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John D. Loeser, MD, Department Editor
Reviewed by Arthur G. Lipman, PharmD FAHSP
Chas Bountra, Rajesh Nunglani, and William K. Schmidt (Eds.), New York, Marcel Dekker, 2003, 968 pages, $228.95 (hard cover), ISBN 0-8247-8865-6.
As described in the preface, this book was designed to describe both basic and clinical elements of the current understanding of pain mechanisms and ways to approach them clinically. Recognizing that such a book is often dated at the time it is published, the editors encouraged authors to list additional readings that appeared after the chapters were written. Over 140 authors, mainly from academia and the pharmaceutical industry, contributed to the work. The editors and authors of this ambitious undertaking deserve congratulations for producing a single volume that summarizes of a broad range of issues relevant to analgesic development and pain management. The book focuses on novel approaches to drug discovery, but other succinct and very well-referenced chapters provide valuable overviews of a range of topics of interest to investigators and clinicians from a broad range of pain-related disciplines, not just pharmacologists.
The book is divided into four sections entitled “Basic Aspects” (9 chapters), “Clinical Aspects” (16 chapters), “Novel Approaches” (4 chapters), and “New and Emerging Therapies” (39 chapters). Important questions addressed in this volume include whether preclinical technologies currently in use are clinically relevant and why it is so difficult to demonstrate proof-of-efficacy in humans with mechanistically based pharmacological approaches.
The first chapter sets the tone for the book by discussing mechanism-based classifications of pain and analgesic discovery. The authors posit that the paradigm of analgesic discovery must change to one based on pain mechanisms. Subsequent chapters in the “Basic Aspects” section describe our current understanding of several important mechanisms of pain transduction, transmission, and modulation (both central and peripheral).
The “Clinical Aspects” section addresses numerous methods, not just pharmacotherapy, for pain source identification and differentiation in addition to management. Topics include relevant anatomy and physiology (e.g., neuropathic and painful disease) and specific pain types (e.g., inflammatory joint disease). The “Novel Approaches to Drug Discovery” section, the shortest of the four sections, addresses molecular biology, genetics, and animal models of pain.
The fourth and longest section, “New and Emerging Therapies,” describes new and emerging therapies, investigational drugs, receptors and other targets for pain therapy, and combination pharmacotherapy (which this reviewer coins as rational polypharmacy); modulation of pain facilitating and inhibiting endogenous transmitters and other chemicals; and some specific drugs classes. Two useful appendices list analgesics marketed in the United States between 1998 and 2001 and a 21-year survey of analgesics in development for acute and chronic pain.
No one book can address in depth all of the topics found in this volume. This unique book provides an impressive breadth of topics in its nearly 70 well-written chapters. In the first three sections, the editors did an admirable job of presenting the topics in a logical, cohesive order and in minimizing the redundancy and stylistic differences that inevitably occur in a book written by so many authors. Unfortunately, the fourth section—the part of the book that might be of greatest interest to clinicians—is at times inconsistent and redundant. The chapter on combining nonsteriodal anti-inflammatory drugs and opioids incorrectly characterizes the approach to analgesia use as stepwise. Both the World Health Organization and U.S. Department of Health and Human Services explicitly state in their guidelines that the 3-step analgesic ladder is not intended to suggest step therapy. For severe pain, the 3rd step is often the proper level at which to initiate therapy. The discussion of neuropathic pain therapy is duplicative in several chapters and somewhat inconsistent. Some of the tables and figures lack sufficiently descriptive captions to be fully understood by readers who are not experts in the topics. The first three sections of the book and selected chapters in the fourth section are well done and deserve the attention of serious students, investigators, and scholars in drug development as well as pain management.
Dr. Lipman is Professor of Pharmacotherapy, College of Pharmacy, Adjunct Professor of Anesthesiology, School of Medicine, and Director of Clinical Pharmacology, Pain Management Center at the University of Utah Health Sciences Center in Salt Lake City.
Reviewer content represents the opinion of the reviewer, not APS.
Please direct your suggestions for future Resource Reviews to John D. Loeser, MD, Department Editor, at jdloeser@u.washington.edu
