Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches

About 1/3 of Americans or 100 million people suffer from chronic pain, a number that is more than the total affected by heart disease, diabetes, and cancer combined. Moreover, the cost of chronic pain to the nation is $635 billion annually in care and lost productivity. Confronted with these figures and following the 2010 Patient Protection and Affordable Care Act, the Institute of Medicine (IOM) of the National Academies commenced a comprehensive evaluation of the state of pain care in the United States. The end result of this committee’s work was a consensus report, released on June 29, 2011 and was titled: Relieving Pain in America: a Blueprint for Transforming Prevention, Care, Education and Research. Given the enormity of the problem, IOM concluded that relieving pain should be a national priority. A major part of the report deals with the need to identify and fill the huge gaps in knowledge about pain: gaps that could be filled by educating health care professionals on how to better understand pain in its many forms and intricacies. One of the results was the writing of this text, directed by the American Academy of Pain as a means to lay down a template for those who care for patients with chronic pain, using evidencebased medicine and relying on the latest research. Comprehensive Treatment of Chronic Pain is a major textbook (it weighs over 7 lb). The chief editor, Dr. Deer, notes in the Preface that he has tried to overcome divisions such as “interventionalist” and “non-interventionalist,” rather emphasizing the diverse overview of the specialty of pain management. The contributors come from all over the United States, with even some input from Canada, and from a wide variety of specialties. The text is separated into 5 sections: (1) medical approaches, which encompasses mainly pharmacologic management, (2) the anatomy and physiology of pain, including neuroanatomy, spinal targets for interventional pain management, and imaging of the spine, (3) neural blockade and neurolytic blocks, (4) neuromodulation, and (5) integrative approaches. The last section covers a wide range of topics including psychological assessments, hypnosis, manual therapies, spirituality, sleep, empowerment, pain at the extremes of age, failures and acupuncture, and billing practices among other topics. Each chapter has a list of key points at the beginning. Sadly, some authors still cling to presenting very long, often outdated lists of references. A box with the abbreviations spelt out is a most useful addition used by all but few writers. The tone of the book is set in the first, excellent chapter by Yaksh and colleagues, surveying systems involved in nociceptive processing. It seems that we are only just beginning to acknowledge something that has been known for centuries but not explained; all patients do not respond in the same manner to medications. Pharmacogenomics uses information provided by genetic studies to identify patients at risk for altered drug responses. The topic is ably addressed by Janicki and no doubt, will receive even more coverage in the near future as advances in human genetics are realized at an ever increasing rate. Not surprisingly, opiate usage is afforded extensive coverage. Neuraxial and patient-controlled analgesia for postoperative pain relief in the opiate-dependent patient are discussed. Increased concern recently over the development of opiate induced respiratory depression, especially in obese individuals and those with obstructive sleep apnea has prompted departments and hospitals to include policies that require more intense postoperative monitoring. Pain doctors are being summoned to step-down units to remove catheters and revise pain medication orders as the monitored beds are required for sicker patients. One wonders how these practices will impact care. Controversy continues over the efficacy of vertebroplasty and kyphoplasty. Dr. Kim does an excellent job in reviewing the negative studies of Kallmes and Buchbinder in the face of 100s of positive results and concludes that it is, nevertheless, a viable technique. However, I am not so sure that the procedure is pain freeyI have found that these elderly, often very sick, patients require constant attention with multiple small doses of analgesics that allow them to tolerate the cement placement and still respond to the instructions of the interventionalist. The section on integrative approaches is certainly a fascinating potpourri of different facets of pain management as noted above. Several phrases in the chapter on acupuncture could have been better edited for clarity. Moreover, D.R. Han indicates that electroacupuncture was introduced in the 1950s and the resurgence in the 1970s. However, Osler advocated acupuncture in his classic textbook in 1892 and noted that “a constant current is sometimes very beneficial. ” This therapy was recommended for the treatment of lumbago, myalgias, and other chronic pain conditions.1 The double effect allows serious harm to a patient as a secondary effect resulting from a primary action that is good. This principle may be applied to medicating a terminal patient with ever increasing amounts of narcotics. As respiratory depression increases, is this death with dignity or physician-assisted suicide? Dr. Webster presents a thought-provoking essay on the specifics, new thinking, and the revised criteria for double effect. The authors has no funding or conflict of interest to disclose. BOOK REVIEW