Chronic Pain-A Primary Care Guide to Practical Management
Marcus, Dawn A, MD, New York: Humana Press (Springer), 2009. ISBN 9278-1-60327-464-7. 442 pages, price.
All clinical practitioners, at some time in their career, will come across a patient with chronic pain. In most cases, primary care physicians are the first to come across these patients and it is not only important to assess the presence of chronic pain, but it is also important to devise an appropriate treatment plan. As the title suggests, this book aims to give the primary care practitioner a practical approach in assessing and treating patients with chronic pain.
This second edition text comprises 442 pages in 17 chapters divided into 5 major sections followed by an appendix. Almost all of the chapters begin with bulleted key points and key words followed by a case history. In addition to the references, each chapter ends with approximately 5 multiple-choice questions. The first 2 sections discuss the pathogenesis and issues surrounding chronic pain management including frequent concerns and risk management that pertain to chronic pain. There is a nice overview on what tools to utilize to evaluate chronic pain including drawing on location and types of pain. Questions on the presence of and the pathogenesis of chronic pain after an injury and its effects on the patient are addressed. The importance of documentation to protect the practitioner and evaluate the effectiveness of certain therapies is discussed. Pitfalls in prescribing schedule II drugs are addressed.
The third and fourth sections are the heart of the book and discuss the assessment and treatment of common chronic pain conditions as well as pain in special groups, such as pediatric, pregnancy, geriatric, and gender/ethnic differences. The topics discussed include headache, neck and upper extremity pain, back and lower extremity pain, abdominal pain, neuropathic pain, myofascial pain, fibromyalgia, and cancer pain. The highlights and positives of these sections:
- The case histories at the beginning of each chapter are great examples of the condition that is being reviewed.
- The tables, graphs, and treatment algorithms are simple to read and understand. The headache section gives an excellent graph on how to differentiate tension, cluster, and migraine headache. All of the other chapters give some type of table or diagram to distinguish between common conditions found in that respective region (cervical radiculopathy vs. shoulder joint pain, various abdominal pain syndromes, neuropathic pain syndromes, arthritides, etc).
- Diagnostic criteria and red flags are mentioned in each chapter.
- Each chapter is relatively comprehensive in the discussion of the topic including the available evidence for treatment options.
- Nice overview of medications with their uses and side effects. For example, the section on neuropathic pain has a figure breaking down the number-needed-to-treat for peripheral neuropathy and post-herpetic neuralgia.
- The importance of multi-disciplinary approach to treating chronic pain is discussed in almost all sections.
- Questions at the end of each chapter help drive home the key points outlined at the beginning of each chapter.
- The section on special groups introduces the presence of chronic pain in the young, pregnant, and elderly patient.
- The chapter on ethnic/gender differences gives a nice overview of the studies done in this category.
The final section discusses the treatment of chronic pain beginning with lifestyle and psychological issues, detailed use of analgesics, and pain management at the end-of-life. This section emphasizes treating all aspects of the patient, such as obesity, nicotine use, sleep disturbance, and psychological distress that contribute to chronic pain. The chapter on analgesia discusses opioid and non-opioid analgesics, which medications have the most evidence demonstrating effectiveness, and the use of opioids in non-malignant pain. The chapter outlines the practical usage of opioids but does not go into the same detail with respect to anti-depressants and anti-convulsants. The final chapter on end-of-life care discusses the issues and services available for patients in the final stages of a terminal illness.
The appendix provides patient educational materials as well as useful diaries and logs to assess various chronic pain states and their responses to treatments. The book includes a DVD which contains some of the figures in the text as well as the entire appendices which contain the aforementioned patient educational materials. There are valuable exercises, pain diaries and logs, diet changes for prevention of headaches, psychological assessment tools, fibromyalgia screening questionnaires, and common medication dosages for pain. The material in the appendices can be helpful to any and all practitioners, especially those that are starting their own practice that includes chronic pain patients. The material is in PDF format and can be easily printed and utilized in one’s practice.
The majority of the book is simple to read, concise, evidence-based, and, for the primary care doctor, comprehensive. There are a few shortcomings. Each section discusses the treatment options, but does not discuss the medico-legal issues that surround certain diagnoses or, more importantly, misdiagnoses. There is no discussion of when to refer patients to chronic pain medicine specialists and how to manage the more complex patients that the book so nicely describes. Sometimes, it may be beneficial to refer a patient early in the course of disease when the required treatment is simpler. The strength of this book, its simplicity, can also be a weakness, as it oversimplifies some of the options for diagnosis and management. There is very little reference to an opioid contract in the book when most data suggests that some form of an opioid contract is desirable.
Overall, the author does a great job of presenting material on a difficult topic. The material is presented in an easy-to-read format and the author relies heavily on scientific evidence and avoids personal bias. The book is very useful for medical students, residents, and primary care doctors as both a reference and introduction to chronic pain. It can be useful for pain specialists, but only in addition to another textbook that has more detailed discussion on diagnosis and intervention. As practicing chronic pain specialists, we highly recommend this book to anyone with an interest in learning the basics of chronic pain, with the understanding that the book is not comprehensive, but a good starting point in dealing with these complex patients.
Mehul Sekhadia, DO
Honorio T. Benzon, MD (corresponding author)
Department of Anesthesiology
Northwestern University Feinberg School of Medicine