Approximately 23.3 million operations were performed in 1989 in the United States, and most of these involved some form of pain management. Unfortunately, clinical surveys continue to indicate that routine orders for intramuscular injections of opioid "as needed"-the standard practice in many clinical settings-fail to relieve pain in about half of postoperative patients. Postoperative pain contributes to patient discomfort, longer recovery periods, and greater use of scarce health care resources and may compromise patient outcomes. There is wide variation in the methods used to manage postoperative and other acute pain, ranging from no set strategy to a comprehensive team approach as advocated in this clinical practice guideline. This guideline sets forth procedures to minimize the incidence and severity of acute pain after surgical and medical procedures and pain associated with trauma in adults and children. It offers clinicians a coherent yet flexible approach to pain assessment and management for use in daily practice. Although it is not practical or desirable to eliminate all postoperative and other acute pain, an aggressive approach to pain assessment and management can reduce such pain, increase patient comfort and satisfaction, and in some cases, contribute to improved patient outcomes and shorter hospital stays. This clinical practice guideline was developed under the sponsorship of the Agency for Health Care Policy and Research (AHCPR), Public Health Service, U.S. Department of Health and Human Services. To develop the guideline, AHCPR convened an interdisciplinary expert panel made up of physicians, nurses, a pharmacist, a psychologist, a physical therapist, a patient/consumer, and an ethicist. The panel first undertook an extensive and interdisciplinary clinical review of current needs, therapeutic practices and principles, and emerging technologies for pain assessment and management. Second, the panel conducted a comprehensive review of the field to define the existing knowledge base and critically evaluate the assumptions and common wisdom in the field. Third, the panel initiated peer review of guideline drafts and field review with intended users in clinical sites. Comments from these reviews were assessed and used in developing the guideline.

Cancer is increasingly prevalent in the United States, and the pain associated with it is frequently undertreated. Cancer is diagnosed in over one million Americans annually, and one of five deaths in the United States---about 1,400 per day---results from cancer. Patients with cancer often have multiple pain problems, but in most patients, the pain can be effectively controlled. Nevertheless, undertreatment is common because of a lack of knowledge by clinicians about effective assessment and management, negative attitudes of patients and clinicians toward the use of drugs for pain relief, and a variety of problems related to drug regulations, and the cost of and reimbursement for effective pain management. This guideline was developed by an interdisciplinary panel of clinicians, patients, researchers, and experts in health policy. The guideline provides a synthesis of scientific research and expert judgment to make recommendations on pain assessment and management. Approximately 470 health care professionals and 70 patients were involved either as consultants and peer reviewers or as participants in pilot testing. The Clinical Practice Guideline for the Management of Cancer Pain was commissioned by the Agency for Health Care Policy and Research (AHCPR). It follows and makes reference to an earlier guideline on acute pain management after surgery or trauma, also commissioned by AHCPR. The cancer pain guideline includes a section on the management of HIV positive/AIDS---related pain because of similarities in the sources of pain and the management approaches. This guideline is designed to help clinicians understand the assessment and treatment of cancer pain and associated symptoms. It reflects a multimodal approach to the management of pain, and it emphasizes the need for careful and continuous assessment to match interventions to the sources of pain in individual patients.

Sodium channels confer excitability on neurons in nociceptive pathways and exhibit neuronal tissue specific and injury regulated expression. This volume provides recent insights into the control of expression, functioning and membrane trafficking of nervous system sodium channels and reviews why sodium channel sub-types are potentially important drug targets in the treatment of pain. The roles of sodium channels in dental and visceral pain are also addressed. The emerging role of sodium channel Nav1.3 in neuropathic states is another important theme.

Authors from the pharmaceutical industry discuss pharmacological approaches to the drug targeting of sodium channels, and in particular Nav1.8, exclusively expressed in nociceptive neurons. The final chapter highlights the functional diversity of sodium channels in part provided by post-transcriptional processing and the insights into sodium channel function that are being provided by tissue specific and inducible gene knock-out technology.

