Who apart from the gods is without pain for his whole lifetime's length?
Life's sharpest rapture is surcease of pain.
- Emma Lazarus, "In Exile"
Pain, as noted by Aeschylus, is universal and inescapable. And providing relief of pain for the suffering patient should be one of the most professionally gratifying experiences for a physician. Why, then, do we, as neurologists, so often dread caring for patients with pain, particularly those with chronic pain? I believe it stems in part from the difficulty in dealing with patients whose ailments we can't ourselves see or hear or feel or smell. Undoubtedly, we also feel discomfort in confronting the psychiatric aspects that invariably accompany the experience of chronic pain-occasionally as the cause, but far more commonly as the consequence of the physical discomfort the patient experiences. Much of our inadequacy, I think, comes from deficiencies in our training to care for people with chronic pain. And, unfortunately, our fears, however groundless, of sanctions or even prosecution for the appropriate prescription of narcotics may further compromise our ability to minister to these often complex and difficult patients.
This issue of CONTINUUM, devoted to the subject of neuropathic pain, should do much to alleviate your own personal angst when faced with patients experiencing chronic pain. Dr John Markman, chair of this issue, has assembled an expert multidisciplinary faculty, including many practicing neurologists, to enlighten us on this difficult area. Chapters include both some on specific pain topics and others that more generally address management of chronic pain.
Dr Roy Freeman kicks off the issue with a discussion of painful peripheral neuropathies, elucidating the assessment of such patients, as well as addressing a variety of both common and less common entities. In another chapter on a specific pain syndrome, Drs Dennis Naleschinski and Ralf Baron bring clarity to the subject of complex regional pain syndromes, an area that has been cloaked in controversy and plagued by changes in nomenclature over the years. Between these two chapters, Drs Meredith Barad, Michael Greicius, and Sean Mackey provide a fascinating review on new approaches to imaging in neuropathic pain, analyzing techniques that can provide new scientific insights and perhaps useful clinical information about this subject.
Author Toni Morrison observed, "When there is pain, there are no words. All pain is the same." While this may not be, strictly speaking, true, there are many similarities among patients with various neuropathic pain syndromes. Thus, the remaining chapters address more generically a variety of therapeutic approaches that may be useful irrespective of the specific etiology of the pain, First, Drs Alec O'Connor and Robert Dworkin discuss "Evidence-Based Treatment of Chronic Neuropathic Pain Using Nonopioid Pharmacotherapy." Their chapter provides not only a set of general principles, but guidance about the use of specific drugs. Dr Miroslav "Misha" Backonja follows this chapter with one entitled "The Role of Opioid Therapy in the Treatment of Neuropathic Pain." I am confident that, after reading this chapter, you will have a much better understanding of the role of this class of drugs and will achieve a substantially higher comfort level about their use. Later in the issue, Drs James Russell and Timothy Collins will amplify this subject, using case-based approaches, in their respective sections on Ethical Perspectives in Neurology and Practice Issues in Neurology. While medication will be the mainstay of the neurologist's armamentarium for the pain patient, in some cases interventional therapy will be appropriate and helpful. Even though you likely do not perform most of these interventions yourself, the information that Dr Markman provides in his chapter about specific procedures will be very helpful in understanding when to refer patients for them. Dr Markman covers a variety of neurologic syndromes that are commonly encountered, including neuralgic pain, low back pain, and headache.
The management of patients with chronic pain is undoubtedly difficult. These patients are complex and experience both physical and emotional suffering. Rarely does a single drug provide a simple cure. Therefore, Drs Charles Argoff, Phillip Albrecht, and Frank Rice address "Multimodal Analgesia for Chronic Pain." Their chapter includes not only a discussion of how to combine medications, but also emphasizes the importance of nondrug modalities in a multidisciplinary approach to care.
As usual, you will be able to hone your clinical skills by working through the Patient Management Problem, developed by Dr David Walk. Finally, remember to further enhance your knowledge by doing the multiple-choice questions, provided for this issue by Drs Ronnie Bergen and Julie Hammack. The questions, which emphasize clinical scenarios, teach as well as test. Julius Caesar noted, "It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience." This emphasizes the difficulties one faces in caring for individuals experiencing chronic pain. I am grateful to Dr Markman and his capable faculty for providing an issue of CONTINUUM that will make you better equipped to endure the pain patient with patience, as well as compassion, empathy, and skill.
- Aaron E. Miller, MD