Describe the key pain management barriers in low-and middle-income countries. Discuss the need for adequate availability and appropriate prescribing of opioid analgesics. Explain the central role of education in improving pain management. Globally, pain is an underdiagnosed and undertreated healthcare problem. Patients the world over are suffering from pain of all typesdcancer and end-of-life pain, acute pain (including pain caused by surgery and injury), and chronic non-cancer pain (CNCP). There is increasing recognition of the contribution of noncommunicable diseases (NCDs) to the global burden of disease. Alongside this, there is a need to recognise the impact of inadequately managed pain. In many resource-poor environments, little or no treatment is provideddthere is a 'treatment gap' between what could be done and what is actually being done. 1 Because of this gap, there are many opportunities to dramatically improve pain management by using simple, cost-effective strategies. These strategies include education and improved availability of low-cost and effective treatments. The scale of the problem The WHO estimates that 5.5 billion people (more than 80% of the global population) do not have access to treatments for moderate to severe pain. 2 Most of these people live in low-and middle-income countries (LMICs). The global burden of pain has numerous aetiologies including surgery, trauma, childbirth, chronic inflammatory conditions (e.g. arthritis), non-specific low back pain, chronic

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The chapter covers pre-op assessment in the context of limited availability to tests and investigations outlining the key considerations that should be made in assessing fitness for and appropriateness of surgery. Key aspects of consent within different cultural contexts are explored as well as important consent considerations for quality improvement and research projects. A practical approach to the assessment and management of pain in the context of limited availability of medications and trained staff is taken including the management of acute pain, non-surgical pain, pain related to cancer, chronic pain, and neuropathic pain. In the last section, key aspects of anaesthesia and resuscitation at high altitude are covered.