Churchill's Pocketbook of Pain. By Catherine F. Stannard and Sara Booth. Philadelphia, Churchill Livingstone, 1998. Pages: 351: Price:$24.95.
Churchill's Pocketbook of Pain is one of several handbooks that have emerged in recent years as a result of the growing popularity of pain medicine. In the preface, the authors cite two important issues surrounding the management of chronic pain:(1) the misconceptions and lack of scientific basis for what we do and (2) deficiencies in the educational preparation of physicians in the diagnosis and treatment of complex pain entities. Anesthesiologists in the United States have taken an active part in addressing pain issues by participating in the development of policies and educational programs to relieve pain and suffering. Advances in research on mechanisms of pain and outcome data are emerging to support and direct appropriate care for this group of patients.
This handbook by Stannard and Booth reflects some practice patterns that are characteristic of the United Kingdom. As with most pocket handbooks, it is intended as a convenient reference, giving the reader a brief overview to the management of more common acute and chronic pain problems. The book is composed of five sections with various chapters within each section.
Section 1, entitled "Principles of Pain Management," describes the anatomy and physiology of pain followed by sections on clinical pharmacology and descriptions of common opioids, nonopioids, local anesthetics, and other coanalgesics used in the practice of pain medicine. Included in this section is a chapter on neurostimulation techniques, including acupuncture. There is also a chapter on the assessment of the patient in pain, a crucial part of the diagnostic work-up and treatment of painful conditions.
Section 2 reviews the treatment of acute pain, including postoperative pain, trauma pain, and two specific groups of patients: obstetric and burn patients. One noted regional variation in practice in the United Kingdom is the use of Entonox, a mixture of 50% nitrous oxide in oxygen, which is available in wards, obstetric units, emergency departments, and some ambulances as a potent inhalation analgesic. The delivery unit is a tight-fitting mask or mouthpiece, which the patient holds and operates to prevent continued administration, reminiscent of the handheld Penthrane units used years ago in obstetric practice in the United States. Safety issues, not only in obstetric practice but also in the trauma patient and emergency department setting, as well as environmental concerns must not be underestimated when using this analgesic mixture.
I have some concerns regarding the section on epidural analgesia for postoperative pain management. The authors list sepsis and coagulopathy as relative contraindications to the use of epidural analgesia. In most textbooks in the United States, these two factors are considered absolute contraindications to the use of neuroaxial techniques. In today's climate of low molecular weight heparin and anticoagulant therapy, the issue of anticoagulants, coagulopathic states, and potential for epidural hematoma is critical in the anesthesiologist's decision to use or not use epidural analgesic techniques.
Section 3 discusses cancer pain and advanced human immunodeficiency virus disease. These chapters give an excellent overview of the pathophysiology, patient assessment, and treatment of cancer and acquired immunodeficiency syndrome pain. However, these chapters, as is the book in general, are weak when considering the diagnostic and therapeutic benefits of interventional modalities for cancer and chronic pain states.
Section 4 includes six chapters on pain syndromes that are frequently observed in the chronic pain clinic, including back and neck pain, muscular pain, scar pain, neuropathic pain, and facial and pelvic pain. The underlying disease or pathologic process is nicely presented, and clinical features and management options are clearly outlined. I found it interesting that the authors failed to mention the use of gabapentin, a newer anticonvulsant that has been used with great success and is now considered a first-line drug in the treatment of neuropathic pain states.
Section 5 covers the psychological aspects of pain and the importance of psychologists in the multidisciplinary management of chronic pain.
This concise and informative pocket reference is well suited for physicians in training, as well as clinical nurse specialists who are part of the pain clinic team. It is a wonderful introduction to the principles and practice of pain medicine for anesthesiology residents.
Ann C. Still, M.D.
Assistant Professor of Anesthesiology; The University of Alabama at Birmingham; Birmingham, Alabama 35233;firstname.lastname@example.org
(Accepted for publication March 18, 1999.)