Pharmacology of Pain

P. Beaulieu, D. Lussier, F. Porreca & A. Dickenson ( Eds ) International Association for the Study of Pain , Seattle , 2010 ISBN 978-0-931092-78-7 , 622 pp., Price £108; US$100 (member price US$80) Pain is a subject that most of us regard as our ‘bread and butter’. Chronic pain anaesthetists practise at one end of the hospital, rarely seen as they are run off their feet in clinics, coping with the expanding chronic pain pandemic we seem to be facing. The acute pain teams frantically move from one surgical ward to another, dealing with the ever-increasing postoperative patient base. Texts have a lot to live up to as their competition and number are so great. The authors of this book have chosen to tackle the pharmacology of pain in huge depth. The writers comprise a physician with an interest in pharmacology research, an anaesthesiologist and a professor of pharmacology and anaesthesiology – all from Canada. Finally, a professor of neuropharmacology from the UK completes the team. Section I of the book starts with a recap of the neurophysiology of pain, beginning at the periphery and its receptors and moving on to a detailed discourse of central pain pathways and complex neuroanatomical/physiological relationships. Next, the authors approach the taxonomy of analgesics with exemplary clarity. There are various clear tables comparing the different existing taxonomies in current use; on reading further it is clear why we all become slightly confused over such classifications, as there appears to be no generic consensus on the correct one to use in everyday practice, or indeed when teaching. Section II explores 14 specific pharmacological pain targets in micro-detail (the cannabinoid system, the cyclo-oxygenase pathway, opioid pathways and the 5-HT receptor system are all examined, as well as others). Armed with this sort of information for a viva, one would expect to be a firm runner for a distinction medal. The authors provide a commendable delineation of the exact modes of action of drugs, at both receptor/effector and microcellular levels. After reading this section, it was clear to me that my knowledge of some of these drugs was somewhat antiquated! It is clear from examining the references and the clear and colourful diagrams that a vast amount of work has gone into this section. Section III focuses on special topics within pain pharmacology. It opens with a fabulous description of addiction and tolerance, from a theoretical and evidence-based platform. The neurophysiological pathways concerned are dissected, revealing that things are far more complicated than we first knew. Patients who seem to lie outside the ‘norm’ are depicted in the next section on pharmacogenetics of pain inhibition. This gives us some idea as to why one patient in recovery seems to have emptied the cupboard of analgesics, while the next patient is narcotised after a minute quantity. Again, the situation is complex, particularly when the list of genes identified extends well into double figures. Following this, the section on why placebo works is enthralling. There are sublime CT and MRI images of the brain, backing up hypotheses from a variety of excellent, well validated studies. The final component to section III discusses animal models of pain. This section may appeal to the more laboratory oriented among us; however, at times I felt mild narcosis myself while attempting to follow some of the complex experimentation and methodology. Finally, the book closes with a section on clinical applications of the pharmacology of pain, including obstetrics, paediatrics, the elderly, obesity and palliative care. In summary, this is a fabulous book, advanced from its outset, but not the easiest of reads. Certainly it offers a wide and experienced knowledge base, backed up by a vast array of clinical and non-clinical research, and I would recommend it for those of us interested in this ever-expanding field of anaesthesia and critical care.

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