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Pain Res Manage Vol 15 No 4 July/August 2010

Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain, Fourth Edition. Philadelphia: Lippincott, Williams and Wilkins, 2010. ISBN 978-0-7817-6827-6; 1661 pages; Hardcover $299.00. Includes access to complete contents online

If the reader would like the short answer about this book without reading this rather long-winded review, I recommend it strongly as an excellent resource. For detailed commentary, read on. In this fourth edition, the editors aim to keep the book to its original manageable size, with a shift in the book’s emphasis from peripheral (anatomically based) mech-anisms to a greater focus on neural (global) mechanisms. New or updated chapters focus on issues that impact clin-ical pain management such as pain train-ing, regulatory and political issues, and conducting clinical trials. The stated goal is to remain faithful to Bonica’s ori-ginal intent to provide a comprehensive reference for practising clinicians across all disciplines. The editors state that every chapter has been substantially rewritten or is completely new. The fourth edition of this well-respected ref-erence book has undergone an almost complete change of section editors and authorship. The four editions have evolved from the almost exclusive work of John Bonica in 1953. The second edi-tion, published 30 years later, was again from Dr Bonica, with contributors for more than one-half of the book. The third edition, published in 2001 and edited by John Loeser, extensively expanded the content related to basic science and clinical pain management. The book is divided into six parts – Part I, Basic Considerations; Part II, Economic, Political, Legal, and Ethical Considerations; Part III, Evaluation of the Pain Patient; Part IV, Pain Conditions; Part V, Methods for Symptomatic Control; and Part VI, Provisions of Pain Treatment. Part II represents new content reflecting the emerging social impact of pain and pain management.

Part I, Basic Considerations, begins with an account of intellectual milestones in pain, and is accompanied by portraits of many well-known historical figures

including several individuals who are known to many of us working in this field. Early photographs of Ronald Melzack and Patrick Wall at the time of their early col-laboration, and John Bonica, Harold Merskey and Clifford Woolf are included. Chapter 2 focuses on pain terms and tax-onomies, including a useful list of defin-itions, many of which are from the International Association for the Study of Pain (IASP) Taxonomy. A concept of acute and chronic pain is proposed based on time and physical pathology. However, the reader may question whether, as sug-gested, chronic cancer pain can be related to this concept because the model implies low pathology with chronic pain. The reader may also challenge whether the recurrent pain of migraines, trigeminal neuralgia and sickle cell disease involves major components of psychosocial and behavioural factors. The definitions from the IASP Taxonomy are usefully indi-cated by an asterisk. Neuropathic pain is defined according to recent suggestions for change; the term ‘dysfunction’ is excluded, with some other changes. The reader needs to be cautioned that these changes have not been accepted by the IASP. There is an exhaustive discussion of taxonomies of pain, including the IASP Taxonomy, which is criticized because it excludes the assessment of psychosocial and behavioural data, and has not been repeatedly evaluated in terms of reliabil-ity, validity and utility. Chapters 3 through 7 logically progress from peripheral pain mechanisms through spinal cord nocicep-tive processing and its modulation, supraspinal mechanisms and psychological aspects of pain. Chapters 8 and 9 discuss individual differences and functional anatomy. The section finishes with a use-ful chapter on clinical trials.

Part II, a new section with five chap-ters, is entitled ‘Economic, Political, Legal, and Ethical Considerations’. It begins with a chapter on sociocultural dimen-sions of pain management. This excellent chapter will be of interest to the general readership and is, in my opinion, a pillar of the book. It is of relevance to both the basic scientist and those in the trenches. The linking of chronic pain to belief, cul-ture and social practice is “exactly what an evidence based molecular gaze cannot ignore”.

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Continued from page 209The conclusion is that there is no ‘magic bullet’ and that

chronic pain cannot be reduced to a diagram of cellular pro-cesses, but that cellular processes are open to modification. The authors suggest that personal, social and cultural factors make it one of the most difficult challenges that pain medicine in the 21st century needs to address effectively. Another chap-ter on ethical issues concludes that the ethics of pain manage-ment are in a profound state of flux. These authors discuss chronic noncancer pain in terms of issues such as opioid con-tracts, drug screening and the issue of trust. The contentious issue of opioids for chronic noncancer pain is highlighted, con-trasting the WHO and IASP, who both call for the recognition of pain relief for all patients with other statements of “dire warnings to clinicians about deceptive drug-seeking patients who must be engaged with extreme caution, robust scepticism and vigorous scrutiny as well as pharmacovigilance”. The increasing number of clinicians engaged in the prescription of opioids for chronic noncancer pain will be attracted to this chapter. Chapters also follow on ethical issues in the care of dying patients, laws and policies affecting pain management, and litigation involving pain management. Finally, in this sec-tion, there is an authoritative and comprehensive chapter by David Joranson and colleagues on opioid policy and availabil-ity, and access to opioids in developing and nonindustrial countries. In this book, I was pleased to see a total of five chap-ters, as well as parts of other chapters, dealing with current issues surrounding opioid use and substance abuse.

