Summer 2010 - The British Pain Society

s u m m e r 2 0 1 0 

pain news 

a publication of the british pain society 

Joint statement from BPS and NICE 

How to create a Special Interest Group 

The Manchester ASM 

New leaflet for Over the Counter Painkillers 

Teaching your grandmother to suck eggs 

The Painful Truth 

Opioid prescribing 

Diamorphine -Necessary or Not? 

Pain and Semiotics 

Painting over the cracks 

The Art of Dying 

End of Life Assistance Bill 

Vitamin C and CRPS 

An Audit of Epidural Injections for pain 

an alliance of professionals advancing the understanding 

and management of pain for the benefit of patients

ADVANCING 

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12 

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PAI N N E W S S U M M E R 2010 

iordan Mihaylov 

shyaM BalasuBraManian 

univErsity hosPitaLs covEntry and 

warwickshirE 


PAI N N E W S S U M M E R 2010 13 

PAI N N E W S S U M M E R 2010 53 

Third Floor Churchill House 

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The opinions expressed in PAIN NEWS do not necessarily reflect those of the British Pain Society Council. 

contents 


BPS Council 

Professor Richard Langford 

President 

Dr Joan B Hester 

Past President 

Dr William Campbell 

Honorary Secretary 

Dr Patricia Schofield 

Honorary Secretary Elect 

Dr John Goddard 

Honorary Treasurer 

Elected members of Council 

Dr Nick Allcock 

Dr Andrew Baranowski 

Dr Sam Eldabe 

Dr Austin Leach 

Dr Edward Lin 

Dr Mick Serpell 

Dr Thanthullu Vasu 

Dr Stephen Ward 

Ms Suzy Williams 

Co-opted members of Council 

Prof. Sam Ahmedzai 

Representative: Association for 

Palliative Medicine 

Dr Mike Basler 

Editor, Pain News 

Mr Neil Berry 

Representative: Psychology 

Dr Heather Cameron 

Representative: Physiotherapy Pain 

Association 

PAIN NEWS is published quarterly. Circulation 

1800. 

For advertising enquiries contact 

Ms Rikke Susgaard-Vigon at 

newsletter@britishpainsociety.org 

The editor welcomes contributions including 

Dr Beverly Collett 

Representative: IASP 

Miss Felicia Cox 

Co-Editor, Reviews in Pain 

Dr Suellen Walker 

Chair, Scientific Programme 

Committee (2011 ASM) 

Prof. Maria Fitzgerald 

Representative: Science 

Dr Roger Knaggs 

Representative: Pharmacy 

Ms Celia Manson 

Representative: Royal College of 

Nursing 

Dr Michael Platt 

Co-Editor, Reviews in Pain 

Mrs Nia Taylor 

Chair, Patient Liaison Committee 

Secretariat 

Ms Jenny Nicholas 

Secretariat Manager 

Mr Ken Obbard 

Events & Membership Officer 

Ms Rikke Susgaard-Vigon 

Communications Officer 

letters, short clinical reports and news of interest 

to members including notice of meetings. 

next submission deadline : 

30th July 2010 

Material should be sent to: 

Dr Mike Basler 

PAIN NEWS Editor 

55 Crawford Road 

Houston 

Johnstone 

Renfrewshire 

Scotland 

PA67DA 

Tel 01505 382 035 

Email newsletter@britishpainsociety.org 

designed and printed by Yves Lebrec (bps@lebrec.com) 

cover illustration © Barry Ward, 2010 

regulars 

4 Editorial 

6 From the President 

8 From the Honorary Secretary 

55 New Members 

59 Letters to the Editor 

ASM 2010 Section 

12 ASM 2010 Section 

14 Citation for award of Honorary 

Membership British Pain Society: 

