Table Of ContentTHE PAIN MANAGEMENT HANDBOOK
CuRRENT o CLINICAL o PRACTICE
The Pain Management Handbook: A Concise Guide
to Diagnosis and Treatment
edited by M ERIC GERSHWIN AND MAuRicE E. HAMILTON, 1998
Allergic Diseases: Diagnosis and Treatment
edited by PHIL LIEBERMAN AND JoHN A. ANDERSON, 1997
Osteoporosis: Diagnostic and Therapeutic Principles
edited by CLIFFORD J. RoSEN, 1996
THE
PAIN MANAGEMENT
HANDBOOK
A
CoNCISE GuiDE
TO DIAGNOSIS AND TREATMENT
Edited by
M.
ERIC GERSHWIN, MD
and
E.
MAURICE HAMILTON, MD
University of California, Davis, CA
~ SPRINGER SCIENCE+
~ BUSINESS MEDIA, LLC
This volume is dedicated by M. Eric Gershwin to his mother,
"Gary, "for her loving dedication and by Maurice E. Hamilton to
the memory of his sister Karen.
ISBN 978-1-4612-7287-8 ISBN 978-1-4612-1796-1 (eBook)
DOI 10.1007/978-1-4612-1796-1
© 1998 Springer Science+Business Media New York
Originally published by Humana Press Inc. in 1998
Softcover reprint of the hardcover 1st edition 1998
For additional copies, pricing for bulk purchases, and/or information about other Humana titles,
contact Humana at the above address or at any of the following numbers: Tel: 973-256-1699;
Fax: 973-256-8341; E-mail: [email protected]
Ali rights reserved.
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the
Publisher.
Due diligence has been taken by the publishers, editors, and authors ofthis book to assure the accuracy ofthe information
published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that
the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time
ofpublication. Notwithstanding, as new research, changes in govemment regulations, and knowledge from clinica!
experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product
information provided by the manufacturer of each drug for any change in dosages or for additional wamings and
contraindications. This is ofutmost importance when the recommended drug herein is a new or infrequently used drug.
It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients.
Further it is the responsibility ofthe health care provider to ascertain the Food and Drug Administration status of each
drug or device used in their clinica! practice. The publisher, editors, and authors are not responsible for errors or
omissions or for any consequences from the application ofthe information presented in this book and make no warranty,
express or implied, with respect to the contents in this publication.
Cover design by Patricia F. Cleary
This publication is printed on acid-free paper.<22)
ANSI Z39.48-1984 (American National Standards Institute) Permanence ofPaper for Printed Library Materials.
Photocopy Authorization Policy:
Authorization to photocopy items for intemal or personal use, or the interna! or personal use of specific clients, is granted by
Springer Science+Business Media, LLC, provided that the base fee ofUS $8.00 per copy, plus US $00.25 per page is paid directly
to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a
photocopy license from the CCC, a separate system ofpayment has been arranged and is acceptable to Springer Science+Business
Media,LLC.
10 9 8 7 6 5 4 3 2 1
PREFACE
Those who do not feel pain seldom think that it is felt.
SAMUEL JoHNSON, The Rambler, no. 48 (September 1, 1750)
Who among us has not experienced the suffering ofa patient with chronic disease, who
in addition to the vicissitudes of fatigue, anxiety, and frustration, must also deal with the
suffering of pain? Who among us has not considered, and then reconsidered, whether a
patient's complaints are worthy ofa narcotic and thence worried about the social and legal
implications of chronic use? Who among us has not refused pain medications to our
patients for fear that use was turning into abuse? Finally, who among us would not have
liked a clinical guide to a myriad of syndromes, all of which have pain as their common
denominator, in the hopes of developing some strategy to prioritize treatment.
Our purpose in preparing The Pain Management Handbook is to provide the informa
tion needed by clinicians to develop strategies that optimize pain management. It is the
goal oft he editors and authors that the present handbook, above all else, will be clinically
useful. Its aim is to provide practical information regarding the diagnosis and treatment
of disorders causing pain, along with tables and graphics to provide the busy practitioner
with rapid access to relevant data. The reader should be able to initiate appropriate
diagnostic tests and therapy on the basis of the information in this book without having
to consult other references. It is not our intention to be encyclopedic, nor to discuss the
pathophysiology of pain. For the latter, there are far more comprehensive texts available.
Rather, we aim to provide a comprehensive yet succinct presentation of the causes and
treatment of acute and chronic pain across a wide variety ofm edical conditions, one that
is sufficiently detailed to provide all the requisite information, but sufficiently compact
to be relatively portable.
