction is a pathological psychological response
characterised by abnormal behaviour which includes a craving
for the drugs.
Addiction is rarely seen in palliative care as the therapeutic
use of oral morphine does not lead to addiction.
• Morphine hastens death:
Morphine can be used for many months and years and is
compatible with a normal lifestyle.
If given correctly, it does not hasten death.
E. Be aware …
• M orphine is safe to use for pain management in people with life-
threatening illness.
• Many health professionals have not been trained to use opioids and
may not feel happy doing it.
• You may experience some resistance from both health professionals
and patients in the use of morphine.
The pharmacokinetics and side effects of opioids
In children:
• I t is safe to use opioids in children, and clinicians should not

withhold analgesia from children in pain.
• Starting doses are calculated according to the weight of the child
and management of pain is individualised according to the child’s
needs for analgesia by titration of the opioid dose.
• Extra cautions should be applied when dealing with neonates.
Neonates are more prone to the central nervous adverse effects
of morphine because of the presence of a poorly- developed
blood- brain- barrier and accumulation of metabolites because
of inadequate carrier- protein in the blood. Lower doses should
thus be used when dealing with neonates.
66
References:
• F aull C, Carter Y and Woof R (1997). Handbook of Palliative Care.
Oxford: Blackwells.
• H
anks GW, De Conno F, Ripamonti C, Ventafridda V, Hanna M,
McQuay HJ, Mercadante S, Meynadier J, Poulain P and Roca i Casas
J of the Expert Working Group of the European Association
for Palliative Care (1996). ‘Morphine in cancer pain: Modes of
administration’ in BMJ 312.823–6.
• H
anks GW (1994). ‘Transdermal ferntanyl in cancer pain’ in J Drug
Devel 6:93–7.
• S chug SA, Zech D, Dorr U (1990). ‘Cancer pain management

according to WHO analgesic guidelines’ in Journal of Pain and
Symptom Management 5(1): 27–32.
• P
ortenoy, R. K. (2011). Treatment of cancer pain. [Review]. Lancet,
377(9784), 2236-2247. doi: 10.1016/S0140-6736(11)60236-5
• Z
ernikow, B., Michel, E., Craig, F., & Anderson, B. J. (2009). Pediatric
palliative care: use of opioids for the management of pain. [Review].
Paediatr Drugs, 11(2), 129-151. doi: 10.2165/00148581-200911020-
00004
67
CHAPTER 5:
NON-PHARMACOLOGICAL
MANAGEMENT OF PAIN
Pain is inevitable – suffering is optional.

(Anonymous)

A. Principles
• P ain is influenced by psychological, cultural, social and spiritual factors.
• Determining the type of pain helps to determine its treatment.
• Psychological factors are as important in dealing with pain as the
• Non-pharmacological pain management is the management of pain
without medications. It utilises ways to alter thoughts and focus
concentration, so as to better manage and reduce pain.
• Complementary or alternative therapies are increasingly being used
to alleviate pain. These are therapies used together with conventional
or orthodox medicine but do not replace this medicine such as
biochemical therapies like herbs, dietary supplements, flower
essences, aromatherapy oils; biomechanical therapies like massage;
lifestyle therapies like environment, diet, exercise and mind-body
techniques such as meditation, relaxation and imagery; bioenergetic
therapies like acupuncture, therapeutic touch etc.
• Current WHO guidelines recommend a combination of
pharmacologic and nonpharmacologic treatment modalities as
standard of care for cancer pain (Jadad & Browman, 1995).
• Both adults and children feel less distress when they understand
what is happening and are involved in their care.
• Children (including newborns) suffer pain as much as adults;
younger children experience higher levels. Fear of treatment may
prevent them from expressing pain.
69
B. Types of non-pharmacological pain management
• T here are a whole range of techniques and expertise that exists to

complement the pharmacological and interventional approaches for
pain management.
• Not all approaches will be appropriate for every patient.
• Complementary therapies work to affect pain perception, assist
relaxation, improve sleep or reduce symptoms by:
Direct analgesic effect, e.g. acupuncture
Anti-inflammatory action, e.g. herbs
Distraction, e.g. music therapy.
• Such therapies include: acupuncture, dance therapy, deep breathing,
distraction, herbs, hot and cold therapy, massage therapy, music
therapy, physical therapy, positioning therapy, relaxation, social
support, and spiritual and religious support. Each is described
further below.
• Some complementary therapies, such as herbs, are used commonly
across Africa.
Acupuncture
• A cupuncture, acupressure, and electroacupuncture are forms of

traditional Chinese medicine in which physical manifestations of the
meridians e.g. joints are assessed.
• Pressure on meridian points can be applied by insertion of small-
gauge needles (eg, acupuncture) or a combination of needles and
low-frequency electric current (electroacupuncture), or by manual
pressure with a finger (acupressure) (Pujol & Monti, 2007).
• The insertion and manipulation of needles, or the application of
pressure at specific points, is offered as a discrete technique for
treating symptoms.
70
Dance therapy
• There are therapeutic benefits of dance therapy, although these

results are based on generally poor-quality evidence. Dance therapy
should be considered as a potentially relevant add-on therapy for a
variety of conditions that do not respond well to conventional medical
treatments (Strassel, Cherkin, Steuten, Sherman, & Vrijhoef, 2011).
• Dance therapy uses movement to improve mental and physical well-
being.
• Clinical reports suggest that dance therapy helps people accomplish
the following:
Developing a positive body image
Improving their self-image and self-esteem
Reducing stress, anxiety, and depression
Decreasing isolation, chronic pain, and body tension
Increasing communication skills
Encouraging a sense of well-being.
• Dance therapy will need to be undertaken within the limits of an
individual’s ability.
Deep and Slow Breathing (DSB)
• D eep and slow breathing (DSB) techniques are widely used in the
relief of a number of palliative care symptoms especially those that
encompass somatic disorders.
• DSB decisively influences autonomic and pain processing in concert
with relaxation in the modulation of sympathetic arousal and pain
perception.
Distraction
• Distraction is used to focus the patient’s attention away from the pain.
Herbs
• H erbs are used in traditional African medicine.

• They may produce physiological effects and these can be positive or
negative, depending on a patient’s situation. However, the physiological
effects of herbs have not always been scientifically proven.
• Some herbs can cause unwanted side effects such as allergic reactions
or direct toxicity on the skin.
71
Hot and cold therapy
• A pplying either a hot or cold compress can help decrease pain.