Dr Joan Hester 



Professor Troels Staehelin Jensen 

15 Poster Prize presentations, 2010 ASM 



Ms Heather Muncey 

17 A personal experience of the ASM 

17 British Pain Society ASM – Manchester 

2010 

18 Reports from the SIG Chairs meeting in 

Manchester 

news 

20 British Pain Society (BPS) and National 

Institute for Health and Clinical Evidence 

(NICE) -Joint Statement 

22 Clinical Excellence Awards Update 

22 New Audit into the impact of migraine and 

headache in children and young people 

24 Creating a Special Interest Group 

25 Formation of New Special Interest Groups 

26 Update from Wales 

27 Napp Awards for Chronic Pain 

Management 

28 New document on Over the Counter 

management of pain 

29 Economics and Utility of Diamorphine Use 

29 House of Commons debate into 

Musculoskeletal Conditions 

30 Obitutary for Dr J Edmund Charlton - 9th 

October 1942 - 3rd April 2010 

professional perspectives 

34 A painful truth? 

38 Opioids for Persistent Pain: a personal view 

39 End of Life Choices? 

41 Diamorphine Necessary or Not? 

45 Teaching your grandmother to suck eggs: 

the pain history (101) 

48 Ethics Special Interest Group Summaries 

52 Narcotic Use in the Creative Era of Jazz 

changing practice 

54 Does Vitamin C have a role in the 

prevention of Complex Regional Pain 

Syndrome? 

56 A Personal Reflection on the British Pain 

Management Programme Society (SIG) 

Conference 2009 

58 Monitoring and intravenous access 

for epidural injections in chronic pain 

management: survey of practice 

book review 

59 Oral feeding difficulties and dilemmas 

pain shortcuts 

60 Incidence and Root Cause Analysis of 

Wrong-site Pain Management Procedures 

60 Intravenous infusions for chronic pain - a 

systematic review 

61 Group cognitive behavioural treatment for 

low back pain in primary care 

61 I.V. Ketamine for C.R.P.S. 

the possession of narcotics. She 

pleaded guilty and was sentenced 

to Alderson Federal Prison Camp 

in West Virginia. Her New York City 

Cabaret card was evoked which 

prevented her from working in 

the clubs for the next 12 years. 

Holiday latterly deeply regretted 

her addiction. She is quoted as 

saying, 

“Dope (Heroin) never helped 

anybody sing better or play music 

better or do anything better. 

All dope can do for you is kill 

you- and kill you the long, slow, 

hard way” 

“If you think dope is for kicks and 

thrills you are out of your mind. 

There are more kicks and thrills to 

be had in a good case of paralytic 

polio or by living in an iron lung” 

She was unable to kick the habit. 

Later in her career her voice began 

to deteriorate under the strain 

of smoking, heroin and alcohol 

abuse. On 31st May 1959, she was 

taken to metropolitan hospital. 

Police officers arrested her for 

possession of heroin and searched 

her room. She remained here until 

her death on July 17th 1959, aged 

44, from cirrhosis of the liver. 

Gilbert Millstein of the New York 

Times described her death in the 

1961 sleeve notes, “in the room 

from which a police guard had 

been removed- by court orderonly 

a few hours before her death, 

which, like her life was disorderly 

and pitiful. She had been strikingly 

beautiful, but she was wasted 

physically to a small, grotesque 

caricature of herself. The worms 

of every kind of excess- drugs 

were only one- had eaten her. “ 

Miles Davis (1926-1991) 

Miles Davis was an infamous 

trumpeter, band leader and 

composer. Davis started using 

heroin around 1950. He became 

depressed after his relationship 

to French actress Juliette Greco 

ended. This combined with a lack 

of appreciation from the critics 

and the fact that many of his 

contemporaries were using drugs 

led Davis to start taking heroin. 

At first he snorted it and then 

went on to using it intravenously. 

Davis was from an affluent family 

and did not seem to have social 

problems like Parker and Holiday. 

In 1953 his drug addiction was 

affecting his performances. Heroin 

had also killed two of his close 

friends Navarro and Webster. He 

CHANGING PRACTICE 

Monitoring and 

intravenous access for 

epidural injections in 

chronic pain management: 

survey of practice 

Epidural injections are performed 

for pain secondary to nerve root 

irritation. The three common 

approaches for the epidural 

injections are lumbar, caudal and 

transforaminal routes. Although 

pain clinicians perform these 

procedures frequently, there 

is paucity of robust guidelines. 