-- Are patients aware of the fact that pharmacological therapies stress the brain in ways which may prevent or postpone symptomatic and functional recovery ? ==================================================== Rethinking Psychiatric Drugs: A Guide for Informed Consent is a critical appraisal of the medications which an estimated 20% of Americans consume on a regular (and sometimes involuntary) basis. It is the philosophically, epidemiologically, and scientifically supported revelation of how and why psychiatry's drug therapies have contributed to a standard of care which frequently does more to harm than to cure. Extensively researched and documented, the book addresses: -- the process by which psychiatric drugs reach the market -- the history and philosophy of Evidence Based Medicine -- the common flaws in research methodologies which negate the validity of the psychiatric RCT (Randomized Controlled Trial) -- the problem of allostatic load (how drugs stress the body) -- the history, long term effects, and utility of the drugs used to suppress symptoms of depression, psychosis, inattention and hyperactivity -- the effectiveness of alternatives to medication Rethinking Psychiatric Drugs: A Guide for Informed Consent exposes the current crisis in medical ethics and epistemology, and attempts to restore to psychiatry an authentically informed consent to care.

Readers have access to legions of books dealing with the molecular, genetic, neurochemical, neurophysiological, neuroanatomical, neuroradiological and psychological aspects of pain as well as with the clinical approaches to pain from various medical disciplines. Why then is it necessary to publish a book on the pathophysiologyofpain perception? Pain can result either from noxious events due to lesions, injuries, diseases, etc. , or from disturbances in the system transducing, transforming, and processing the potential pain signal or from an interaction of both. Under certain pathological conditions, the pain-processing system, which includes both physiological and psychological components, can produce the experience of pain in the absence of any peripheral noxious event. This book primarily ex- amines these pathological alterations in the pain-signalling system, and the authors provide information on the functioning of the pain-processing system under normal and pathological conditions. The understanding of pain perception is essential for optimal diagnosis and treatment of acute and chronic pain. Considerable evidence now indicates that alterations in pain per- ception are characteristic of many clinical pain states. Whether disturbed pain perception is a truly etiological or only a maintaining factor-c-or even a mere epiphenomenon of chronic functional pain-is reviewed in detail by L. Arendt-Nielsen, C. R. Covelli, R. B. Fillingim,]. M. Gillespie, T. Graven-Nielsen, E. Kosek, S. Lautenbacher, M. Peters, A. Pielsticker, DO. Price, G. B. Rollman, P. Svensson and G. N. Verne for headache, back pain, fibromyalgia, myofascial pain, temporomandibular pain disorder, irritable bowel syndrome and menstrual cycle-related pain disorders.

Immune Mechanisms of Pain and Analgesia is the first volume to discuss a new concept of immune-neural interplays leading to pain or analgesia. It argues the classical view that pain and its control are restricted to the nervous system, offering a comprehensive overview of the emerging area of immune mechanisms in pain and its control. It challenges the traditional view that pain sensation or suppression is attributed exclusively to the nervous system and presents a critical analysis of this new concept. The book is written by an internationally recognized group of researchers and discusses complex and controversial issues such as cytokines and their pain-exacerbating but also analgesic effects, the production of opioids by immune cells, peripheral analgesic and anti-inflammatory actions of opioids, immunomodulatory effects of opiates, and immunosuppressive effects of pain.