• Some types of pain improve best using heat, while other types of pain
improve most with cold.
Massage therapy
• M assage includes rubbing and manipulating muscles, which increases

blood circulation and enhances relaxation.
• Massage is safe but should be avoided with certain conditions such
as joint inflammation or injury, open wounds, skin infections, or
phlebitis.
• Massage can enhance a patient’s feeling of well-being and comfort.
Music therapy
• M usic can reach deep emotional levels, and types of music may hold
specific meaning for individuals.
• Music therapy may involve listening to music, creating music, singing,
and discussing music. Guided imagery with music can also be
beneficial.
• Music can also help accomplish the following:
Relieving stress, apprehension, and fear
Improving mood
Lowering heart rate, blood pressure, and breathing rate
Relieving depression
Relieving sleeplessness
Relieving muscle tension and providing relaxation.
• Music increases blood flow to the brain and helps you take in more
air.
• Scientific studies have shown the positive value of music therapy on
the body, mind, and spirit of children and adults.
Physical therapy
• P hysical therapy involves movement of the body to achieve and

maintain a healthy condition and state of physical fitness.
• Breathing exercises, walking, washing, and fetching water are all
activities that can help to build strength, maintain energy, and
contribute to overall well-being.
72
• Studies have shown that physical exercise:

Reduces anxiety or depression
Reduces fatigue
Improves blood flow to the legs and reduces the risk of
blood clots
Reduces pain
Reduces the incidence of diarrhoea and constipation
Prevents osteoporosis
Reduces the risk of heart disease
Increases overall physical functioning
Reduces dependence on others for the activities of daily living
Improves self-esteem.
• Be aware that problems or complications are possible if a patient
exercises above a level of exertion that is appropriate for them.
• For those who are bedridden, range-of-motion exercises are helpful
in preventing stiffness and maintaining mobility in joints.
Positioning therapy
• W hen people are bedridden, they can begin to experience pain and
stiffness in their muscles and joints.
• Moving bedridden patients and changing their position is an important
way to prevent the formation of bed sores and injury in those who
require assistance to move.
Relaxation
• R elaxation techniques are the most commonly used techniques in

psychological pain management.
• They teach patients to train and intentionally relax, which is a
psychophysiological process that reduces stress and pain.
• As patients learn these techniques, they are better able to recognise
internal tension and stress.
Social support
• U nresolved social problems can aggravate pain, whereas recognition

and management of social issues can greatly facilitate pain control.
• This includes supportive counselling, practical assistance such as the
provision of aids for daily living, and accessing community resources
and services.
73
• A
sensitive approach to culture, ethnicity and language will prevent
the aggravation of pain and will help to reduce emotional distress.
Spiritual and religious support
• R ecognition and successful management of spiritual problems is an

important part of pain control.
• Depending on a patient’s beliefs and faith, prayer and meditation may
be of support.
• It is important not to confuse spiritual care with religion.
C. Other non-pharmacological measures

• A wide range of other interventions can alleviate or manage pain.
• If available, consider the following:
Surgery:
-- Can help to reduce the source of the pain, e.g. de-bulking

tumours.
-- Can help for orthopaedic complications and visceral
obstructions.
Radiotherapy:
-- Local pain due to tumour infiltration usually responds to

local radiotherapy.
-- The doses used for the palliation of pain in patients with
advanced disease are usually much lower than the doses
used to treat a cancer and may often be administered in a
single dose even in previously treated areas.
-- Radiotherapy is however limited or may not be available in
all African countries
Reflexology:
-- Reflexology is a natural healing art based on the

principle that there are reflexes in the hand and feet that
correspond to every part of the body.
74
-- Stimulating and applying pressure to the feet or hands in

the areas that correspond to the site of pain can bring
about pain relief.
Aromatherapy:
-- Aromatherapy is the art and science of using essential oils
to balance, relax and stimulate the body, mind and soul.
-- Each oil has a specific effect on an individual – for example,
lavender oil can relieve stress and help the patient to relax,
thereby reducing their anxiety and their pain.
D. Be aware …
• N ot all methods of non-pharmacological pain management will be
appropriate for any one individual.
• There are some contra-indications for non-pharmacological methods.
• Non-pharmacological methods of pain management should be used
alongside pharmacological methods and not instead of them.
• Just because natural remedies such as herbs have been around for
years does not mean that they work or that they are harmless.
75
• Non-pharmacological approaches can be highly effective in children.

• They are not commonly used in Africa but arguably, in view of the
problems of getting hold of strong analgesics in many areas, they
should be core learning topics for medical professionals caring for
children.
• They are easy to learn and should be used whenever possible to give
the child some control in the management of pain.
• Non-pharmacological methods of pain control useful in children
include:
Emotional support
Physical methods, e.g. touching
Cognitive methods, e.g. music therapy
Prayer – depending on the family’s practice.
• Deep breathing:
The child is instructed to take a deep breath through the
nose and blow it out through the mouth. Making a conscious
effort to count the child’s respirations focuses attention on
the breathing.
For school-age children, asking them to hold their breath
during a painful procedure transfers their focus to their
breathing and away from the procedure.
• Distraction:
Simple distraction techniques can be very effective in
decreasing pain in children.
Simple measures such as looking at books, blowing bubbles,
and counting are favourite distraction techniques for children.
Touch can be an important distraction technique – stroking,
patting and rocking infants and children who are in distress.
• Music therapy:
Children across the African region have an inmate
understanding of music and respond well to different forms
of music therapy.
• Use non-pharmacological methods regularly in children
76
References:
• C
enters for Disease Control and Prevention / Columbia University
(2009). Complementary and alternative medicine for serious illness.
Definitions. Accessed via internet 24 August 2009
• O
´Callaghan C and Magill L (2009). ‘Effect of music therapy on
oncologic staff bystanders: a substantive grounded theory’ in Palliative
and Supportive Care 7: 218-219.
• P
ujol, L. A., & Monti, D. A. (2007). Managing cancer pain with
nonpharmacologic and complementary therapies. [Review]. J Am
Osteopath Assoc, 107(12 Suppl 7), ES15-21
• S trassel, J. K., Cherkin, D. C., Steuten, L., Sherman, K. J., & Vrijhoef,
H. J. (2011). A systematic review of the evidence for the effectiveness
of dance therapy. [Review]. Altern Ther Health Med, 17(3), 50-59.
• W
oodruff R, Doyle D (2004). The IAHPC Manual of Palliative Care,
2nd edition. Houston, Texas: International Association of Hospice
and Palliative Care Press.
• Z
ambian Ministry of Health (2005). A Training Package for
Community Home Based Care: Palliative Care Module 7, 25–7.
Lusaka: Government of Zambia.
• University of Virginia Health System. Articles accessed via
• www.healthsystem.virginia.edu/UVAHealth/hub_cancer/altther.cfm.
• w
ww.drugs.com. ’Non-pharmacological pain management therapies
for adults’. Article accessed via website.
77
CHAPTER 6:
MANAGEMENT OF
PSYCHOLOGICAL, SPIRITUAL
AND CULTURAL PAIN
The realisation that life is likely to end soon may

