British Journal of Anaesthesia 111 (4): 681–3 (2013)
BOOK REVIEWS Oxford Pain Management Library—Opioids in Non-Cancer Pain, C. Stannard, M. Coupe and T. Pickering (editors). Published by Oxford University Press. Pp. 112. Price £12.99. ISBN 978-0-19967807-5.
A. Moore Oxford, UK E-mail: [email protected]
SBAs and MCQs for the Final FRCA, R. Tandon (editor). Published by Oxford University Press. Pp. 287. Price £34.99. ISBN 978-019-96613-6. The Single Based Answer (SBA) is a form of multiple choice question which is characterized by a stem, a specific lead-in question, and five optional answers. The advantage of the SBA is that it measures the candidates’ understanding of a clinical problem rather than ability to memorize large numbers of facts. In response to the recommendations of the Postgraduate Medical Education and Training Board (PMETB), the College of Anaesthetists recently changed the MCQ paper of the final part exam to include 30 SBAs along with 60 traditional true –false questions. SBAs and MCQs for the Final FRCA, edited by Rakesh Tandon, consultant anaesthetist based at Addenbrookes Hospital, Cambridge, has been written to accommodate the new examination. The book consists of four practice exams, each using the same exam format detailed above. Detailed answers follow each exam, and importantly are based on evidence from peer-reviewed publications. References are provided after each answer allowing further detailed investigation and learning. The fifth chapter is divided into three SBA exams, each with 30 questions. Thus, in total, the book provides 240 true –false questions and 210 SBA questions. The nature of the questions follows the final part exam. The SBA component differs from the traditional true –false MCQ by placing a greater emphasis on clinical anaesthesia problem solving. Twenty questions reflect clinical anaesthesia, five intensive care, and five pain management. I found this book extremely informative and a good resume of knowledge and general clinical practice. The questions are well thought out and the references of high standard and easily accessible. It clearly fulfils a need and I would thoroughly
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What is the role of opioids in chronic non-cancer pain? They are used frequently: about 1% of the UK population is using an opioid for chronic non-cancer pain at a cost of around £250 million a year in primary care in England. On the one hand, the evidence base for efficacy in any type of chronic noncancer pain is at best weak, and probably non-existent. As we look at the evidence of efficacy with an increasingly cold and fishy eye because of emerging knowledge about biases in clinical trials, we can find little or no evidence that opioids actually work in chronic non-cancer pain, with the exception of tapentadol. On the other hand, developing evidence associates opioids use with considerable harm, particularly in older people. How did it get to this? For musculoskeletal pain, the coxib cardiovascular hype of the 1990s resulted in a mass movement away from all non-steroidal anti-inflammatory drugs, leaving paracetamol and opioids as more or less the only pharmacological alternatives. Guidelines for neuropathic pain have tended to suggest the use of only a few drugs, and, in primary care particularly, local prescribing advice meant that newer, probably better, but more expensive drugs were not on formulary and were not prescribed. Again, opioids filled the gap. We are in an uncomfortable place, beset by concerns about what to do for the best at what may just be a tipping point. Many of us feel the need for a guiding hand and a word of wisdom. Help is at hand, in the form a splendid little book from Cathy Stannard and colleagues from Bristol. It is beautifully written, well informed on the topic of opioids for chronic non-cancer pain, and neatly packaged into only 112 pages. It is replete with good common sense and devoid of brain-warping statistics. Each chapter presents its information under appropriate headings. Above all it is a book that is fun to read—more like a conversation with a wise and respected colleague than a learning chore. The format is a series of 14 short chapters and four useful appendices. It starts with a history of opioids and their pharmacology, moves through the international perspective on opioid prescribing, benefits and harms, and concentrating on evidence for the use of opioids in back pain, osteoarthritis, and neuropathic pain. Along the way, it provides some useful insight into pharmacology and genetics, without stretching the neurones too far. The evidence base may not be great, but that does not prevent the book coming with lashings of wisdom about the hows and whys of prescribing opioids. For a non-clinician, it was a bit of an eye-opener to consider the practical problems around opioid prescribing and the relationship to addiction,
in the longest chapter in the book. The standout pragmatic guidance was that prescribing more than 120 mg of oral morphine equivalents a day may not be the best idea. The first edition of this book came out in 2007. The intervening 6 yr have seen a lot of changes. Between now and any future edition (in 2020, say), there will be more, and some of those changes are not easy to predict. For those having to prescribe opioids in the meantime, reading this book represents a painless and pleasurable way of getting up to speed with what is known now, and should make negotiation of the changes to come a good deal easier.