Pain Education Curricula for Low- and Middle-Income Settings: Two models for Further Capacity Building

Pain Education Curricula for Low- and Middle-Income Settings: Two Models for Further Capacity Building

Authors:

• Nantthasorn Zinboonyahgoon, MD, Mahidol University, Thailand¹ 
• Pramote Euasobhon, MD, MMed, Mahidol University, Thailand¹
• Jocelyn Que, MD, MMed, University of Santo Tomas, Philippines²

Pain is a hidden, but significant global health problem. Although it affects all populations, regardless of age, sex, income, race, ethnicity, or geography; its impact is not distributed equally across the globe². In low- and middle-income countries (LMICs) or settings, where the burden of acute and chronic pain is greater, treatment is even more challenging. This challenge arises not only due to limited access to specialized care and resources, but also from poor knowledge and attitudes among healthcare professionals (HCP) regarding pain management ^4,5.

Cognizant of the need for comprehensive pain education for all HCP, the IASP has developed pain curriculum outlines for each health-related discipline based on the four domains of the IASP Core Curriculum.^1,3 There are small differences among the curricula since not all disciplines require the same type and scope of pain-related knowledge and skills, such as physical therapists not requiring in-depth knowledge of pharmacology.  An objective of these curricula is to instill the knowledge and skills necessary to advance the science and management of pain as members of an interprofessional team³.  However, there is considerable variation in the academic structure, health care systems, and sociocultural settings among countries.  For LMIC, constraints in staffing, equipment and finances significantly limit pain services, education and training.

To help address these disparities and challenges, the IASP curriculum is oriented towards competency based education to be relevant and applicable across all settings. It can be integrated within programs using whatever educational models and strategies appropriate to the local professional and program needs and the health priorities of that setting. We describe two pioneering pain education and training programs in LMICs as examples of educational models where IASP curriculum have been fully integrated. The early models for pain education in LMICs in South East Asia include the Siriraj Clinical Pain Management Training Center, Bangkok, Thailand, and the Master in Pain Management program, Center for Pain Medicine, Faculty of Medicine and Surgery, University of Santo Tomas (UST), Manila, Philippines established in 1989 and 2008, respectively.

The Siriraj Clinical Pain Management Training Program

The Siriraj Clinical Pain Management Training Center offers multidisciplinary pain management services for both inpatients and outpatients in a tertiary care teaching hospital. The center addresses various pain conditions, including complex acute pain, cancer pain, chronic musculoskeletal pain, and neuropathic pain. It also serves as an academic center, providing one-year clinical pain management program for physicians from LMICs in the Asia-Pacific region. Supported by the International Association for the Study of Pain (IASP) and the World Federation of Societies of Anaesthesiologists (WFSA) since 2008, the program has trained 35 pain physicians serving LMICs such as Myanmar, Vietnam, Laos, Cambodia, Indonesia, Nepal, and others ⁸.

Compared to high-income countries, pain education programs in LMICs focus on simple, low-cost treatments that maximize existing resources rather than emphasizing high-cost technologies or advanced interventions. This curriculum aligns with the IASP curriculum by providing multidisciplinary foundation of standard knowledge and integrative local traditional medicine with the core elements of the training program as follows;

1. Comprehensive Clinical Training and interdisciplinary focus: Trainees undergo extensive rotations in chronic pain, palliative care, acute pain services, psychiatry, rehabilitation and Thai traditional medicine. Training includes pain assessment, pharmacological treatment, and hands-on experience with basic pain interventions. The program collaborates with mentioned multidisciplinary teams to deliver holistic care.
2. Research and Academic Writing: Trainees are encouraged to conduct research and publish academically ^6,7.
3. Evaluation and examination: The program evaluates trainees’ competencies using multiple modalities such as written and oral examinations, case presentations, and checklists during clinical work such as Entrustable Professional Activity (EPA) and Direct Observation Procedure (DOP) evaluation checklist.

