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Edited by H S Smith. Hanley and Belfus, 2002, £28.99, softcover, ISBN 1560535113
The practice of clinical medicine is challenging. This is so, even when the clinician has both a reasonable grasp of the pathophysiology underlying a patient’s presenting symptoms and an understanding and knowledge of the therapeutic tools available to manage these conditions. Pain provides a major challenge for the clinician then, as we often fall at both these hurdles. We are challenged by patients presenting with distress of long standing, where pain is often a major component, and the symptom complex does not comply with a medical science based, recognisable distribution and pattern. Yet the patient is genuinely distressed, and this distress is often transferred to the clinician through the feeling of therapeutic impotence. With insecurities about what is being treated, we can either stick to drug regimens with which we are familiar, but that do not adequately assist the patient, or dabble superficially with therapeutic options that are poorly understood.
Dr Howard Smith, Director of Pain Medicine and Professor of Anaesthesia at Albury Medical Centre, New York has sought to meet these needs by putting together a tome outlining types of pain and the underlying mechanisms, with an in depth discussion of available drugs. He has personally contributed a significant portion of the book and has assembled a team of like minded clinical and academic contributors providing discourse in their unique areas of expertise and excellence.
The book includes chapters on the pathophysiology of pain, with a discussion of agents available including simple analgesics and anti-inflammatories. There is detailed discussion of opioid use and adjunct drugs—anti-epileptics, psychotropics, and more recent receptor antagonists. There is description of regional blocks, topical analgesics, and recent novel drug delivery options. The clinically challenging areas of headache, migraine, and metastatic pain are specifically addressed, with chapters devoted to each. The content for each topic is in depth and accompanied by a very comprehensive reference and bibliography listing.
Personally, as my introduction implies, I needed a book such as this to assist in my clinical practice. This need is more than met in terms of explanations underpinning the physiology of pain and pharmacological options for treatment. However, possibly there could be a little more concrete direction in terms of specific algorithms for clinical scenarios, such as is addressed in the headache and migraine sections. For instance, the book refers to opioid stingy and opioid heavy practitioners, yet did not assist in the non-malignant area—in outlining a middle of the road, clinically applicable path. On the other hand, this possibly reflects the subjective nature of the condition being managed, the fact that there will be differences in clinical practices, and the fact that this science is still very much in evolution.
I found this book an excellent outline of where pain science is today, and a useful aid to the understanding of this complex area. I hope that there will be a sequel directed to clinical application based on the principles outlined in this very complete tome.
Evidence basis 15/20
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