Both patients and doctors express confusion today about chronic pain management in the medical community. The issue of how to cope with chronic pain is a growing one primarily because people are living longer with chronic illnesses. Medical advancements have made life possible for many (especially the very young and the very old) who couldn’t have survived even in the recent past.

But along with longer lives comes greater complexity in the care required. Caregivers can easily be overwhelmed by the prospect of treating a host of various pain diagnoses, especially when comorbidity is a primary factor. Undermedication is probably the most common problem in good pharmacologic pain management and it stems largely from the lack of adequate medical school training and post-medical school information coupled with longstanding prejudices about pain-relieving medications. As recently as 1993, a study available on Medscape showed that medical students exhibited significant "opiophobia." Students’ choices for a specialty was an important variable in these attitudes: "students with a preference for pediatrics, surgery, and anesthesiology tended to have the least positive attitudes about pain and pain treatment, while students with a preference for psychiatry had the most positive attitudes." Even pediatrics is taking a hard look at the traditional belief that babies don’t feel pain and is re-examining the use of pain medications in their procedures, especially in the premature. There is a huge need for a clear and succinct discussion of the pharmacologic options in pain management today.

This book is the latest volume in the American Psychiatric Association’s "Review of Psychiatry" series and is directed at psychiatrists who are uncomfortable with trying to manage their patients’ pain–and especially those who don’t consider pain management to be a part of their responsibility–but it can also be very useful to other caregivers involved in chronic pain management. The book’s existence is based on the knowledge that

Psychiatric comorbidity is important to chronic pain management: a pain treatment failure often indicates the need to treat both the pain and the psychiatric disorder. The presence of psychiatric illness complicates the evaluation and treatment of the pain.

The first chapter reviews what we think pain is and how we think it develops. Our understanding of both acute and chronic pain has improved considerably over the last twenty years, but there remains a considerable amount we do not yet comprehend about how we perceive pain. In the third chapter’s discourse on models of pain, the author contends that the primary barrier to further comprehension exists in the traditional but incorrect notion of Cartesian dualism: that psyche and soma are two separate and distinct aspects of our person. This is reflected in the models of psychogenic pain that are discussed. Each of them focuses on either the body or the mind and none of them adequately appreciates the interplay between the body and the mind along with the society in which they exist. The majority of pain experts today believe that the biopsychosocial model of pain is the only one that can really be effective in helping to alleviate the pain that people experience. The term "experience" is especially important because the pain that an individual feels is not necessarily correlated to an organic disease or injury and how an individual perceives her pain is critical to its effective treatment.

Several authors throughout the volume comment on the problems of translating research results into actual patient treatments. This difficulty is examined in an excellent editorial from "Medscape Mental Health" entitled Recovery vs Response. Researchers generally categorize "response" to a particular drug "as a 50% or greater reduction in symptoms." However, in practice, a 50% response is not what any patient or clinician hopes for; rather, "the goal is to have them recover from the illness that is causing them to seek treatment." Also, the way in which drug trial participants are screened is not realistic to clinical practice. Very few, if any, patients have no comorbid conditions, especially chronic pain patients. So, not only is the language of research different from clinical work, but the methods and goals are different.

The last chapter seeks to bridge this gap somewhat by presenting grand rounds. Four case studies are presented for a panel of experts (in psychiatry, oncology/palliative care, psychoanalysis, psychology, fibromyalgia) to weigh in on. The patients present with headache, fibromyalgia, back and neuropathic pain all complicated by psychologic and sociologic factors. The authors are to be commended on their choice of cases since these symptoms can be controversial and are open to a range of interpretations. The panel members’ comments coupled with the second chapter’s information on (primarily pharmacologic) treatment protocols delineated in several comparative tables gives readers much information toward treating their own patients.

Although this volume is clearly addressed to allopathic professionals and includes technical language, laypersons could also benefit from reading it. It does not discuss specific therapies that can be effective in pain control beyond psychotherapy in general such as cognitive-behavioral therapy nor does it consider other influences such as that of religion (which my next book review will cover: "The Psychology of Religion and Coping"). However, at 188 pages including the index, this is a very succinct yet effective analysis of the mostly pharmacologic aspects of pain management.

References: (Requires signing up for Medscape)

Kramer AM: Medscape Psychopharmacology Today: Recovery vs Response. Medscape Mental Health 5(4);

Weinstein SM, Laux LF, Thornby JI, et al: Medical students’ attitudes toward pain and the use of opiod analgesics. South Med J 93(5):474.

Categories: General, ClientReviews