We approach The Pain Management Handbook as specialists in internal medicine,
family practice, rheumatology, neurology, anesthesia, cardiology, gastroenterology,
urology, physical medicine and rehabilitation, and oncology--every writer here has had
considerable experience in treating patients with pain. We believe that this perspective
has helped us create a text that all health care providers will find a highly practical
resource for the diagnosis and treatment of patients in clinical practice. Recognizing the
diverse and multidisciplinary nature of pain treatment, we have provided multispecialty
coverage.
We introduce The Pain Management Handbook with a chapter on the medical evalu
ation of the patient with pain, emphasizing aspects of the history and physical examina
tion that are necessary to correctly diagnose the cause of pain. The following chapters
offer a detailed discussion of the differential diagnosis of pain, presented by anatomical
region in order to facilitate ready use oft his book. Each chapter in this section summarizes
diseases that may cause pain in the affected area and describes appropriate laboratory
studies that will help confirm the diagnosis. Treatment of these diseases is discussed in
practical terms, providing the physician with specific information (including medica
tions and doses) necessary for bedside diagnosis and treatment. These chapters include
v
vi Preface
coverage ofp ain in the head, neck pain, pain in the shoulders and upper extremities, chest
pain, abdominal pain, pelvic, perineal and genital pain, low back pain, and pain in the hips
and lower extremities. Where appropriate, reference is made to chapters dealing with
specific disorders in more detail.
Causes ofm ore generalized pain, such as systemic rheumatic diseases, are considered
in a chapter devoted to musculoskeletal pain. Another chapter describes the treatment of
cancer pain. We have also devoted chapters to postoperative pain and other causes of
pain, including herpes zoster, postherpetic neuralgia, central pain, and psychogenic pain.
The penultimate chapter describes various general aspects of pain treatment. The
pharmacology of analgesic medications is summarized, and adjunctive therapeutic mea
sures, including physical therapy, acupuncture, biofeedback, psychotherapy, and
multidisciplinary (pain) clinics, are reviewed. In addition, special considerations related
to addiction and legal issues are addressed. Finally, because of the increasing issues of
liability, we have included a chapter on key medicolegal aspects of pain management,
including a brief discussion of euthanasia.
Many people helped us in the preparation of the book, especially our thoughtful con
tributors, all from the University of California at Davis. However, we especially want to
thank Nikki Phipps, who assembled the manuscripts and typed many of them. Finally, a
debt ofg ratitude is owed Paul Dolgert, our editor at Humana, who encouraged this project
and helped in its timely delivery. Whatever flaws, errors, or shortcomings that may yet
be found here are ours alone.
M. Eric Gershwin,
MD
Maurice E. Hamilton, MD
CONTENTS
Preface ...................................................................................................... v
Contributors .............................................................................................. ix
1 The Assessment of the Patient with Pain ......................................... 1
Steven H. Richeimer
2 Pain in the Head ............................................................................. 25
N. Vijayan
3 Neck Pain ....................................................................................... 45
N. Vijayan and Stanley M. Naguwa
4 Pain in the Shoulders and Upper Extremities ............................... 57
James C. Leek
5 Chest Pain ....................................................................................... 79
William R. Lewis and Ezra A. Amsterdam
6 Abdominal Pain ............................................................................ 117
R. Erick Pecha and Thomas Prindiville
7 Pelvic, Perineal, and Genital Pain ............................................... 147
Anthony R. Stone and Jae H. Kim
8 Low Back Pain: Diagnosis and Management ............................. 165
E. Ralph Johnson and Viviane Ugalde
9 Pain in the Hips and Lower Extremities ...................................... 191
James C. Leek
1 0 Musculoskeletal Pain ................................................................... 201
Richard H. White
11 Comprehensive Pain Management in the Patient
with Cancer .............................................................................. 219
Scott Christensen, John Linder, John Meyers,
and Frederick J. Meyers
12 Postoperative Pain ........................................................................ 239
Dennis L. Fung
13 Pain by Etiology ........................................................................... 261