well … give rise to feelings of … the unfairness
of what is happening, and of much of what has
gone before, and above all a desolate feeling of
meaninglessness. Here lies, I believe, the essence
of spiritual pain.
(Dame Cicely Saunders)
A. Principles
• A ssessment and management of pain hinges on effective
communication.
• Psychological interventions play a well-established role in pain
management and should be an integral part of care.
• Psychosocial therapy and counselling are key components of pain
management.
• Information-giving and patient education should be an integral part of
managing pain.
• Spirituality is an important factor in coping with pain.
• Culture provides a framework in which people can understand their
pain.
• Each cultural group has its own views about pain and this will affect
how individuals respond to their pain.
B. Psychological therapy/counselling
• P sychological therapy and/or counselling is key to the non-
pharmacological management of pain.
• It may involve:
Individual counselling
Family counselling
Group counselling.
• Psychological factors play a crucial role in an individual’s ability to
manage and cope with their pain.
• Psychological distress related to chronic pain often manifests as
depression or anxiety but may also present as anger, frustration,
hopelessness, helplessness, denial, grief, sadness or withdrawal.
• Management should facilitate the patient’s adaptive and coping
mechanisms and decrease their feeling of helplessness.
• Most health professionals can give some psychological support, such
as:
Good communication
Patient education
Basic counselling
Helping patients to develop realistic expectations for the
future.
79
• Other, more specialist support may be needed for therapies such as:
Cognitive restructuring
Biofeedback
Stress management
Relaxation training.
The importance of effective communication in pain management
• E ffective communication enables a patient and their family to talk

about their pain and their fears and concerns.
• It also fosters a very strong relationship between the care giver and
the patient.
• Communication is seen as a therapy, which is used to help a patient to
either cope with or solve a problem.
Principles to help care providers communicate effectively
• C ommunicate with sensitivity, empathy, compassion and support to

the patient and family.
• Listen attentively and allow tears and emotions to be expressed
without rushing the patient.
• Take into account the family and its ethnic, cultural and religious
roots.
• Pay attention to the patient, family members and fellow care
providers.
• Be aware of the importance of non-verbal communication such as
facial expressions.
• Use clear and suitable language that is understood by the patient); use
an interpreter if necessary.
• Ask appropriate questions, and allow the patient and family to ask
questions each time you see them.
• By asking questions, paraphrasing, summarising etc., ensure that the
patient and family have understood what you are saying, and that you
have understood what they are saying.
80
Basic communication skills
• A ctive listening: i.e. hearing with interest, attention and

understanding verbal and non-verbal messages that patients
and families are communicating. The indicators of attention are
summarised as “ROLES”:
Relax
Openness
Lean forward
Eye contact
Sit near (comfortably near).
• Check understanding through paraphrasing and summarising the
patient’s story, and identifying and reflecting the person’s feelings and
emotions from their story.
• Ask questions: focus on questions that are purposeful to the patient
and the care provider. They should aim to:
Get information
Assess knowledge
Direct and focus decisions
Get a deeper understanding of the person’s problems
Prioritise issues
Set the pace of the dialogue with the person seeking
assistance
Show that the care provider is trying to understand the
person and the problem better.
• Use mainly open-ended questions, i.e. those that are thought
provoking, and invite the person to talk and explain a situation and
offer a variety of responses – for example, “What makes you feel
bad?”, “How did you feel when you were diagnosed with cancer?”
“What worries you most?”
• You can use some closed-ended questions if necessary. These are
brief and restricting and are used to obtain facts and not knowledge
of feelings – for instance, “Does this part of your body hurt?”
• Avoid leading questions – these suggest a preferred answer or
desired response, for example “I know you must be feeling a lot of
pain – isn’t that so?”
81
• When answering questions:

Understand that behind every question is a story; therefore
be honest and give accurate answers.
Give correct information.
Provide clear and simple information.
Check for understanding or misunderstanding.
Respect and reinforce important information.
• Use positive attitudes:
Non-judgmental: treat people as they are, with respect and
dignity and avoid condemning or criticising them.
Confidential: do not reveal any information obtained from the
patient unless consent is given. Every patient has a right to
confidentiality and should feel secure as they communicate.
Empathetic: put yourself ‘in the patient’s shoes’ by
understanding and accepting their situation.
Caring: give attention or be concerned about someone
else’s well-being. We show care by being approachable and
welcoming, by showing interest, etc. This entails making the
patient feel at home and the care professional responding
with interest to what they are saying.
C. Patient education
• E xplaining to the patient about the cause of their pain and possible
management will help to:
Build their confidence
Gain realistic expectations
Build trust and relationship
Aid adherence to medication
Reduce stress and anxiety.
• Fear and anxiety exacerbate pain.
• Explain to the patient what is happening – involving and informing
them helps to ease tension and thereby to reduce anxiety and pain.
• It is important that, when giving medication to manage pain, the
health worker explains clearly to the patient how and when to take
their medication.
82
This should include:

Name and formulation of the medicine
Why they need to take it
Dose to be taken and, if a liquid, how to draw up the correct
dose
At what times to take it and whether they need to take it
with food etc.
Possible side effects of the medicines
How to store the medicine
When and how to get more medicine
Who to contact if they are worried, experiencing side effects
or their pain is not controlled.
D. Spiritual and cultural care

• A n individual’s spirituality is shaped by the culture in which they live.
• Spirituality is also shaped by the individual’s journey – e.g. being faced
with a life-threatening illness.
• Patients may go through a period of doubt, conflict and confusion – all
of which are natural in the face of life-threatening illness and through
which they need to be supported.
• In Africa, spirituality has a practical, social and material impact on
people’s daily lives – we cannot address the needs of the patient
without addressing their spiritual needs.
• Most health professionals will provide some spiritual support – for
instance:
Listening to their fears and concerns
‘Being with them’
Praying with them, as appropriate and as requested.
• Other more specialist support may be needed at times, for example:
Specific rituals relating to their religion
In-depth spiritual counselling.
• Support may need to be given to the patient in different ways – e.g.
if the patient has important things to complete, or if experiencing
anticipatory grief or anxiety.
83
E. Be aware …
• E ffective psychological and spiritual care takes time.
• Sometimes people in pain may need pharmacological treatment for
their anxiety or depression, alongside psychological counselling and
support.
• Do not replace pharmacological management with these therapies
but use them in an integrated manner to manage pain effectively.
• It is not always possible to ‘make things better’ but as a health worker
the important thing is to be there with the patient and support them
in their spiritual journey.
• When communicating with children, use language and media that

children understand according to their age – e.g. drawing, pictures,
music, dance and drama, stories etc.
• Explain to a child in an age-appropriate manner.
References:
• Saunders C (1988) Spiritual pain. Journal of Palliative Care. 4 (3) p29-
32.
84
CHAPTER 7:
SPECIAL CONSIDERATIONS FOR
PEOPLE WITH HIV/AIDS, THE
ELDERLY, AND THOSE AT THE
END-OF-LIFE
There is nothing I do, because I cannot walk

or even crawl. I stay here from morning to
day break, I just get my rosary and pray … My
biggest challenge is pain – I have a burning
pain in the legs. It’s eating me up.
(An elderly gentleman in Kenya)
Every child should expect individualised, culturally and age appropriate palliative
care as defined by the World Health Organization (WHO). The specific needs of
adolescents and young people shall be addressed and planned for.

