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xiv Foreword
code to light up the part of the body hurting in a brilliant color, the intensity of
which would vary with the degree of pain. Unfortunately, there are no
objective findings that define the presence of pain. A change in vital signs
(e.g. tachycardia) does not mean that there is pain, and stable vital signs do not
mean pain is absent. Moreover, the vital sign changes are often inconsistent;
pain can simultaneously elevate blood pressure and decrease heart rate.
Furthermore, we are conditioned to worry about causing or contributing
to addictive behaviors, although it is impossible to show that diseases (e.g.
sickle cell) that cause significant episodes of pain lead to addiction. Because
of these worries, we often underdose analgesic therapy, and formulate
incorrect perceptions about patients when they are in-between pain crises.
For example, if one sees a patient with renal colic, the perception of the
patient’s pain is quite different if the patient is viewed during stone movement
rather than during the periods between movement.
This text is an effort to help to solve some of the dilemmas that exist in the
recognition and management of a patient’s pain. By reviewing the data that
exist concerning the efficacy of various forms of pain relief in different
conditions, we hope to assist the physician in forming intelligent judgment
about which therapies are efficacious, what dosages to use, and what therapy
does not work despite the legends that surround it.
The book cannot replace an empathetic and sensitive physician evaluation.
There is no question that some patients cannot describe the nuances of
their pain; they either do not have the language skills, or they are so focused
upon their distress that they cannot talk about it. They know they are hurting,
and whether the pain is throbbing, stabbing, radiating, or the worst they have
ever felt is colored by their individual abilities to withstand discomfort, as
well as their individual abilities to describe it. It requires experience and
sympathy, as well as a willingness to trust the patient, to obtain an appreciation
of how the patient feels. Many older patients appear stoic, but this may
be because they cannot perceive or describe pain as readily as a younger
patient, even though they are hurting. Some patients are so frightened of pain
that any degree is enough to induce hysteria and even collapse. Some of this
may be learned behavior, induced by the patient’s historic and immediate
culture. Some of this is variation on how patients tolerate discomfort. Some