Pain Management—A Practical Guide for Clinicians

Recently I was asked to see a patient with a very difficult pain problem related to reflex sympathetic dystrophy (now known as complex regional pain syndrome). I reached for Pain Management: A Practical Guide for Physicians to find out what to do. The relevant chapter is detailed, evidence-based and well referenced. Although I cannot claim to have cured the patient of her pain as a consequence, the text (which is written by members of the American Academy of Pain Management) gave me all the up-to-date information that I needed. I have since delved into other sections of the book that are of particular interest to me. Our unit is one of several involved in a clinical trial of the use of cannabis for the control of cancer-related pain. I was therefore keen to read the chapter on the role of cannabis and cannabinoids in pain management. In his introduction, the author proposes to examine the use of cannabinoids ‘historically, scientifically and anecdotally in relation to a variety of pain syndromes’. He obviously believes strongly in the benefits of these compounds, but as yet there are few hard clinical data to support their use as analgesics. Most of the evidence is in the form of case studies or anecdotal reports—hence the strong emphasis on history and anecdote. The management of neuropathic pain is complex and is often frustrating to patient and physician alike. The chapter on neuropathic pain and its management is excellent. It gives an unbiased, evidence-based, well-referenced over-view of the current situation. It is obviously written by someone who has much clinical experience in the area and not by a laboratory-based academic reporting on what should happen on the basis of rat-tail flicks. The author stresses that it is important to have realistic expectations when treating patients with chronic nerve damage. Complete pain relief is unlikely. Improving function, providing a degree of comfort and treating associated problems are more appropriate goals. ‘The difficulty in treating this pain probably stems from our relatively poor understanding of the mechanisms and the limited efficacy of currently available analgesics’. Non-pharmacological methods may be as effective as pharmacological approaches. Patient support is paramount. There is relatively little on the use of NMDA antagonists in this chapter. This is appropriate. Despite animal studies suggesting similarities between opioid intolerance and neuropathic pain, there is little to support their use clinically and considerable concern about side-effects. Within the chapter on drug misuse and detoxification there is an interesting section on iatrogenic dependence. As more and more opioids are becoming licensed for use in benign pain, the author points to an unfortunate paradox. Whereas patients with chronic non-malignant pain are increasingly being prescribed opioids and other dependence-producing medications, pain in the terminally ill is still commonly under-treated. A frequent cry by authors in this book is for more emphasis and teaching on proper pain management techniques as opposed to treatment of all pain as acute pain. This chapter lacks a section on how to treat pain in drug abusers, a difficult and not uncommon dilemma, especially in oncology. The multitude of nerve blocks that have been used in the management of common pain syndromes are all very well described. I would have welcomed more diagrams to support the text; also, there is no discussion as to the efficacy of each technique in relation to standard analgesia. This book has a very wide scope, embracing such techniques as Koryo hand therapy, Tai Chi Chuan, magnetic stimulation and Qigong. The emphasis throughout is on pain management rather than drug treatment, which is laudable. There are lengthy discussions on how to set up and support a pain clinic and the necessity for multiprofessional input. As one of the authors points out, ‘the best pharmacotherapeutic approach to pain management is no drug therapy at all’. This might explain why the section on drug management is so short. With the recent explosion of new and alternative opioids onto the market, a somewhat deeper discussion of opioid pharmacology might have been warranted. In summary, Weiner's text is state-of-the-art on all aspects of pain and its multidisciplinary management. It rises to the fact that pain (especially chronic benign pain) is ‘the most common medical complaint of civilised man’. Unusually for a tome this large, it makes for quite a good read. It even tells you how to fix a headache.