(ICPCN Charter, 2008)
A. Principles
• T he basic principles of pain control are the same for everyone.
• The best approach for treating pain in HIV and AIDS is multimodal.
• There are some unique features about the very elderly that need to
be considered.
• For the elderly, the motto is ‘start low, go slow’ in the use of
analgesics.
• Control of pain and other symptoms is paramount in end-of-life care.
B. Specific considerations for pain management in

people with HIV/AIDS
• P ain in HIV is highly prevalent, has various syndromal presentations,
can result from two or three sources at a time and has the potential
of being poorly managed.
• The pain might be directly related to HIV infection,
immunosuppression or HIV therapy.
• In South Africa the prevalence of neuropathic pain in AIDS patients
was 62% prior to antiretroviral therapy, with men more likely to
experience pain than women.
• The most common syndromes reported in HIV-positive adults (see
Table 5):
Painful peripheral neuropathy
Pain caused by extensive Kaposi’s sarcoma
Headache
Oral and pharyngeal pain
Abdominal pain
Chest pain
Arthralgias and myalgias
Painful dermatological conditions.
86
Table 5: Common sources of pain in HIV and AIDS patients
Cutaneous/ Neurological/
Visceral Somatic
Oral Headache
• HIV-related
headaches:
encephalitis, meningitis
etc.
• Kaposi’s • HIV-unrelated
• Tumours headache: tension,
Sarcoma
• Gastritis • Rheumato- migraine etc.
• Oral cavity pain • Iatrogenic (AZT)
• Pancreatitis logical disease
• Herpes zoster • Peripheral neuropathy
• Infection • Back pain
• Oral/ • Biliary tract • Myopathies • Herpes neuritis
oesophageal disorders • Neuropathies
candidiasis associated with DDI,
D4T toxicities
• Alcohol, nutritional
deficiencies
Modified from Carr
• P harmacological pain management should be as per the WHO

analgesic ladder, as discussed in Chapter 4.
• NSAIDs, adjuvants e.g. tricyclic antidepressants, anticonvulsants and
nonpharmacological interventions are important in the control of pain
in HIV/AIDS. Use NSAIDs with caution in patients with low platelets
and those with history of gastrointestinal disease such as peptic ulcer
disease.
• Many of the ARVs, especially the protease inhibitors, cause abdominal
discomfort, nausea and vomiting.
• Headache and peripheral neuropathies are also common side effects
of ART.
• Some antiretroviral medicines interact with analgesics, and so caution
needs to be shown when giving analgesics to patients on ART. In
particular:
The main interactions occur with the adjuvant analgesics
such as phenytoin, carbamazepine, dexamethasone and
amitriptyline.
Possible interactions are set out in Appendix 3.
• Many people with HIV and AIDS will also have cancer and so it is
important to be aware of specific pain-related syndromes in both HIV
and cancer as well as those related to treatment interventions (see
Table 6).
87
Table 6: Specific pain-related syndromes in HIV and cancer
Clinical
Pain type Causes Treatment
presentation
DISEASE RELATED – HIV AND AIDS
Remove offending agents if
possible: change from D4T to
Burning pain: hand Abacavir, or from Efavirenz
HIV itself (distal
and feet to Ritonovir/-Lopinavir
sensory neuropathy)
Peripheral Pins and needles
Post-herpetic
(Kaletra).
Neuropathy Allodynia (the
neuralgia;
Treat Herpes Zoster early
experience of pain with Acyclovir to limit post-
HAART: especially
from a stimulus that herpetic neuralgia.
D4T and Efavirenz
would not usually Use WHO analgesic ladder:
Other treatments:
cause pain in a NSAIDs and opioids
chemotherapy,
normal individual) Gabapentin (where available)
Isoniazid,
Pain relieved by local in resistant cases
Metronidazole
pressure Try topical analgesics
Localized neuropathies: nerve
block
Diagnose and treat
TB abdomen underlying cause if possible
MAC Start HAART if indicated
Pancreatitis Treat pain according to WHO
Peptic ulcer disease analgesic ladder
(PUD) and gastro- Beware of ileus/constipation
oesophageal reflux caused by opioids: can make
disease (GORD) pain worse
Abdominal pain
Abdominal Can present as acute
Gall bladder and Remember morphine causes
pain in HIV or chronic pain
biliary tract disease contraction of sphincter of
Malabsorption Oddi, so Pethadine is a better
syndromes choice in pancreatitis
Drug side effects; For MAC Immune
Neuropathic Reconstitution Inflammatory
abdominal pain Syndrome (IRIS), try low dose
(diagnosis of steroids
exclusion) Beware NSAIDs and gastritis
HAART
Caused by HIV itself Levodopa (extrapyramidal
in the form of HIV dysfunction)
encephalopathy with Analgesics (level two: non-
Muscle spasm Muscle spasm
increased tone opioid + weak opioid)
in HIV Secondary to cerebral NSAIDs may help for
insults from bacterial musculo-skeletal pain
or tuberculous Baclofen (for muscle spasm,
meningitis can cause seizures)
Adjuvants, especially Rivotril
88
Clinical
presentation
Treat pain according to WHO
Raised Headache Cryptococcal analgesic ladder
Intracranial Focal neurological meningitis Morphine and Pethadine are
pressure deficits Toxoplasmosis contraindicated for raised
intracranial pressure
DISEASE RELATED – CANCER
Infiltration of bone
Skeletal metastases
- irritation and
stretching of pain
Aching to sharp receptors in the NSAIDs
severe pain generally periosteum and Corticosteroids
more pronounced endosteum Opioids (initially)
Bone pain with movement Prostaglandins Radiation
Point tenderness released from bone Adjuvants (Carbamazepine)
common destruction; Bisphosphonates
Infiltration of nerves
(in Haversian canals)
neuropathic
component
Nerve injury caused

Abnormal or
by tumour infiltration;
unpleasant
can also be caused by Opioids (initially)
sensations, generally
injury from treatment Adjuvants (Amitryptaline or
described as tingling,
(e.g. vincristine Carbamazepine)
burning, or stabbing
toxicity) Gabapantin
Neuropathic Often a delay in
Infiltration or Nerve blocks for local
pain onset
compression of neuropathies secondary to
Brief, shooting pain
peripheral nerves tumour invasion
Increased intensity of
Surgical interruption Radiotherapy
pain with receptive
of nerves (phantom
stimuli (allodynia)
post-amputation pain)
Obstruction - bowel,
urinary tract, biliary
Visceral pain tract
Give opioids and non-opioids
Soft-tissue Poorly localised Mucosal ulceration
Avoid morphine in bowel
tumours of Varies in intensity Metabolic alteration
obstruction and biliary colic
the bowel or Pressure, deep or Nociceptor
Adjuvants may also be
retroperitoneum aching activation, generally
indicated
from distention or
inflammation of
visceral organs
89
Clinical
presentation
TREATMENT-RELATED PROBLEMS WITH BOTH DISEASES
Can be caused by candidiasis,

herpes or mucositis
Treat the underlying cause.
Difficulty swallowing,
Ensure adequate oral intake
pain from lesions in
Give regular paracetamol
Mucositis the oropharynx. May
4–6hrly before feeds
extend throughout
Use mouthwashes as
the entire GI tract
appropriate
Use to gargle with and
spit out
Infection may be Direct side effects of

localised pain from treatment for cancer
a focused infection Chemotherapy
Infection or be generalised
Treat the underlying infection
Radiation
(especially Surgery
neutropaenic sepsis)
Bed rest, simple analgesics,

