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Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
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Chapter 38 – Chronic and Cancer Pain Care: An Introduction and Perspective

Chronic and cancer pain evokes many images to physicians, patients, and families. For too long chronic and cancer pain has been an undertreated and neglected part of our society’s medical care delivery system. Those of us involved in pain medicine, both physicians and patients, know that these pain states are very real and often poorly managed by both colleagues and patients.

Many have considered short-term approaches to pain care as ideal, using nerve blocks to the exclusion of other therapies. Other colleagues have vigorously and actively avoided using any regional analgesia techniques in the chronic or cancer pain patient. As a physician with a practice of pain medicine spanning over two decades, I believe those at both polar ends of this conceptual continuum ( Fig. 38-1 ) have selected incomplete and inappropriate approaches to pain medicine patient care. In my practice over the years and in a wide variety of patients, few of the patients have received recommendations for an exclusive regional analgesic/anesthetic approach to their pain control or rehabilitation regimen. In fact, many of my patients are given oral analgesia options with a physical rehabilitation and activity regimen, without any regional techniques as part of their therapy. These concepts do not suggest that regional analgesia/anesthetic regimens are not indicated in our patients. Conversely, they are indeed indicated in many patients, but they should be used with a clear indication of how they can help with the diagnosis or for pain control and a rehabilitation regimen in the chronic pain patient. Their use should be incorporated into a chronic rehabilitation and cancer pain control regimen that focuses on return of function, always keeping in mind our charge as physicians to balance the risk and benefit for each patient as an individual.

Click to view full size figure

Figure 38-1  Concept of a continuum of pain medicine for patient care.

I ask that each of us use the techniques described in the following chapters on chronic pain medicine without seeking to establish positions at either pole of the regional anesthesia technique continuum. These opposing poles are represented by nerve block nihilism and exclusively nerve block care. Our patients can best be cared for by mature, logical application of the rehabilitation and palliation options so well outlined in the following chapters. I particularly thank Dr. James Rathmell for providing his sound insights into the many new chapters found in this section of the Atlas.

The techniques outlined represent a select group of techniques in pain medicine practice. The list is not exhaustive but, rather, a group of techniques that my contributors and I have found helpful in our own pain medicine practices. Most important with any of these techniques is to approach the patient as an individual with unique needs while always thinking first like a physician and holding that age-old tenet of “first, do no harm” close to the decision making.

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