Book Review

Pain Management: Theory and practice

N Engl J Med 1996; 335:904-905September 19, 1996

Article

Pain Management: Theory and practice
(Contemporary Neurology Series.) Edited by Russell K. Portenoy and Ronald M. Kanner. 357 pp. Philadelphia, F.A. Davis, 1996. $99. ISBN: 0-8036-0171-9

Pain Management: Theory and Practice is an ambitious attempt to integrate recent advances in pain research and therapy within and across disciplines, with particular emphasis on clinical management. The editors are aware of their daunting task and have invited clinicians with impressive academic credentials to contribute to the book. The aim of the book is to “[empower] clinicians to take a more active role in treating painful disorders and obtaining expert care for patients when this is needed.” The emphasis is on treatment. The book has three parts: an introduction, a section on specific pain syndromes, and a review of therapy. The majority of the authors are neurologists, but anesthesiologists, neurosurgeons, rheumatologists, physiatrists, and psychologists also contributed.

The introductory chapter defines pain, suffering, and related sensations and discusses the differences between acute and chronic pain. The authors illustrate the principles of pain assessment and therapeutic strategies by means of a complex case of “reflex sympathetic dystrophy” after the excision of a Morton's neuroma of the foot. This example directs the reader to other chapters for additional information and emphasizes the benefits of a multidisciplinary, multimodal approach.

An elegant chapter on basic mechanisms summarizes current opinions and knowledge of the neuroanatomy and neurochemistry of nociception and neuropathic pain, indicating both what is known and what is uncertain. The third chapter reviews the interpretation of data, including epidemiology and survey data.

The section on pain syndromes contains six chapters on headache and facial pain, neuropathic pain, low back pain, fibromyalgia and myofascial pain syndrome, chronic arthritis and painful diseases of bone, and pain syndromes in patients with cancer. For each of these topics there is already a monograph in the literature, and the editors realize the difficulty of distilling the clinically relevant knowledge into a brief chapter. It is not obvious that they have achieved this goal. I expected the authors to identify the relevant papers that support their views or that form the basis of an evidence-based model. But most authors do not indicate the relative strength of the evidence, which ranges from anecdotal to statistically significant. The chapter on headache, for example, contains 21 pages of text, 4 pages of the International Headache Society classification of headache syndromes, and 276 references, ranging from opinions in a 1938 textbook to a 1995 pharmacologic study. This approach may be valuable to the researcher or trainee, but not to clinicians, who may not have the time or resources to check each reference. This problem also appears in the chapter on low back pain. In one paragraph it attributes “locked back syndrome” to slippage of an articular facet (with a single textbook reference), but a later paragraph — unreferenced — questions the very existence of a facet syndrome. No mention is made of the controversy surrounding the widespread use of epidural corticosteroids. By contrast, the chapter on pain syndromes in patients with cancer is a distillation of Dr. Kathleen Foley's years of research and clinical experience. Her chapter is valuable for physicians experienced in the treatment of pain and physicians who see only the occasional patient with cancer. It serves to remind both types of practitioner of the complexity of this problem.

The final section, on therapeutic interventions, contains six chapters on nonopioid and adjuvant analgesics, opioid analgesics, anesthetic techniques for pain control, surgical approaches to chronic pain, physiatric approaches to pain management, and psychological issues in chronic pain. The first of these contains a very useful and clinically relevant summary of medications, including information on doses, dosing intervals, half-lives, and cost. It lists categories of medications that have been used in the management of chronic pain, including antidepressants, neuroleptics, anticonvulsants, GABA agonists, sympatholytics, α-agonists, benzodiazepines, muscle relaxants, and corticosteroids. The chapter covers much territory (201 references in 23 pages), but relative strengths of recommendations are not given.

The chapter on opioid analgesics distills decades of basic and clinical research and experience by the senior editor. It is succinct and user-friendly, with useful tables of opioids, doses, side effects, types of aberrant behavior, and a proposed guideline for the use of opioids for chronic nonmalignant pain. It is generously referenced (176 references). The remaining chapters (on anesthetic techniques, surgical approaches, physiatric approaches, and psychological issues) are relatively brief and uncritical overviews of ancillary techniques.

This volume should be in the libraries of pain clinics, but its value to the practicing pain clinician may be limited. It is not a cookbook of treatment, but it could be very useful, as the editors intended, to physicians who treat the occasional patient and who need a multidisciplinary perspective. Its strength lies in the expertise of the contributors, and it appears to have achieved its goals.

Peter R. Wilson, M.B., B.S., Ph.D.
Mayo Clinic, Rochester, MN 55905