Severe headache
Post-LP following lumbar
adequate hydration. May
headaches puncture
require epidural blood patch
Caffeine may be beneficial
Skin inflammation
Radiation causing redness and Topical corticosteroids
dermatitis breakdown
Pain related to tissue

Appropriate post-operative
Post-surgical trauma secondary to
pain management
surgery
90
Peripheral Neuropathy
• I t is more common in adults than children, but does occur in

children and often under-diagnosed.
• When treating it, add adjuvant: Carbamazepine for young.
children, Amitryptaline for older children. It is best not to use
Carbamazepine and Efavirenz together, so if necessary switch
Efavirenz to Kaletra.
Muscle spasm in HIV
• C
hildren with basal ganglia disease and abnormal movements may
also experience considerable pain from muscle spasm.
Treatment-related problems with HIV and AIDS and cancer
• M
ucositis - Use mouthwashes as appropriate, e.g. in children 10
ml lignocaine (1%), 30ml mycostatin suspension and 15–30mg of
morphine. Use to gargle with and spit out.
C. Special considerations for pain management in

the elderly
• A n elderly person is defined as someone with advanced biological age,
and they often have multi morbidity.
• The treatment of the elderly is complicated when dementia is present.
• The percentage of people with chronic pain rises in the elderly.
• Pain in old age is often seen as ‘part of life’ and doctors often think
that they cope better with pain than the younger generation.
• In the elderly, pain can be due to multiple causes – e.g. osteoarthritis,
polyneuropathy, post-herpetic neuralgia, or cancer.
• Challenges for pain management in the elderly include:
Communication problems and misconception of pain
Compliance, as the elderly might have practical problems
with taking medication – e.g. impaired vision so cant see
instructions or medication properly, limited mobility or
dexterity in taking medication, or memory problems
91
Availability and prescription of opioids

Co-morbidity
Pharmacokinetic changes, causing dangerous drug
interactions and unpredictable plasma levels.
• One of the major reasons for lack of adequate pain control is poor
assessment, particularly in those with dementia.
• Assessment can be made:
Using the normal pain assessment tools as appropriate (see
Chapter 2)
Using an observational tool that assesses pain in patients
who are cognitively impaired (e.g. with dementia), such as the
Pain Assessment in Advanced Dementia (PAINAD) Scale:
this consist of five items assessed using a three-point scale
giving an overall score ranging from 0 (meaning no pain) to 10
(meaning severe pain) – see layout below.
Table 7. Pain Assessment in Advanced Dementia (PAINAD) Scale
Items 0 1 2 Score
Noisy labored
Breathing Occasional labored breathing. Long
independent of breathing. periods of
Normal
vocalization Short period of hyperventilation.
hyperventilation Cheyne–Stokes
respiration
Occasional moan
Repeated troubled
or groan. Low
Negative calling out. Loud
None level speech with
vocalization moaning or
a negative of
groaning. Crying
disapproving quality
Smiling or Sad. Frightened.

Facial expression Facial grimacing
inexpressive Frown
Rigid. Fists clenched.

Tense. Distressed Knees pulled up.
Body language Relaxed
pacing. Fidgeting Pulling or pushing
away. Striking out.
Distracted or
No need to Unable to console,
Consolability reassured by voice
console distract or reassure.
or touch
Total:
92
Reprinted from Warden et al. (2003), ‘Development and Psychometric Evaluation

of the Pain Assessment in Advanced Dementia (PAINAD) Scale’ in Journal of the
American Medical Directors Association (Jan–Feb 2003); with permission from
Elsevier.
• Tips for pain management in the elderly:

Include relatives in the process.
Provide written information as appropriate and in clear
writing, enlarged for those with visual impairment.
• Anticipate pain and treat accordingly.
• Use reassurance.
• Titrate doses individually, starting with very low initial doses (e.g.
2.5mg oral morphine 4hrly) – ‘start low and go slow’.
Use co-analgesics carefully to avoid drug interactions and
unwanted side effects.
D. Special considerations for pain management at the

end-of-life
• A s a disease advances so that the patient moves towards the end of
life, there may be an escalation in pain and other symptoms requiring
ongoing increases and adjustments to be made in drug therapies.
• If a patient has received good palliative care, then their pain should
be controlled before they enter the terminal stage of the illness;
however, this will often not be the case.
• The pain assessment and management measures addressed in earlier
chapters are still appropriate for the terminal phase of an illness,
although several alternative methods of administering analgesics may
be required as a result of decreased oral intake and consciousness.
• Alternative methods of providing analgesia include:
Rectally
Sublingual or bucally
Transdermally via pain patches such as fentanyl
Subcutaneously – can be done at home
Via a nasogastric or gastrostomy tube
Intravenously (in hospital).
93
Rectal analgesia
• M orphine suppositories are sometimes available.

• Long-acting morphine such as MST 12-hourly can be used by the
rectal route.
Sublingual or buccal analgesia
• M orphine solution is absorbed from the buccal mucosa – however as

absorption is variable, a larger dose may be needed.
• Such analgesia can therefore be given in moribund patients.
Subcutaneous analgesia
• T he subcutaneous route is useful if the patient is unable to ingest

medication.
• Intermittent dosing via a subcutaneous needle (butterfly) can be given
such as 4-hourly morphine.
• This method of applying analgesia is often as effective as infusions and
more accessible and affordable in a resource-limited setting.
• Syringe drivers (or syringe pumps), when available, can be used
to administer analgesics and other symptom-control drugs
subcutaneously in a safe and relatively painless way. This method is
often used in a hospice or home care setting. A syringe driver is a
small infusion pump used to gradually administer small amounts of
medication to a patient. In palliative care, syringe drivers are used to
continuously administer analgesics, antiemetics and other drugs.
• There are different types of syringe drivers available – the most
frequently used is the Graseby MS26 infusion pump, which delivers a
constant amount of analgesia through a butterfly needle inserted into
the subcutaneous space over a 24-hour period.
• To deliver analgesia via a syringe driver, you need to:
Convert the dose of morphine from the oral dose to a
subcutaneous dose – this is done by adding up the total oral
dose over 24 hours and dividing it by 2. For instance, 10mg
4-hourly = 60mg/24hrs orally = 30mg/24 hours parenterally.
94
Dilute this amount of parenteral morphine in a luer-lok

