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Chronic Pain.

Section Editor(s): Ellison, NorigBallantyne, Jane C. MD, FRCA

Book and Multimedia Reviews: Media Review

Chief, Division of Pain Medicine Department of Anesthesia and Critical Care Wang Ambulatory Care Center Boston, MA jballantyne@partners.org

Chronic Pain. Marcus DA. Totowa, NJ: Humana Press, 2005. ISBN 1-58829-501-X. 333 pages, $89.95.

For anesthesia pain specialists, the principles of pain management described in this book may seem far removed from those of their own practice. Interventional pain management is mentioned only in passing: “Nerve blocks are reserved for adjunctive therapy in patients with clearly identified nerve root irritation”; likewise, drug therapies are described in the briefest terms. Yet this book is not written for anesthesia specialists, but instead written as a guide for primary care physicians (PCPs). The author expounds a sensible approach to the primary care management of common chronic pain conditions, emphasizing that most of these conditions can be controlled without resort to high-tech interventions or even, in many cases, to drugs. From the perspective of a society that demands quick fixes, this book reminds us that realistic expectations and simple interventions often work best.

The author has selected those pain conditions that dominate in primary care practice: headache, cervical and lumbar pain, abdominal pain, arthritis, neuropathic pain, myofascial pain, and fibromyalgia. After two introductory sections (introduction and pathogenesis), each of these selected conditions is described in its own chapter. A fourth section is dedicated to special patient populations—children, pregnant women, the elderly, and different gender and ethnic groups. A fifth section describes the influence of comorbidities; a chapter is included here on the growing problem of obesity and chronic pain. Finally, the troubling issue of opioid use for chronic pain is afforded its own section. Educational materials for patient use are provided as appendices. Each chapter engages the reader by starting with a case history that describes a common clinical scenario. The author then interprets the scenario. Next, key points to be covered in the chapter are listed. The layout of each chapter is logical and easy to follow. The text is supplemented by algorithms, simple drawings, figures, Web site listings, and “boxes” in which summary information is listed. This makes it easy to maneuver through the book and to use it as a source of reference. Many of the author’s recommendations are evidence based and accurately supported by references. An electronic version of the book is included with the purchase of the printed version, and CME credits can be claimed by completing and submitting CME questions at the end of each chapter. The book becomes, then, an excellent tutor for those interested in learning the fundamentals of primary care pain practice.

The headache chapter (chapter 4) is an excellent example of the author’s ability to focus on the diagnosis and treatment of the most common presentations, while not ignoring rare but serious alternative diagnoses. This chapter chiefly describes migraine and tension headaches, but warning signs and symptoms of serious causes of headache as well as how to evaluate these are also described. As with all the chapters, the epidemiology and impact of the conditions are described. The author provides guidance on what questions to ask the patients and what advice to give them. Examples of headache diaries are provided. The effects of menstruation, pregnancy, and medication overuse are considered. Appendix E—a guide for patients—complements the chapter, and describes mechanisms, dietary advice and medication choices, doses, and side effects. Together the headache chapter and appendix provide a greater level of detail than other chapters, possibly reflecting the author’s comfort and experience with this particular area of pain medicine. Yet her common-sense approach persists throughout the book. The chapter on cervical and lumbar pain (chapter 5) deemphasizes the role of interventions and medications, but rightly emphasizes the importance of the rehabilitative approach and of patients’ own engagement in their recovery being the best hope of reducing the many costs (societal, medical, and personal) of persistent spine pain. The chapter on opioids in chronic pain (chapter 17) again describes a sensible approach to a treatment quandary that has troubled physicians for many years: opioids can reduce pain more effectively than any other medication, yet their abuse potential cannot be ignored. The chapter suggests a rational approach for choosing opioid therapy and provides helpful guidelines and examples of documentation charts, a consent form, and appropriate treatment goals.

It is clear when reading the introductory chapters, that patients are the focus of this book. Descriptions of the rationale and scientific basis for pain and pain treatment are too simplistic for physician, particularly specialty, readers, but as material for other practitioners and for patients themselves, they are probably helpful. This author’s strengths are her clinical insights. She states that patients who understand their own pain and the process by which it has arisen, are in a vastly better position to deal with it—and this reviewer would support this contention. Educational materials are provided for patients, easy to print out from the ebook, which can be very helpful to practitioners in busy practice settings. This is not a book for those seeking detailed descriptions of interventional or drug therapies, but it is a marvelous resource for practitioners trying to cope with the burden of chronic pain in general medical practice. The author can be commended for giving us the benefit of her wisdom, based on years of pain practice, by laying out her experience and extensive knowledge in a logical and readable way.

© 2005 International Anesthesia Research Society