Part III has all-new authors and deals with the evaluation of the pain patient. This section retains the same chapter headings as in the previous volume with two exceptions. A comprehen-sive chapter on the medical evaluation of the chronic pain patient refers to various outcome measures that can be used both in the office and for research. Additional chapters discuss the electrodiagnostic evaluation of pain syndromes, diagnostic imaging and the measurement of pain, psychosocial evaluation, disability evaluation of painful conditions and multidisciplinary assessment of patients with chronic pain. All of these are worthy successors to the chapters found in the previous volume.

Part IV is a critical part of this book dealing with various pain conditions. Separate sections are included on neuropathic pain; psychological contributions; vascular, cutaneous and musculoskeletal pain; cancer pain; and acute pain. A new chapter focuses on pain and special populations such as patients with a history of substance abuse. The chapters on visceral pain; headache; chest, abdominal and pelvic pain; regional pain in the head, neck, arm, chest and lower extrem-ity; and low back pain are important and comprehensive.

With regard to neuropathic pain, these authors are well-known authorities on specific syndromes including neurop-athies, complex regional pain syndrome, phantom pain, herpes zoster pain and central pain. The psychological contributions appear authoritative and a chapter on the psychology of addic-tion is included, adding to this important focus of the book. The section on cancer pain deals with specific issues in this regard and appears to be very comprehensive.

The section on regional pain affecting the neck and arm includes a discussion of Waddell’s nonanatomical signs and

emphasizes that these are signs (as Waddell described initially) of significant psychosocial stress, and are not indicative of signs of malingering or secondary gain. The illustrations in this sec-tion, and throughout this book, are particularly clear and attractive. The low back pain section is also of particular importance and includes contributions from Nikolai Bogduk and his colleagues. Dr Bogduk expands and reprises his import-ant assessment points here, as in a recent review (1). Either should be required reading for all specialists dealing with chronic back and leg pain patients.

Part V contains six sections on pharmacological, psycho-logical, physical, and various interventional and surgical approaches for the control of pain. The pharmacological ther-apies section begins with an excellent introductory chapter on rational pharmacotherapy, emphasizing that drugs are probably overused and should be combined with other modalities. The chapter on nonsteroidal anti-inflammatory drugs and aceta-minophen is comprehensive. A mandatory chapter by Charles Inturrisi and Arthur Lipman is included for those who prescribe opioid analgesics which, with four other major chapters, and sections in other chapters, on different aspects of these drugs and chemical dependency, indicates the appropriate import-ance the editors have placed on this controversial area. The final two chapters include skeletal muscle relaxants and topical agents, and a thorough chapter on neuropathic pain pharmaco-therapy. The psychological technique section deals with import-ant issues including anger and pain, cognitive behavioural therapy, pain and its relationship to anxiety and depression, hypnosis, relaxation therapy and group therapy. The final chap-ter is on motivating pain patients for behavioural change. All of these are critical and perhaps overlooked approaches essential for a multidisciplinary approach, which is also a theme of this book. The section on physical and other noninterventional therapeutics has been expanded and retains only one previous chapter on basic concepts and biomechanics in musculoskeletal rehabilitation. An important chapter is included on the assess-ment and treatment of chemical dependency.

The three chapters on implanted electrical stimulators are comprehensive and authoritative. Interventional pain man-agement includes nerve blocks, epidural steroids, intrathecal drug delivery, intradiscal therapies for low back pain and neurolytic blockade for noncancer pain. The authorship, including Nikolai Bogduk, James Campbell and colleagues, ensures the high quality of this section. There is an emphasis here on the importance of selecting patients carefully, the pos-sible complications of these procedures, and the lack of a sig-nificant evidence base supporting these treatments. These sections are very useful for both the nonsurgeon and the interventionalist.

The discussion of nerve blocks emphasizes that a positive response to a somatic or sympathetic nerve block should not be assumed to be predictive of a favourable outcome to treat-ment such as ablative procedures. This view of the value of prognostic use of blocks seems to persist. The chapter con-cludes with a challenge to experts in this discipline to provide greater evidence supporting the validity of the use of nerve blocks.

