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This chapter provides some insights into the book's recommendations for safe and effective practice of pain management in day-to-day emergency department (ED) practice. Pain is a cultural phenomenon as well as a physical one. Certain kinds of patients obtain more attention from their relatives or immediate companions and friends, and seem always to overreact to pain. There appear to be many patients (e.g. some with sickle cell crisis) who prefer meperidine to morphine for pain relief. It is wise to remember the three missions of medicine:to cure disease, to relieve ongoing ravages of disease, and to provide comfort. As an overarching guide, remember that because pain is subjective to the patient, it is also subjective to the physician. We have the training, the experience, and the expertise to interact in a way that provides comfort. It never hurts to lean to the side of providing that comfort.
Acute care providers need to be familiar with phantom limb pain (PLP) as the complaint occurs in up to 80% of patients after amputation and it is important to institute early and effective intervention. Opioids are commonly recommended for acute treatment of PLP. Oral opioids, usually in combination with another agent (e.g. calcitonin), form the mainstay of PLP therapy. The benzodiazepines, which potentiate the spinal neuronal inhibitory effects of gamma-aminobutyric acid (GABA), may ameliorate pain from acute PLP flares. In contradistinction to their utility in other forms of neuropathic pain, antidepressants have only a limited role for acute PLP. The anticonvulsants have been investigated for PLP, with mixed results. Carbamazepine is postulated to be of utility, but supporting evidence for its use in PLP is anecdotal. There is stronger evidence for gabapentin prescription in PLP.