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Anesthesiology:
doi: 10.1097/ALN.0b013e3182a4e840
Reviews of Educational Material

Essential Pain Pharmacology: The Prescriber’s Guide. By Howard S. Smith, M.D., and Marco Pappagallo, M.D.; Stephen M. Stahl, M.D. (consultant editor). Cambridge, United Kingdom, Cambridge University Press, 2012. Pages: 575. Price: $75.00.

Schuyler, Walter J. III M.D.

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The practice of pain medicine is a daunting and challenging endeavor. The patients who seek our expert advice are looking for relief from their pain while also obtaining some semblance of the life they once enjoyed. As interventional pain physicians, we are apt to think that we can inject our patient’s pain away, although as we all know this is folly. Interventional procedures can and do help millions of people a year, but they are not a panacea for chronic pain. There is more to being a pain medicine physician than acting as a pure interventionalist. A broad knowledge of pain physiology, pharmacology, and pharmacokinetics, and the use of medications and injections to treat patients is what sets true pain physicians apart from others that only perform injections. Being able to offer a safe and effective therapeutic regimen is of paramount importance, especially in the setting of the opioid abuse epidemic. The contemporary pain physician needs to be multifaceted, with not only superb procedural skills, but also the expert knowledge to treat their patients with medication management. The Essential Pain Pharmacology: The Prescriber’s Guide is an excellent reference book to help guide the pain clinician in the art of pain pharmacology.
The book is organized alphabetically, with each drug having its own chapter. There are also three indexes at the end of the book, which allow the reader to search for medications by name, drug class, and disorder. The authors arbitrarily chose 107 generic medications based on what they felt to be the most practical and useful in the practice of pain medicine. Interestingly, they also added 11 other compounds in a section entitled nutraceuticals and medical food. This organizational structure makes the book well suited as a reference in a busy practice setting. This format is not meant to be read cover to cover and would not be useful studying for specialty boards. However, this book would have a lot of value in a training program in which trainees are actively seeing patients and using it as a tool for prescribing medications. Active use of this book in the clinical setting would passively prepare a clinician for their specialty boards.
All drugs and the corresponding chapters are presented in the same format, which facilitates finding the specific information for a given situation. Each drug is broken down into five sections, each designated by a unique background color. The five sections include therapeutics, adverse effects, dosing and use, special populations, and the art of pain pharmacology.
The therapeutic section is where the reader will find the class of drug, the major brand names, the Food and Drug Administration-approved use, and what the medication is commonly used for off-label purposes. There is a brief description on the mechanism of action and the pharmacodynamics of the given medication. There is also advice on what to do if the medication is not effective and how to augment the medication for partial responders. By the authors’ own admission, they were not setting out to include all available information on each and every pain medication. Therefore, there are times when the information is superficial. Anything more comprehensive would defeat the main purpose of the book, and is an excellent reference source that includes the most critical and practical aspects of the most useful medications in the clinical setting. The realistic advice on how to proceed based on the effectiveness of the medication is what sets this book apart from other pharmacology reference guides.
The second section of each chapter details the adverse effects of each medication. An explanation is offered on the mechanism of action causing the side effect and highlights the notable severe and life-threatening possibilities of each medication. This section gives precedence to two of the most disconcerting side effects for our pain population: weight gain and sedation. The authors understand the importance of these adverse effects for our patients. They used a prominent and eye-pleasing graphic that details the incidence and makes it easier to recall if a medication may precipitate these unwanted side effects.
The following section details dosage and serves as a guide on how to start a patient on a given medication. There are also recommendations on how to titrate the medication to optimal effect. This section provides details on what can occur with an overdose, how to discontinue the medication, drug interactions, and pharmacokinetics.
The last two sections of each chapter are unique and provide another reason this book stands out. The first of these sections details how to use these medications in special populations, including patients with renal, hepatic, or cardiac disease. For the last section, the authors have drawn on their extensive knowledge of pharmacology and experience of treating patients to develop this section entitled the art of pharmacology. In this section, the authors give opinions on the advantages and disadvantages on each of the medications they covered in the reference book. They discuss the primary symptoms they are attempting to target and then dive into clinical pearls on what to look for and how best to use the medication. Although some of the pearls offered in the book are general knowledge for most pain practitioners, there are many that will likely be of use to even the most senior clinician. This section alone is worth the price of the book, especially for a newly minted pain physician.
One suggestion for the next edition would be to eliminate some of the redundancy with the opioids that were covered. Instead of repeating the adverse effects of opioid therapy for each and every opioid, the authors could create one chapter detailing these issues. This would make the book smaller and even more portable and also allow the clinician to read through an individual opioid chapter with more ease.
In conclusion, I would recommend The Essential Pain Pharmacology: The Prescriber’s Guide to both trainees and colleagues with no hesitation. As a recently graduated pain medicine fellow, I have used and will continue to use this book as an excellent reference source to help me safely and effectively prescribe medications for my patients. The authors should be content that their work will serve their readers well.
Walter J. Schuyler, III, M.D.
, Northwestern University Feinberg School of Medicine, Chicago, Illinois. b.j.schuyler@gmail.com

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