Local anesthetic techniques can provide excellent postoperative pain relief and their use should be encouraged whenever possible, by whichever route possible, even if only by local infiltration. Limited postoperative facilities and equipment shortages limit some of the more advanced options (epidurals and continuous plexus blockade), but simple techniques remain underutilized and have a low incidence of adverse effects.

Single shot techniques including spinal anesthesia, plexus blockade, caudal anesthesia in children, and infiltration of local anesthetic into wounds can be accomplished with minimal resources but great effectiveness. These techniques work most effectively using bupivacaine if it is available, but the use of shorter acting drugs such as lidocaine with epinephrine is also effective. The use of additives such as ketamine and clonidine should be encouraged, if available, but it is important to avoid additives with preservatives. Both surgeons and anesthesiologists need training to develop the use of these straightforward techniques. Liposomal bupivacaine offers the opportunity to provide more than 24 h of analgesia.

Many anesthesiologists in LDCs do not own an anesthesia textbook. Publications such as Update in Anaesthesia and the Tutorial of the Week published by the World Anaesthesia Society show how simple, cost-effective, practical information can be made available to isolated anesthesiologists in LDCs, both in hard copy and via the Internet. Open access journals are a newer approach to presenting information in the LDCs. Encouraging links between developed and developing countries (e.g., by linking academic anesthetic departments) can lead to the sharing of ideas and problems, and exchange visits of personnel, and may even help with the supply of essential equipment and drugs.

Refresher courses provide invaluable opportunities to share ideas about analgesia (Please also see details of the NYSSA Visiting Scholar program in the vignettes section) and can reach a large number of staff. Materials can be modified for the level of resources found in the country, local protocols developed, and expertise can be brought to bear on particular local problems.

On a cautionary note, care should be taken to ensure that training programs are relevant to the problems that are encountered in everyday practice. For instance, it is important to include consideration of the side-effects of different drugs, especially in hypotensive patients. Intramuscular opioids should be used carefully in such patients (i.e., it is preferable to titrate intravenous opioids) and trainers should be aware of the limitations or lack of monitoring in ward areas.

Although classroom teaching can improve knowledge, the best way of improving practice is to be taught in the operating room or recovery area by an anesthesiologist. As well as providing personal attention and mentorship, it allows anesthesiologists to act as role models and to stress the effectiveness of basic techniques and the importance of patient safety. In addition, it may help to recruit young doctors in training into a career in anesthesia. Training the local trainers and adding to the anesthesia workforce are important steps on the route to sustainability in developing countries.

Chronic pain management requires pharmacological and non-pharmacological therapies with attention to other needs of the patient (psychosocial and spiritual). In Nigeria, a pain clinic [11] was first established at the University College hospital, Ibadan, by the Department of Anesthesia in 1979 but the clinic failed to survive the period of specialist medical manpower exodus from the country in the late 1980s. The clinic was reestablished by a multidisciplinary group as a Pain and Palliative Care Clinic in 2005 to treat cancer and non-cancer pain. The analgesics available were mainly non-opioids until recently, when opioids including oral morphine solution have become available and used for cancer patients. Both physical and psychological therapies are offered by the multidisciplinary team.