This book is an extension of my 1992 book entitled The Social Context of Chronic Pain Sufferers. Many ideas nominally explored there are elaborated in this volume, which is an attempt to fill a major gap in the chronic pain literature. Although there has been a virtual flood of new works on the medical and psychological aspects of chronic pain, such enthusiasm is somewhat muted in relation to the social environment of the patient. Although there is universal recognitionamongpain expertsthat biological, psychological, and socialfactors influence the experience ofpain, the social component (forreasons that are - clear) has failed to attract much attention. Theneed forabook focusedonsocialrelationsisobvious.Thepatientisnot merelyacarrierof symptoms.Thereis alargesocialrealityinthe background of each patient; that reality can have multidimensional consequences, from the way pain is perceivedto seriousfinancialhardshipand other sourcesof stress, c- plicating treatment, management, and, ultimately, the prognosis. Clinicians rec- nize the value of incorporating the social dimension in the overall evaluation and treatment of the patient. This book attempts to accomplish that task. In order to achieve that objective, this volume addresses many important e- ments inthepatient'ssocial environment-the mostsignificantbeingthefamily. Beyond the family, for a vast majority of patients, work represents a major source of economic security and self-esteem. Job loss, common in this population and a major cause of much personal and family distress, needs critical examination.

This book is an in depth guide to chronic and neuropathic pain. The issue of chronic and neuropathic pain is very prevalent, yet only a fraction of the symptoms and root causes, as well as potential treatment plans, are properly understood. Additionally, less than half of cases are accurately identified and properly treated. The existing drugs, although classified as very strong and powerful, cannot provide lasting relief to chronic and neuropathic pain. Thus, with all the unique features of this condition, this book presents a systematic way of diagnosing and approaching this condition so every practitioner can appropriately treat their patients. In addition to introducing key concepts, like classification of chronic pain and the challenges patients and practitioners face when dealing with and treating chronic and neuropathic pain, this book also covers different syndromes that can lead to neuropathic pains. It discusses how to monitor progress by using outcome measures, the presence of chronic and neuropathic pain in children and young adults, and the pathophysiology of neuropathic pain as it relates to the release of pro-inflammatory cytokines. Interestingly, the latter is not presently addressed except with the usual pain drugs for general pain-this book aims to revolutionize the approach to chronic and neuropathic pain by exploring it separately from the clinical approach to general pain. It is interesting to note that these cytokines require a specific mode of action if we want to neutralize them in our system, and this concept will be discussed in the regenerative intervention sections. Since it is so necessary to address the many factors to chronic and neuropathic pain as laid out in the proposed table of contents, it is also critical include as varied authors as possible to address this condition from all areas being covered. The team assembled to author the chapters included in this text come from diverse backgrounds of practice and clinical and research interests, from physical medicine and rehabilitation to anesthesiology to radiology and interventional pain medicine. This is an ideal guide for all clinicians caring for patients with chronic and neuropathic pain.

The interest of researchers, clinicians, practitioners and surgeons in critical care medicine is growing. Clinical pharmacology and new technologies now allow more appropriate therapies, and the commitment of all those involved in this field is of fundamental importance for reaching high interventional standards, in both the prevention and treatment of critical conditions, but also for satisfying the concept of cost-effectiveness in critical care. In this volume advances in critical care medicine are described, including the application of new technologies in the clinical setting, the full integration of computers and informatics, and the continual training of physicians and technicians.

If you are one of the 45 million Americans suffering from chronic pain, you've most likely seen numerous doctors and tried a wide range of medicines and treatments, only to alleviate your pain. You've probably come to believe that there's nothing to be done and that your chronic pain, is, well, chronic. Now, in a groundbreaking contribution, Dr. Scott Fishman introduces an interdisciplinary pain-management approach that integrates traditional and alternative techniques including pharmcology, neuroscience, experimental precedures and mind-body medicine. For anyone who suffers from chronic pain conditions such as back pain, post-surgical pain, migraines, and arthritis, The War on Pain, with the latest research personal stories of patients, and the wise and compassionate advice of a leading pain expert, is a patient's best defense.

With new chapters on herbs and vitamins, "triptans," headache during breast feeding, menstrual migraine, opiate abuse, cervicogenic causes of headache, and exercise and sexual headache plus full revisions and updates, Management of Headache and Headache Medication presents a full and indepth range of information for the management of headache by primary care physicians and neurologist.