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Pain Res Manage Vol 15 No 4 July/August 2010 21

Continued from page 212The chapter on epidural steroids is thorough and cautions

that, although some observational studies have reported short-term success over 20 to 30 days, long-term controlled trials have shown no attributable effect. The author concludes that injection, rather than what is injected, may be the reason the treatment appears to work.

A thorough chapter on intrathecal drug delivery concludes that it is a viable option for patients with intractable pain that cannot be managed by other means. While the procedure itself is relatively simple, the authors emphasize that the manage-ment of these patients is far from simple, particularly for non-cancer pain conditions. Multiple issues can develop during the course of treatment and, therefore, the treatment should not be entered into lightly. The importance of judicious patient selec-tion, meticulous surgical technique and diligent patient man-agement is emphasized.

Intrathecal disc therapy is a practical chapter pointing out that preventing or treating disc degeneration may have limited clinical relevance. Disc changes are found in the majority of asymptomatic adults, and clinical correlation of the symptom complex with the radiological abnormalities is underlined. The authors point out that, although there is the potential of regenerative approaches, their ultimate role is unclear. Neurolytic blockade for chronic noncancer pain is thoroughly covered. The authors suggest caution regarding the lack of, and difficulties regarding, placebo-controlled trials in this area, and make a strong case for good observational data.

The final section of part V describes surgical approaches to pain. The chapter on surgery of the peripheral nervous system is comprehensive and was contributed by James Campbell and colleagues. The chapter includes discussions on peripheral neurectomy, nerve entrapment release procedures, dorsal rhi-zotomy and ganglionectomy, and sympathectomy. It empha-sizes the importance of careful patient selection and clear establishment of the etiology of the pain condition and surgical technique as critical to ensure successful analgesia; enthusiasm for these procedures must be tempered by a keen appreciation of potential complications, particularly the possibility of anes-thesia dolorosa with nerve transection. The importance of the release of nerve root entrapment is appropriate, and entrap-ments that are less common than carpal tunnel and ulnar nerve entrapment may be overlooked or misdiagnosed. The appropriately infrequent use of dorsal rhizotomy and ganglion-ectomy, and sympathectomy only in refractory patients, is cautionary.

The surgical management of trigeminal neuralgia chapter is practical, emphasizing the preferred, potentially curative oper-ation of microvascular decompression except in elderly patients with significant comorbidities in whom percutaneous

procedures and radiosurgery may be more appropriate. The discussion of drug therapies for trigeminal neuralgia is succinct and also available in more detail elsewhere in the book under Cranial Neuralgias.

A chapter on the various ablative neurosurgical procedures for chronic pain completes this section and points out that these procedures have been largely replaced in developed countries by improved pharmacotherapy, intrathecal delivery systems and high frequency stimulation techniques in patients without contraindication due to underlying medical conditions.

Part VI focuses on pain treatment delivery and begins with an interesting discussion of the rise and fall of interdisciplinary chronic pain management, with a perspective on the history, current status and future viability. Issues regarding the reduc-tion in the once-abundant programs in the United States are discussed in detail. The specific issue of spine clinics and their utility comprises a second chapter. An important chapter on pain management and primary care focuses on how developing a patient treatment plan and mutually agreed-on goals enables the physician to conduct a follow-up visit in 15 min. One chapter provides a thorough discussion of pain management at the end of life and expresses the need for a well-functioning interdisciplinary team, combining the expertise of each indi-vidual to provide optimal care to this vulnerable group. A discussion of palliative sedation is presented here. A chapter on training pain specialists, written by four authorities in this area, describes the challenges and future of training pain spe-cialists. Chapters on dealing with emergencies in the pain clinic, pain management in the intensive care unit and pain management in the emergency department will be of great interest to specific readers. The final chapter is a brief epilogue on the future of pain medicine.

In summary, I highly recommend this book as a reference volume to anyone intensively involved in the problems encountered clinically or in research with acute and/or chronic pain. It is a most worthy successor to the superb first two edi-tions edited by John Bonica and the excellent third edition edited by John Loeser. It is an encyclopedic – but easily read-able – book that should be on the shelf of those working with pain patients. The illustrations are of particular value. This book is authoritative and comprehensive, emphasizing multi-disciplinary and multimodal approaches to managing pain – all significant components of which are found within its pages.

C Peter N Watson MD FRCPCDepartment of Medicine, University of Toronto

Toronto, Ontario

RefeRence1. Bogduk N. On the definitions and physiology of back pain, referred

pain, and radicular pain. Pain 2009;147:17-9.

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