Book Review

The Management of Pain

N Engl J Med 1998; 339:275-276July 23, 1998

Article

The Management of Pain
Edited by Michael A. Ashburn and Linda J. Rice. 714 pp., illustrated. New York, Churchill Livingstone, 1998. $95. ISBN: 0-443-07679-0

My favorite medical textbook is Where There Is No Doctor (edited by D. Werner et al. Berkeley, Calif.: Hesperion Foundation, 1992), written originally as a medical bible for paramedics in South American villages. It is short and cheap, but above all, it is clear. The page with drawings of spots is terrific, even though the drawings are in black and white. The index, however, does not include the word “pain” — different cultures, different priorities. The Management of Pain is a big book about acute and chronic pain in developed countries. The 40 chapters cover fundamentals, chronic pain, terminal disease, acute pain, and pain in children. The chapters are heavily referenced, but have many copy-editing errors. I suspect (from the dates of the references) that there was a long gestation period for this book. For instance, I found no mention of nonsteroidal antiinflammatory drugs that inhibit the cyclooxygenase-2 pathway. These agents will be an important advance in pain management.

The bias of the book is perhaps toward invasive techniques rather than pills and chat — what doves might call “psychiatry with needles.” This raises the specter of a double standard, because whereas the evidence of the efficacy of drugs (e.g., tricyclic antidepressants for neuropathic pain) is reasonable, we do not have equivalent evidence of the efficacy of many of the nerve-block techniques. I found the book reasonably comprehensive but uncritical. The clinical question is often, “Are pills or needles better in this condition?” But when pills and needles are discussed in separate chapters, the book ducks the important compare-and-contrast question.

Good discussions of chronic pain are presented in the chapters on myofascial pain and “sympathetically maintained pain.” Both syndromes involve problems of definition, but both present real clinical challenges. No one who treats patients with these syndromes would say that life is simple for them, and the relevant chapters in this book reflect the reality.

We use textbooks differently at different stages of our careers. Those starting out in pain management and looking for a one-stop textbook on pain should check this one out. Seasoned campaigners who need to look up rare problems and rare solutions, which they perhaps knew about once but have now forgotten, should keep looking.

Henry McQuay, D.M.
University of Oxford, Oxford OX3 7LJ, United Kingdom