The UST Faculty of Medicine and Surgery – Master in Pain Management Program

The Master of Medicine/Master of Science in Pain Management Program offered by the Center for Pain Medicine, UST Faculty of Medicine and Surgery in Manila, Philippines is a two-year multidisciplinary distance learning postgraduate degree course. It is offered to physicians (Master of Medicine) and allied health professionals (Master of Science) respectively, who are citizens and residents of Southeast Asia, India and Pakistan and who want to enhance their knowledge in the field of Pain Management as clinicians, educators and researchers.

With the 2006 IASP Initiative for Improving Pain Education in Developing Countries grant and a license agreement with the University of Sydney, this innovative program was launched in 2008.  The core elements of this purely online educational program include:

1. Comprehensive advanced, evidence-based and clinically relevant curriculum that adheres to the IASP Curriculum Outline on Pain for Medicine ³.
2. Interdisciplinary Focus: where faculty and students come from varied disciplines and specialties to study the biopsychosocial dimensions of pain and the interdisciplinary approach to pain management
3. Research: where students are required to submit a completion project at the end of the 2-year program
4. Evaluation and examination: where students participate in online discussions, interactive self-assessment quizzes, oral presentations, and assignments applied to clinical scenarios.
5. Basic Computer Literacy skills are developed and enhanced to optimize online learning.

To date, the program has graduated 29 Masters of Medicine (physicians)) and 6 Masters of Science (2 nurses, 3 dentists, and 1 chiropractor), 6 Graduate Diplomas and 7 Graduate Certificate holders serving LMICs such as Malaysia, Thailand, Indonesia, India and the Philippines. 

Key Outcomes and Alumni Achievements

Both institutions are committed to advancing pain management through education, training and research, aiming to improve patient outcomes and quality of life for pain patients in LMICs. The ultimate goal of education and training is not just to train individual physicians, but to develop leaders or champions to share their knowledge and create a chain reaction in their homeland and even further.

Alumni have demonstrated transformative potential and have pioneered efforts to improve pain management in their institutions and communities. Examples include implementing multidisciplinary approaches, establishing protocols for pain management, and developing community outreach programs to enhance medical personnel education in rural regions. Additionally, many alumni have engaged in national and international pain advocacy by initiating essential pain management programs, raising pain awareness, improving patient education through national broadcasts, or being appointed as leaders in pain management in their respective countries ⁸.

Conclusion

The curriculum is a vital step toward addressing disparities in global pain management. The IASP Curriculum is relevant and applicable in LMIC. By combining updated clinical knowledge, multidisciplinary approaches with cultural and resources adaptability, these curricula may serve as models for enhancing global pain management.

References

1. Fishman et al. Core competencies for pain management: Results of an interprofessional consensus summit. Pain Medicine 2013; 14:971-981.
2. Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health. 2011; 11:770.
3. International Association for the Study of Pain. IASP Curriculum Outline on Pain for Physical Therapy. Available at: https://www.iasp-pain.org/education/curricula/iasp-curriculum-outline-on-pain-for-physical-therapy, retrieved 01/03/2025
4. Kopf A, Patel N, editors. Obstacles to pain management in low-resource settings. In: Guide to Pain Management in Low-Resource Settings. International Association for the Study of Pain; 2010. p. 9-12.
5. Morriss WW, Roques CJ. Pain management in low- and middle-income countries. BJA Educ. 2018;18(9):265-270.
6. Sanansilp V, Euasobhon P, Than QV, Rushatamukayanunt P, Jirachaipitak S, Eiamtanasate S. Effectiveness of the Four-Frequency Protocol of Repetitive Peripheral Magnetic Stimulation (rPMS) for Chronic Pain. Siriraj Med J 2022;74(8):518-529.
7. Thapa P, Euasobhon P. Chronic postsurgical pain: current evidence for prevention and management. Korean J Pain. 2018;31(3):155-173.
8. Zinboonyahgoon N. Siriraj Clinical Pain Management Center’s report to IASP 2012-2024. (unpublished report)

Author Affiliations:

1. Siriraj Clinical Pain Management Training Center, Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
2. Center for Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine and Surgery, University of Santo Tomas, Philippines

Fact Sheet Reviewed By:

• Roger Goucke FFPMANZCA, MBChB, University of Western Australia, Perth, Australia
• Quyen Van Than, MD, Pain Clinic, Hospital 199, Department of Anesthesiology, Vietnam