syringe with normal saline/ sterile water and fill up the
syringe to a fluid length of 48mm (around 8–9mls). (Note:
normal saline should not be used with cyclizine as it causes
crystallisation.)
If a Graseby MS26 syringe driver is used, then set it at a
rate of 2mm/hr in order to provide 24 hours of continuous
morphine.
Insert a butterfly needle under the skin over the abdomen,
upper arm or thigh.
• Other drugs can also be given via the syringe driver, such as anti-
emetics (e.g. cyclizine), metoclopramide, haloperidol, hyoscine or
midazolam.
• Care needs to be taken to ensure that, if more than one drug is
given via the syringe driver, the drugs can be mixed safely. Note, for
example, that dexamethasone should not be mixed with other drugs
as then it will precipitate out.
• Challenges to the subcutaneous route include the following:
In some places especially in sub-Saharan Africa this route is
not a very common practice of delivering pain medicines.You
should involve the patient and their family – there is often
disquiet about using syringe drivers.
Which machine to use is often a challenge, taking into
account possibly conflicting characteristics of simplicity,
convenience, availability and cost. The ‘Springfusor’ may be
used instead of the Grassby pump as it uses a spring so does
not need batteries, and it is simpler and cheaper.
Some drugs are too much of an irritant to be given
subcutaneously – e.g. diazepam, chlorpromazine and
prochlorperazine.
Drugs need to be changed every 24 hours and the needle
site checked so that the patient needs to be seen by a health
professional every 24 hours, which may not be possible in
some settings.
95
E. Be Aware …
• P ain in HIV/AIDS is highly prevalent but unfortunately undertreated;
• Herpes zoster may occur early in HIV disease and may be severe with
persisting post-herpetic neuralgia.
• The biggest challenge in managing pain in HIV and AIDS is access to
appropriate medications such as oral morphine.
• Stigma associated with HIV disease can cause stress and anxiety and
thus impact on pain sensation.
• There is evidence to show that the elderly do not receive adequate
pain relief.
• Pain is often undiagnosed and undertreated in the elderly – always ask
an elderly patient whether they are in pain.
• End-of-life decisions should respect the wishes of patients.
References:
• C
arr DB. ‘Pain in HIV/AIDS: A Major Health Problem’. IASP/EFIC
(press release). Available at http://www.iasp-pain.org/AM/Template.
cfm?Section=Press_Release&Template=/CM/ContentDisplay.
cfm&ContentID=2910. Accessed March 2010.
• W
arden V, Hurley AC and Volice L (2003). ‘Development and
Psychometric Evaluation of the Pain Assessment in Advanced
Dementia (PAINAD) Scale’ in Journal of the American Medical
Directors Association, 4(1): 1–8.
96
REFERENCES
The following books have been used as core texts throughout the pocketguide:
• Amery J (2009). Children’s Palliative Care in Africa. London: Oxford

University Press.
• APCA (2009). Competency framework for palliative care. Kampala:
African Palliative Care Association.
• APCA (2009). Standards for palliative care in Africa. Kampala: African
Palliative Care Association.
• Gwyther L, Merriman A, Mapanga Sebuyria L and Schietinger H
(2006). A Clinical Guide to Supportive and Palliative Care for HIV and AIDS
in Sub-Saharan Africa. Kampala: African Palliative
Care Association.
• Hospice Africa Uganda (2006). Palliative Medicine: pain and symptom
control in the cancer and/or AIDS patient in Uganda and other African
Countries (4th Edition). Uganda: Hospice Africa Uganda.
• INCTR (2008). INCTR Palliative Care Handbook. INCTR Publication No
3.
• Kopf A and Patel NB (eds) (2009). Guide to Pain Management in Low
Resource Settings. United States: IASP Press.
• Lavy V, Bond C and Wooldridge R (2007). Palliative Care Toolkit:
Improving care from the roots up in resource-limited settings. London:
Help the Hospices and WPCA.
• Meiring M (2009). Guidelines for managing pain in children. Adcock
Ingram, South Africa.
• Twycross R (2003). Introducing Palliative Care. Economy reprint for
Indian subcontinent and Africa. University of Witwatersrand.
• Watson, M, Lucas C, Hoy A and Wells J (2009). Oxford Handbook of
Palliative Care. Second Edition. Oxford University Press.
• World Health Organization (1996). Cancer pain relief with a guide to
opioid availability. Geneva, Switzerland: World Health Organization.
• World Health Organization (2004). Palliative Care: Symptom
management and end-of-life care. Integrated management of adolescent
and adult illness. Geneva: World Health Organization.
97
• World Health Organization (2007). WHO Model List of Essential

Medicines – 15th List. Geneva: World Health Organization.
• www.palliativedrugs.com. ‘Palliative drugs: Essential information for
palliative and hospice care’. Accessed March 2010.
• Cousins MJ, Brennan F, Carr DB (2000). ‘Pain Management: A
fundamental human right’ in Medical Journal of Australia 172:3.
• Garcia M, Jemal A, Ward EM, Center MM, Hao Y, Siegel RL, Thun MJ
(2007). Global Cancer: Facts and figures 2007. Atlanta, GA:
American Cancer Society.
• Harding R, Molloy T, Easterbrook P, Frame K, Higginson IJ. Is
antiretroviral therapy associated with symptom prevalence and
burden? International Journal of STD & AIDS Harding R, Higginson IJ.
Palliative care in Sub-Saharan Africa. Lancet 2005 Jun 4;365(9475):
1971-72006 Jun;17(6):400-5.
• Harding R, Powell RA, Kiyange F, Downing J and Mwangi-Powell F
(2007). Pain-relieving drugs in 12 African PEPFAR Countries: Mapping
current providers, identifying current challenges, and enabling expansion of
pain control provision in the management of HIV/AIDS. Kampala, Uganda:
African Palliative Care Association.
• International Narcotics Control Board. Use of essential narcotic
drugs to treat pain is inadequate, especially in developing countries.
Austria: International Narcotics Control Board; 2004 Mar 3. Report
No.: Press Release No. 6.
• Joint United Nations Programme on HIV/AIDS (2008). Report on the
Global AIDS Epidemic. Geneva: UNAIDS.
• Mathews WM, Christopher MD, McCutchan JA, Asch S, Turner BJ,
Giffird AL, et al. National estimates of HIV-related symptom
prevalence from the HIV Cost and Services Utilization Study.
Medical Care 2000;38(7):750-62.
98
• Mwangi-Powell F, Ddungu H, Downing J, Kiyange K, Powell RA and