Designed and written by a team of clinically established academics, this is a unique book that is an excellent manual for physicians practicing pain medicine or treating pain in neurosurgery, orthopedic, neurology, or family practice clinics. As a practical resource, this book is written to be more accessible to the reader and is designed to be more clinically-focused and useful in day-to-day practice. This 102 chapter volume is divided into seven separate sections: Anatomy and Physiology of Pain, Psychology of Pain, Pharmacological Treatment of Pain, Interventional Treatment of Pain, Adjuvant Therapies for Pain and Suggested Reading. The calculated organization of this book is supplemented by key photos, drawings and a self-assessment of four key questions at the end of each chapter -- thus making it an indispensable, pragmatic resource that will benefit anyone working in the pain management field. Deer's Treatment of Pain: An Illustrated Guide for Practitioners contains pearls for improving knowledge and improving one's practice as a physician.

Within the past few years, it has become recognized that the immune system communicates to the brain. Substances released from activated immune cells (cytokines) stimulate peripheral nerves, thereby signaling the brain and spinal cord that infection/inflammation has occurred. Additionally, peripheral infection/inflammation leads to de novo synthesis and release of cytokines within the brain and spinal cord. Thus, cytokines effect neural activation both peripherally and centrally. Through this communication pathway, cytokines such as interleukin-1, interleukin-6 and tumor necrosis factor markedly alter brain function, physiology and behavior. One important but underrecognized aspect of this communication is the dramatic impact that immune activation has on pain modulation. The purpose of this book is to examine, for the first time, immune-to-brain communication from the viewpoint of its effect on pain processing. It is aimed both at the basic scientist and health care providers, in order to clarify the major role that substances released by immune cells play in pain modulation. This book contains chapters contributed by all of the major laboratories focused on understanding how cytokines modulate pain. These chapters provide a unique vantage point from which to examine this question, as the summarized work ranges from evolutionary approaches across diverse species, to the basics of the immune response, to the effect of cytokines on peripheral and central nervous system sites, to therapeutic potential in humans.

Pain and inflammation are inextricably linked phenomena. The observation that chemical mediators with combined pro-inflammatory, algesic and/or hyperalgesic activity occur at the site of inflammation is fundamental not only to our present understanding of the inflammatory process but also to our attempts to devise clini- cally useful anti-inflammatory therapies. Over a hundred years ago it was recognised that primary sensory neurones play a crucially important "dual" role in inflammation. By affecting the transfer of infor- mation from peripheral nociceptors to the spinal cord, a subpopulation of sensory nerves {"pain fibres"} initiate algesia and hyperalgesia, whose sensations are then modified and fine-tuned in the central nervous system. Equally important is the release from the peripheral terminals of sensory neurones of neuropeptides, the acute effects of which are observed as changes in microvascular tone and perme- ability leading to neurogenic inflammation. Over the last decade it has become increasingly clear that this view of the func- tion of sensory nerves is somewhat over-simplified. For example, the mechanisms underlying hyperalgesia may, in certain circumstances, be mimicked in other condi- tions such as the hypersensivity associated with asthma. Furthermore, it has become increasingly evident that over a longer time period the release of neuropeptides from peripheral sensory nerve endings may also have modulating effects on inmune cells and that this may be relevant to chronic inflammatory disease and possibly also to inflammatory hyperalgesia.

In "The Pain Cure", Dharma Singh Khalsa, M. D., and Cameron Stauth team up again to offer a comprehensive, proven program for chronic pain sufferers. Combining physical, mental, and spiritual strategies, this new program will help patients lead pain-free lives again and regain their sense of personal power and control over their lives. Dr. Khalsa's case histories show that even with the most serious conditions, success has occurred, and it is possible to return to a life of feeling great. For the millions living with chronic pain syndrome, this is truly a book that will change their lives.

