Pain Management: Expanding the Pharmacological Options. By Gary J. McCleane, M.D. West Sussex, England, Wiley-Blackwell, 2008. Pages: 192. Price: $99.95.

Despite the large body of knowledge gathered over the last decade regarding pathophysiology and treatment of chronic pain, many pain specialists and primary care physicians experience frustration with the lack of effective therapeutic options facing our patients. Treating chronic pain is difficult and challenging. Even experienced pain physicians occasionally exhaust all available treatment options without success.

In an attempt to find something that might help, we may resort to unproven treatments that have anecdotally helped others with similar conditions, or we escalate doses of medications hoping that higher doses will have some effect in controlling our patient’s pain. However, many times by doing so, we find ourselves with diminishing returns. An example of this is the escalation of opioid analgesics to the point of severe side effects or states of hyperalgesia.

Clearly, increasing doses of approved analgesics beyond reasonable levels is not advisable, since the consequences can create new problems that are often harder to manage than the presenting complaint. Experienced pain practitioners will often resort to adjuvant medications and coanalgesics to add to the effects of currently acceptable medication in the treatment of pain and at the same time limit the side effects caused by higher doses of these agents. However, until now it has been difficult to find a concise source that lists and describes the clinical application of effective analgesics that do not have formal approval for the treatment of pain.

Dr. McCleane, in his book Pain Management: Expanding the Pharmacological Options , provides the rationale and scientific evidence as to why medications not initially intended for the treatment of pain may be useful and, at times, necessary as part of the overall management of patients.

In Part 1 of his book he shares a number of pharmaceutical agents ranging from topical compounds and oral preparations to those used intravenously in severe or persistent pain. Drugs not usually viewed as analgesics such as antidepressants, anticonvulsants, and local anesthetics are discussed, as well as other less conventional agents such as nitrates, L-carnatine, Baclofen, and botulinum toxin.

Part 2 of his book is dedicated to the discussion of different commonly encountered pain conditions such as neuropathic pain, complex regional pain syndrome, postoperative pain, low back pain, and cancer pain. For each, he provides an overview of the problem and treatment options. In addition, algorithms are provided to guide one through the treatment of difficult pain conditions. These algorithms take the physician beyond accepted and conventional treatments and provide ideas on how alternative pharmaceuticals can be used in the treatment of refractory pain conditions.

A particularly useful section is the appendix, which lists the medications discussed throughout the book. This section has a table format that clearly outlines suggested doses, formulations, unit doses, dose escalations, times to effect, and predominant side effects of various medications. This concise table is easily accessible for immediate and future reference in the pain clinic, making this a handy book for busy practitioners.

For those who practice in the field of pain medicine, this book provides good information on additional pharmacological options and alternatives to the conventional treatment of pain. I recommend this book to physicians who have ever experienced the frustration of having exhausted their treatment options and wished there was something else that could be done to help their chronic pain patients.

University of New Mexico School of Medicine, Albuquerque, New Mexico.