Maurice E. Hamilton
14 Treatment of Pain ......................................................................... 283
Maurice E. Hamilton and M. Eric Gershwin
15 Legal Issues in Pain Management: Walking the Tightrope
Between Legal Restrictions and Medical Ethics .................... 353
Charles Bond and Susan L. Ballard
Index ..................................................................................................... 369
vii
CONTRIBUTORS
EzRA A. AMSTERDAM, MD • Division of Cardiovascular Medicine, University
of California at Davis School ofM edicine, Davis, CA
SusAN L. BALLARD, JD • Charles Bond & Associates, Berkeley, CA
CHARLES BoND, JD • Charles Bond & Associates, Berkeley, CA
ScoTT CHRISTENSEN, MD • Division ofH ematology and Oncology and the West Coast
Center of Palliative Education, University of California at Davis School
ofM edicine, Davis, CA
DENNIS L. FUNG, MD • Department ofA nesthesiology, University of California
at Davis School ofM edicine, Davis, CA
M. ERIC GERSHWIN, MD • Division Chief, Rheumatology, Allergy and Clinical
Immunology, University of California at Davis, School ofM edicine, Davis, CA
MAURICE E. HAMILTON, MD • Division ofR heumatology, Allergy and Clinical
Immunology, University of California at Davis School ofM edicine,
Davis, CA
E. RALPH JoHNSON, MD • Department ofP hysical Medicine and Rehabilitation,
University of California at Davis School ofM edicine, Davis, CA
JAE H. KrM, MD • Department of Urology, University of California at Davis School
ofM edicine, Davis, CA
JAMES C. LEEK, MD • Division ofR heumatology, Allergy and Immunology, University
of California at Davis School ofM edicine, Davis, CA
WILLIAM R. LEWIS, MD • Division of Cardiovascular Medicine, Department
ofI nternal Medicine, University of California at Davis School ofM edicine,
Davis, CA
JoHN LINDER, LCSW • Division ofH ematology and the West Coast Center
ofP alliative Education, University ofC alifornia at Davis School ofM edicine,
Davis, CA
FREDERICK J. MEYERS, MD • Division ofH ematology and Oncology and the West
Coast Center ofP alliative Education, University of California at Davis School
ofM edicine, Davis, CA
JoHN MEYERS, PHARM DD • Pharmaceutical Services, Division ofH ematology
and Oncology and the West Coast Center ofP alliative Education, University
of California at Davis School ofM edicine, Davis, CA
STANLEY M. NAGUWA, MD • Division ofR heumatology, Allergy and Immunology,
University of California at Davis School ofM edicine, Davis, CA
R. ERICK PECHA, MD • Division of Gastroenterology, University of California
at Davis School ofM edicine, Davis, CA
THOMAS PRINDIVILLE, MD • Division of Gastroenterology, University of California
at Davis School ofM edicine, Davis, CA
STEVEN RrcHEIMER, MD • Department ofA nesthesiology, University of California
at Davis School ofM edicine, Davis, CA
ix
X Contributors
ANTHONY R. STONE, MBCHB, FRCS(ED) • Department of Urology, University
of California at Davis School ofM edicine, Davis, CA
VIVIANE UGALDE, MD • Department ofP hysical Medicine and Rehabilitation,
University of California at Davis School ofM edicine, Davis, CA
N. VIJAYAN, MD • University of California at Davis Headache Clinic, University
of California at Davis School ofM edicine, Davis, CA
RICHARD H. WHITE, MD • Division of General Medicine, University of California
at Davis School ofM edicine, Davis, CA
1
THE AssESSMENT
OF THE PATIENT WITH PAIN
STEVEN H. RICHE/MER, MD
Key Points
• The primary categories of pain are nociceptive and neuropathic.
• The assessment should focus on understanding the category, cause, and addi
tional emotional and environmental factors that relate to the patients's pain.
• Nociceptive pain is usually very responsive to opioids and NSAIDs.
• Neuropathic pain may respond better to antidepressants, anticonvulsants,
antiarrhythmics, and sympatholytics.
• Treatment ofr elated emotional and environmental factors will improve outcomes.
• Examining coexisting medical and psychosocial conditions can help to prevent
poor outcomes and complications.
• Careful taking ofthe history and performance ofthe physical examination should
provide the critical diagnostic information.
• Pain medications have considerable potential for side effects and drug interac
tions. It is important to obtain careful medication histories.
• The evaluation should include a screening assessment oft he patient's psychological
state, which can uncover signs that more formal psychological assessment is needed.
OVERVIEW
Core Questions to Be Answered as Part of a Pain Assessment
1. What is the type or category of pain?
2. Is there a primary cause of the pain?
3. What additional factors are contributing to the pain?
4. Are treatments available for the primary cause of the pain?
5. Are treatments available for the additional factors which contribute to the pain?
6. Are there other medical or psychosocial conditions that should influence the
choice of treatment?
1