Pain Management and Anesthesiology contains the presentations made at the 43rd Annual Postgraduate Course in Anesthesiology sponsored by the University of Utah and held at Snowbird, Utah, USA, February 20-24, 1998. This volume addresses recent advances in the understanding of the basic science and clinical management of pain. The textbook includes sections on recent advances in the understanding of pain signal processing, as well as reviews of the clinical management of acute, chronic, cancer-related, and pediatric pain. In addition, this text includes a discussion of the behavioral assessment and treatment of the pain patient. This textbook is the sixteenth in a continuing series documenting the proceedings of the postgraduate course.

Greek and Swedish ethnologists, anthropologists, psychiatrists and psychologists provide 11 essays which aim to describe how people handle pain culturally and how they define themselves and those around them. The essays take up life histories of people suffering pain, of those trying to come to grips with psychosomatic disorders, of children exposed to traumatic experiences, and of patients living with leprosy. They also discuss: the problems that people encounter when exposed to diagnosis of elevated cholesterol levels; how notions of masculinity have been forged through asceticism towards pain; and how death, body, pain, and suffering are interpreted in different cultural settings.

Chronic Pelvic Pain: Evaluation and Management presents a clinically oriented, multi-disciplinary approach to the diagnosis, treatment, and management of chronic pelvic pain in women -- one of the most common problems encountered in the practice setting. The editors present this challenging and often vexing subject in a practical, user-friendly, highly illustrated text, including chapters on: physiology of pain; pain associated with endometriosis; pain associated with fibroids; surgical management; the role of office based surgery; the role of the psychiatrist in pain management; pelvic pain of urinary origin; pelvic pain of gastrointestinal origin. Designed to be incorporated into the every day practice, this book is a must for all clinicians in obstetrics-gynecology as well as for any physician involved in the health care of women.

Cancer: Palliative Care examines the nature of the care and support that can be provided to those in need of palliative care and their families. This covers not only the physical treatment, such as pain management, but also the psychological well-being of patients. Health workers, clinicians, specialist nurses and medical students will find a balanced and thoughtful overview of the subject which will be of value in managing patients and helping them to come to terms with their condition.

The management of critically ill patients has, in the past few years, been a discipline at the forefront of development which continues to make progress with the support of basic and clinical research in the broadest sense. The application of biotechnology in this particular area has revealed itself to be essential in an attempt to provide the best interpretation of the bio-humoral and functional alterations present in a long series of often complex clinical conditions. The care of the critically ill is also at the forefront in the application of increasingly sophisticated clinical monitoring systems that also contribute to standardizing certain procedures, establish guidelines, and evaluate the efficacy of therapeutic interventions and their costs

There is no ideal analgesic and the most potent drug is not always the best because of its side-effects. Non-opioid analgesics, including the non-steroi- dal anti-inflammatory drugs and the non-narcotic analgesics, play an im- portant role in the relief of a wide spectrum of painful conditions, though they vary in efficacy and safety. This book reviews the role which non-opi- oid analgesics play in the relitff of pain, particularly with regard to post- operative and cancer pain. Emphasis is placed on the clinical indications for the non-acidic analgesic, dipyrone, and its relative safety in comparison to other non-opioid anlgesics. Michael J. Parnham 9 Introductory remarks Klaus A. Lehmann, Department of Anaesthesiology and Operative Intensive Care, University of Cologne, J osef-Stelzmann-Str. 9, D-50924 Cologne, Germany Opioids are considered to be the most potent analgesics for the manage- ment of acute and chronic pain. Much progress has been achieved with respect to their general availability in most countries, and health care per- sonnel have been encouraged to use these drugs more generously in a vari- ety of pain syndromes, including post-operative or cancer pain. The intro- duction of new techniques such as Patient-Controlled Analgesia (PCA) or guidelines such as the WHO ladder concept for cancer pain mangement have considerably increased our knowledge of their benefits and prob- lems.