Baguma A. (2010). ‘Palliative Care in Africa’ in Textbook of Palliative
Nursing, Ferell BC and Coyle N (eds). London: Oxford University
Press.
• Oxford English Dictionary. Oxford, UK: Oxford University Press.
• Solano JP, Gomes B, Higginson IJ. A comparison of symptom
prevalence in far advanced cancer, AIDS, heart disease, chronic
obstructive pulmonary disease (COPD) and renal disease. Journal of
Pain and Symptom Management 2006; 31: 58-69.
• Sternsward J, Foley K, Ferris F (2007). ‘The public health strategy for
palliative care’ in Journal of Pain and Symptom Management 33: 486–93.
• World Health Organization (2002) Palliative care. Available from:
www.who.int/hiv/topics/palliative/PalliativeCare/en /. Accessed 01/10.
• WHO. Palliative care. 2002 [cited 2005 Mar 23];Available from: URL:
http://www.who.int/cancer/palliative/en/
• WHO. Palliative Care. 2005 [cited 5 A.D. Mar 22];Available from:
URL: http://www.who.int/hiv/topics/palliative/PalliativeCare/en/
• UNAIDS. AIDS Epidemic Update 2007: Sub-Saharan Africa. http://
data.unaids.org/pub/EpiReport/2007/04-Sub_Saharan_Africa_2006_
EpiUpdate_eng.pdf 2007
• WHO. Who’s pain ladder. 2007 Available from: URL: http://www.

who.int/cancer/palliative/painladder/en/
99
APPENDICES
Appendix 1: The three pillars of pain treatment: management,
assessment and measurement
Patient: child
Admission to hospital = pain, anxiety or discomfort
Symptoms / diagnosis Pain

measurement,
Pain assessment:
• Approach,
• previous pain
• Frequency
experiences
Definition of pain, • Action
• previous medical
classification of pain, • Repeat
history
types of pain measurement
• treatment
• reaction to
treatment
• current pain
experience
• beliefs about the Drug therapy /
pain non-pharmacological
• pre-morbidity management
personality
• non-verbal
language
• developmental Potential barriers to
levels pain management,
risk factors
Develop individual pain management plan, implement plan and explain to patient
and carers
Reassess efficacy and change where necessary
100
Appendix 2: Possible interactions between ARVs and medicines used

in the management of pain
Time
ART Analgesic Effect Severity Comments
course
May rarely Intermittent use of

Zidovudine result in paracetamol is considered
Paracetamol Delayed Minor
(AZT) granulocytopenia safe. Adverse effects not
and hepatotoxicity consistently reported.
May decrease
Consider alternative
Nevirapine Phenytoin and serum levels
Delayed Moderate anticonvulsant as an
(NVP) carbamazepine of NVP and
adjuvant analgesic.
anticonvulsants
May decrease
Efavirenz Phenytoin and serum levels
(EFV) carbamazepine of EFV and
adjuvant analgesic.
anticonvulsants
May decrease
serum levels
Phenytoin and of IDV; IDV
Indinavir Delayed Moderate anticonvulsant as an
carbamazepine may increase
(IDV) adjuvant analgesic.
serum levels of
anticonvulsants
May decrease
Clinical significance
Dexamethasone serum levels of Delayed Moderate
unknown.
SQV
May decrease Consider alternative

Phenytoin and Moderate
serum levels of Delayed anticonvulsant as an
carbamazepine
SQV adjuvant analgesic.
Saquinavir
(SQV)
May increase
Monitor closely and adjust
Amitriptyline serum levels of Immediate Minor
medication as needed.
tricyclics
101
Time
course
Prolonged
sedation due to Monitor closely and adjust
Benzodiazepines Delayed Major
accumulation of medication as needed.
benzodiazepines
May decrease
Ritonavir serum levels
(RTV) Phenytoin and of RTV. RTV
adjuvant analgesic.
serum levels of
anticonvulsants
Increased Monitor closely and adjust

Antidepressants serum levels of Immediate Major dose or changed medication
antidepressants as needed.
Prolonged
benzodiazepines
Nelfinavir
(NFV) May decrease
serum levels Consider alternative
Phenytoin and of NFV. NFV anticonvulsant as an
Delayed Moderate
carbamazepine may increase adjuvant analgesic.
serum levels of
anticonvulsants

Midazolam Prolonged sedation Immediate Major
Dexamethasone May decrease APV Delayed Moderate Use with caution.
Amprenavir
(APV) May increase
Amitriptyline serum levels of Immediate Moderate
tricyclics
May significantly Consider alternative

Phenytoin and
decrease serum Delayed Moderate anticonvulsant as an
carbamazepine
levels of APV. adjuvant analgesic.
102
Time
course
Prolonged
benzodiazepines
Increased
Lopinavir/r Antidepressants serum levels of Immediate Moderate May increase toxicities.
(LPV/r) antidepressants
Phenytoin May significantly Consider alternative

(also decrease serum Delayed Major anticonvulsant as an
carbamazepine) levels of LPV/r. adjuvant analgesic.
Prolonged
benzodiazepines
Atazanavir
(ATV) May decrease
serum levels
Phenytoin and of ATV. ATV
adjuvant analgesic.
serum levels of
anticonvulsants
Adapted from the Clinical Guide to supportive and palliative care for HIV/AIDS in
sub-Saharan Africa (APCA, 2006)
103
Appendix 3: List of medicines used in the pocketguide

(excluding ARVs)
Medicine
Amitriptyline
Buprenorphine
Carbamazepine
Chlorphenamine (Chlorpheniramine)
Chlorpromazine
Clonazepam
Codeine phosphate
Cyclizine
Dexamethasone
Diazepam
Diclofenac
fentanyl (Durogesic)
Gabapentin
Haloperidol
Hydromorphone
Hyoscine butylbromide
(Buscopan / Scopolamine)
Ibuprofen
Methadone
Metoclopramide
Midazolam
Morphine
Naloxone
Oxycodone
Pamidronate
Paracetamol (Acetaminophen)
Pethidine (Meperidine)
Phenytoin
Prochlorperazine
Ranitidine
Sodium valporate
Tramadol
104
LIST OF ACRONYMS
ABC Abacavir
ACMP Access to Controlled Medications Programme
AIDS Acquired Immune Deficiency Syndrome
AIDSTAR AIDS Support and Technical Resources
APCA African Palliative Care Association
APV Amprenavir
ART antiretroviral therapy
ATV Atazanavir
AZT Zidovudine
CD4 Cluster of Differentiation 4
COPD chronic obstructive pulmonary disease
CPCNO clinical palliative care nursing officer
D4T tavudine
DDI Didanosine
EFV Efavirenz
FLACC Faces, Legs, Activity, Cry, Consolability [Scale]
GI gastro-Intestinal
GORD gastro-oesophageal reflux disease
HAU Hospice Africa Uganda
HIV human immunodeficiency virus
hrs hours
hrly hourly
IAHPC International Association of Hospice and Palliative Care
IASP International Association for the Study of Pain
ICPCN International Children’s Palliative Care Network
IDV Indinavir
IM intramuscular
INCB International Narcotics Control Board
INCTR International Network for Cancer Treatment
and Research
INH Isoniazid
IPPF International Pain Policy Fellowship
IRIS Immune Reconstitution Inflammatory Syndrome
IQC Indefinite quantity contract
IV (or iv) intravenously
kg kilogram
LP lumbar puncture
LPV/r Lopinavir/r
105
MAC Mycobacterium Avium Complex

max maximum
mcg microgram
mg milligram
MoH Ministry of Health
MST morphine sulphate tablets
NFV Nelfinavir
NIPS Neonatal Infant Pain Scale
NSAID non-steroidal anti-inflammatory drug
NVP Nevirapine
OI opportunistic infection
PAINAD Pain Assessment in Advanced Dementia
PCCO Palliative Care Clinical Officer
po by mouth, orally
pr rectally
POS Palliative Outcome Scale
PUD peptic ulcer disease
RTV Ritonavir
SC (or sc) subcutaneous
SQV Saquinavir
TVP Touch Visual Pain [Scale]
UN United Nations
UNAIDS Joint UN Programme for HIV/AIDS
USAID United States Agency for International Development
USG United States Government
VAS Visual Analogue Scale
WPCA Worldwide Palliative Care Alliance
WHO World Health Organization
106
The African Palliative Care Association (APCA)

