James C. Eisenach, M.D., Editor

Pain Management for the Practicing Physician. Edited by G. A. Irving and M. S. Wallace. New York, Churchill Livingstone, 1997. Pages: 330. Price:$49.95.

Most physicians must evaluate and treat patients with pain on a regular basis. Pain is the most common complaint for patients seeking medical advice and treatment. Despite this, few physicians receive training in pain management, and standard textbooks barely mention the topic. Recognizing this deficit, Drs. Irving and Wallace have written a pain textbook aimed explicitly at the practicing, non-pain specialist. In addition to physicians with office-based practices, medical students, residents on a pain rotation, or interested anesthesiologists will find that this book offers a practical introduction to many important topics related to acute, cancer, and chronic pain management.

The bulk of the book (23 of 34 chapters) is devoted to discussions of specific pain syndromes followed by treatment algorithms and case discussions. I found this format to be an engaging and efficient way to illustrate unique and common issues related to a wide diversity of pain topics. The algorithms present comprehensive and ambitious treatment plans that may stretch the resources of busy primary care physicians, but certainly provide a reasonable approach for common pain problems. The lack of literature comparing treatment paradigms for complex pain patients means that the algorithms presented represent the authors' biases and experiences rather than consensus drawn from scientific study. Their focus on normalizing function while minimizing expensive and invasive treatments is made clear in the treatment outlines. Each chapter includes a helpful description of the types of patients to consider referring to a pain specialist and educates the clinician about what to expect from a pain management referral.

Sections of the text devoted to psychological aspects of chronic pain and non-pharmacologic treatment answer many common questions regarding the role of psychological factors and the use of ancillary treatments such as physical therapy. A particularly helpful chapter addresses the problems that primary care physicians must address when caring for “the difficult pain patient.” This chapter explains the process of individualizing care, recognizing difficult personalities, avoiding wasteful referrals, and adjusting one's expectations for outcome.

I gave the book a trial run with a representative of its intended audience: a medical student on her pain rotation. She found the book practical and helpful and thought it gave her a basis for thinking about pain patients. Despite her endorsement, I noted some deficiencies in the book that lowered my enthusiasm for it. First, editing errors abound in the text and references (inaccurate abbreviations, incorrect citations, inconsistent use of brand names and generics, definition of the visual analog scale several chapters after it is used in the text, and so on). Second, the limited references make it difficult for the average reader to distinguish between writer opinion, established fact, and points open to contention. Finally, a few factual errors serve to perpetuate misunderstanding of some issues (inclusion of sigma receptors in the opioid table, reference to trigger points in fibromyalgia).

Despite these deficiencies, I found the book to be a helpful, straightforward guide well aimed at its intended audience. Those without a pain text or specific pain background should consider this book as an inexpensive starting point ($49.95), whereas those with more extensive libraries or training may find the algorithms and case discussions provoking and of interest. Irving and Wallace are to be commended for their efforts at addressing this underserved area of pain medicine. If primary care physicians incorporated even a small part of the information in this book into their practices, pain patients would be well served.

Brett R. Stacey, M.D.

Director; Pain Management Center; Oregon Health Sciences University; Portland, Oregon 97201–3098