August 2011  << Back  

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Behavioral and Psychopharmacologic Pain Management

Richard Balon, MD

Wayne State University, Detroit, MI, USA

Edited by Michael H. Ebert and Robert D. Kerns. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-88434-1; pp 506; $99 (hardcover).

According to the International Association for the Study of Pain, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (p 5). Two dimensions of pain—sensory-discriminative and affective emotional—can be distinguished (p 5), the former representing “the ability to localize a stimulus in space and time and assess its intensity, and the latter consisting of evaluation and interpretation of the meaning of the pain experience” (p 5). These statements set the stage for this book on behavioral and pharmacological management of pain and for advocates of modern, multidimensional, and multidisciplinary management of pain.

Contemporary pain management is indeed multidisciplinary and usually involves pain management physicians, psychiatrists, psychologists, physical therapists, pharmacists, in some instances podiatrists, neurosurgeons, and orthopedic surgeons, and maybe other specialists. As the make up of pain is multidimensional, “clinicians must recognize the intimate relationship between pain and factors such as mood, activity, social relations, quality of life, pain beliefs, and motivation for self-care” (p 62). This complex picture requires a complex approach by well-trained pain management specialists. New pain medicine training requirements ask faculty involved in training pain medicine specialists are board certified in anesthesiology, psychiatry, neurology, or physical medicine and rehabilitation, and training programs accept trainees from these disciplines only. Pain specialists should be well versed in behavioral and pharmacological interventions as well as procedural and invasive interventions usually performed by anesthesiologists (therefore, in my opinion, pain management training would be difficult for psychiatrists and neurologists). This volume intends to provide all pain specialists and others interested in pain management with a comprehensive review of behavioral and pharmacological strategies of pain management, but not with any invasive or procedural interventions.

The book is divided into 5 sections. The first section, “The basis of pain management,” focuses 3 chapters on the process of pain management and the biopsychosocial model of pain and pain management. The second section, “The assessment of pain,” covers in 4 chapters various aspects of pain assessment including assessment of functioning and disabilities in pain syndromes, pain and psychiatric comorbidities, and emotional functioning in persons with pain. The chapter on comprehensive assessment of pain emphasizes key areas that should be addressed during a pain interview include the location of pain, onset and pattern, intensity, description of pain, aggravating and relieving factors, previous interventions, effects of pain, and patient’s pain goals (eg, comfortable and consistent sleep, comfortable movements). The chapters of this section also review various assessment tools and scales.

The third section, “Psychopharmacologic, behavioral, and psychotherapeutic approaches,” reviews in 9 chapters areas such as interdisciplinary pain rehabilitation programs, pharmacological approaches to pain management, chronic opioid therapy of pain, behavioral and cognitive behavioral approaches, nonpharmacologic neuromodulatory approaches to pain management (eg, cortical stimulation, transcranial magnetic stimulation, hypnotic analgesia, biofeedback), cognitive coping strategies in pain management (imagery), couple and family psychotherapeutic approaches to pain management (mostly grounded in cognitive-behavioral theory), and psychotherapeutic and psychopharmacologic approaches to pain management (here focusing on antidepressants and anticonvulsants). The last chapter of this section emphasizes the lack of evidence-based research of the effectiveness of combining psychotherapy and pharmacotherapy in pain management. One would wish the discussion on using antidepressants and anticonvulsants provided more specific information, eg, recommended dosages, rather than just a plain review of the topic.

The fourth section, “Integrative approaches to the management of painful medical conditions,” discusses in 8 chapters topics such as management of spinal pain, musculoskeletal pain, pain in arthritis, neuropathic pain, headache pain, pain in palliative medicine, pain and associated disability in children and adolescents, and pain in geriatric patients. The chapter on spinal pain reminds the reader low back pain is second only to upper respiratory problems as a symptom related reason for visits to physicians (p 271) and many patients do not seek help because the pain resolves itself in a short period of time. The chapters on musculoskeletal and neuropathic pain finally provide recommended dosages of various medications. The discussion of the role of sleep in neuropathic pain with some management suggestions is useful, although brief. The chapter on pain in geriatric patients contains a good discussion of various myths of pain and aging, eg, pain is part of getting older, pain worsens as people get older, older adults get used to living with pain, and older adults seek medical treatment as the primary way of dealing with pain.

The last section, “Practice, policy, and research,” summarizes in 5 chapters policy and practice issues in pain management, diversity and disparities in pain management, directions in pain research, ethics and pain management, and—as in many other textbooks—the future.

As I noted at the beginning of this review, this book does not cover procedural and invasive interventions and therefore cannot serve as a complete textbook of pain management. I also missed a solid discussion of cultural aspects of pain and pain management. Most of opioid prescriptions for pain (about 90%) is limited to the United States. Patients from different cultures cope with pain in different ways; some cultures use other pain management modalities, eg, acupuncture. A discussion on the use or misuse of herbal remedies in pain management did not make it into this volume, either—not that I advocate using them, but many patients use and abuse these modalities. The book also could be less wordy and avoid overlapping at times. Nevertheless, this is a useful volume for anybody involved in pain management and in teaching pain medicine. It presents a lot of useful information. It emphasizes the only way to manage pain appropriately is a multimodal interdisciplinary approach. Because psychiatrists clearly should be part of an interdisciplinary team managing pain, this book certainly will help them with what they need to know about their part in pain management. Once they get involved, they will find there are some fascinating similarities and parallels between psychiatry and pain management and the field of pain management is ready for full psychiatric involvement.