Acknowledging the genesis of modern palliative care within the United
Kingdom, APCA strives to adapt it to African traditions, beliefs, cultures and
settings, all of which vary between and within communities and countries on
the continent. As such, in collaboration with its members and partners, APCA
provides African solutions to African problems, articulating them with what is
the recognized regional voice for palliative care.
APCA’s vision is to ensure access to palliative care for all in need across Africa,
whilst its mission is to ensure palliative care is widely understood, underpinned
by evidence, and integrated into all health systems to reduce pain and suffering
across Africa. APCA’s broad objectives are to:
• S trengthen health systems through the development and

implementation of an information strategy to enhance the
understanding of palliative care among all stakeholders;
• Provide leadership and coordination of palliative care integration into
health policies, education programmes and health services in Africa;
• Develop an evidence base for palliative care in Africa;
• Ensure good governance, efficient management practices and
competent human resources to provide institutional sustainability;
• Position palliative care in the wider global health debate in order
to access a wider array of stakeholders and to develop strategic
collaborative partnerships, and;
• Diversify the financial resources base to meet APCA’s current funding
requirements and to ensure the organisation’s future sustainability.
www.africanpalliativecare.org
107
AIDSTAR-One
The AIDS Support and Technical Resources (AIDSTAR) mechanism is an
indefinite quantity contract (IQC) managed out of the Office of HIV and AIDS
in USAID’s Bureau for Global Health. AIDSTAR-One is a flexible mechanism
available to US Government (USG) country teams, USAID/Washington
operating units, missions and other USG agencies to access technical expertise
and implementation support across a broad range of HIV- and AIDS-related
technical areas. AIDSTAR-One may be used for:
• Long- or short-term technical assistance and programme

implementation support in specialised HIV/AIDS technical areas,
including behaviour change; clinical and community-based HIV/AIDS
services; care for orphans and vulnerable children; monitoring and
evaluation; and health systems strengthening specific to HIV/AIDS
services
• Long- or short-term in-country support for coordination and scale-
up for HIV/AIDS activities in support of US Government country
strategies
• Documenting and disseminating successful innovative approaches
and sustainable models; evidence-based best practices and lessons
learned; and new approaches, tools and methodologies in HIV/AIDS
programming.
www.aidstar-one.com
108
PERSONAL NOTES
Further information about the pocketguide and the African Palliative Care Association can
be found at www.africanpalliativecare.org or by emailing [email protected].
Further Information about medicines used in pain management for palliative care can be
found at www.palliativedrugs.com.
109
PO Box 72518
Plot 850 Dr Gibbons Road
Kampala, Uganda
T. +256 414 266251

F. +256 414 266217
Email: [email protected]
Website: www.africanpalliativecare.org
NGO Registration Number 4231
© African Palliative Care Association (APCA) 2012

All rights are reserved, whether the whole or a part of the material is concerned, particularly the
rights to reproduce images or text, or to translate or reprint. Requests for permission to reproduce
text or images, or to translate APCA publications, or any other enquiries, should be directed to
APCA, PO Box 72518, Kampala, Uganda, Tel: +256 414 266251, fax: +256 414 266217,
email: Email: info@ africanpalliativecare.org.

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African Palliative Care Association

Beating Pain 2nd Edition

EDITORS AND LIST OF CONTRIBUTORS

• Dr Renee Albertyn, Red Cross Children’s Hospital, Cape Town,

ISBN 978 9970 204 01 4

It is worth mentioning that this pocket guide is not intended to cover

Dr. Faith Mwangi-Powell

Dr. Jon Kaplan – CDC, Atlanta

Dr. John Palen – USAID, Washington, D.C.

1. Classification of pain Page 7

Pain is an unpleasant sensory and emotional

• Children (including newborns) suffer pain as much as adults.

Table 1: Definition of pain terms

Absence of pain in response to stimulation which would normally be

A transitory exacerbation of pain that occurs on a background of

An unpleasant abnormal sensation which can be either spontaneous or

Hyperaesthesia An increased sensitivity to stimulation

Hyperalgesia An increased response to a stimulus that is normally painful

A painful syndrome characterized by an increased reaction to a

Occurs only in certain circumstances, such as after a particular

Neuralgia Pain in the distribution of a nerve

Neuropathy A disturbance of function or pathological change in a nerve

Pain which is transmitted by a damaged nervous system, and which is

A receptor preferentially sensitive to a noxious stimulus or to a

Pain which is transmitted by an undamaged nervous system and is

An unpleasant sensory and emotional experience associated with

Pain related to procedures /interventions: this is especially important in

Sympathetically Caused by damage to sympathetic nerves – a part of the autonomic

1.Classification according to Duration

• Is usually due to a definable acute injury or illness

• R esults from a chronic pathological process;

Treatment is directed at the underlying disease where possible, along with

2.According to underlying mechanism

Nociceptive pain is produced by stimulation of specific sensory receptors

Capsular Bowel Cardiac Bone Soft tissue

Source: Watson et al, 2009, p226.

• Somatic pain: superficial (cutaneous) in skin, subcutaneous tissue or

Produced by damage to the central or peripheral nervous system. (the nerves

Nerve Nerve injury

Source: Watson et al, 2009, p227.

• Burning pain (dysaesthesia)

• Pain is influenced by psychological factors as it affects the human

• S piritual and existential distress may manifest themselves in physical

• U nresolved social factors can aggravate pain, and management of such

I think that the simplest and probably the

(Dame Cicely Saunders)

• P ain can be both a disease and a symptom, and should be carefully

• P ain intensity should be carefully measured based on a thorough

• P ain should be carefully managed based on thorough assessment and

B. Goals of assessing and measuring pain

Right Left Right

• A ssessment should not be confused with measurement, where a

C. Barriers to pain assessment and measurement

• P ain is subjective; therefore encourage the patient to report about

Standard assessment guideline:

Pain assessment through:

• D ata collection and interviews should be conducted in a relaxed,

• T he PQRST pneumonic offers valuable guidelines for questions to

Pain assessment in children

Never use slow-release opioids as rescue medication.