We require evidence based 

information on the medications 

used, need for intravenous access 

and the minimum monitoring 

standards during and after the 

procedure. The Royal College 

of Anaesthetists and British 

Pain Society have published 

recommendations in 2002 

regarding the minimum standards 

of monitoring required for the 

performance of epidurals via 

the lumbar and caudal routes if 

local anaesthetics are injected. 

This includes blood pressure and 

pulse oximetry during and blood 

pressure and heart rate after the 

procedure (1). 

We conducted a prospective 

survey of practice of members 

attending the Interventional 

Pain Medicine Special Interest 

Group meeting in Manchester, 

9th October 2009. Fifty two out 

of fifty eight clinicians completed 

the survey questionnaire, making 

it a 90% response rate; 46 were 

consultants, one was an associate 

specialist and five were trainees. 

Results 

There was a wide variation 

with the amount and volume 

of medication injected. In the 

caudal and lumbar approach, 

the local anaesthetic injected 

ranged between three and twenty 

mls of 0.25% bupivacaine (or 

levobupivacaine). The volume was 

between one and four mls in the 

transforaminal approach. Two of 

the participants preferred lidocaine 

0.5% over bupivacaine for the 

lumbar and caudal approach. 

The status of intravenous access 

for these procedures and the 

monitoring used are presented in 

the tables 1-3. 

The results highlight that about 

one third of the epidural injections 

are done without intravenous 

access. It is debatable whether 

intravenous access is necessary if a 

small amount of local anaesthetic 

is injected into the epidural 

space (although the potential risk 

of intrathecal spread is always 

present). We noticed that many 

of the clinicians inject significant 

eventually managed to kick the 

habit after returning to his father’s 

house in St Louis. After this he 

would spend time in towns like 

Detroit where he knew heroin was 

difficult to obtain. Davis’s addiction 

to heroin is unique in that it only 

lasted 4-5yrs. Davis never returned 

to heroin but it is reported that in 

his latter career he was addicted to 

other drugs, mostly cocaine. He 

finally managed to kick his cocaine 

habit in 1979 after he rekindled 

his relationship with actress Cicely 

Tyson. 

Davis died age 65 in 1991 from a 

stroke and pneumonia. 

Conclusion 

Jazz musicians of this time had 

many reasons for turning to 

heroin. Whether they used it 

to escape from troubled social 

circumstances, to cope with a 

disapproving society, to provide 

them with a “high” or in the 

mistaken belief that it would 

increase their creativity, most 

deeply regretted their addiction. 

Tolson and Cuyjet summarized the 

lives of these addicted artists in 

their 2007 paper,” the untapped 

potential that was languished on 

drugs and alcohol by these artists 

shall never be fully revealed.”” The 

reality is [that] for most jazz artists, 

amount of bupivacaine 0.25% (5 – 

20 ml) without intravenous access. 

The results also suggest that the 

level of monitoring was often 

better after the procedure rather 

than during the procedure. Whilst 

the post-procedure monitoring 

is more important to rule out 

any haemodynamic changes, 

monitoring during the procedure 

may equally be necessary 

to identify episodes such as 

vasovagal syncope. The purpose of 

the audit is to survey the practice 

rather than analyse the outcome 

of these procedures. 

Conclusion 

The practice guidelines from 

International Spine Intervention 

Society (2) recommends 

physiologic monitoring and 

intravenous access for all 

procedures in which needles are 

placed near the dural sac. 

Although epidural techniques for 

pain management have been in 

existence for several decades, 

practitioners learn the techniques 

and the practice in different 

ways. The performance is based 

on personal experience rather 

than on robust evidence. One 

of the widely raised concerns 

particularly during the creative 

period from 1940-1960, substance 

abuse did more harm than good, 

and rather than being the road to 

creative genius, it was the pathway 

to premature death.” 

REFERENCES 

Tolson,G.H. and Cuyjet M.J. (2007) 

jazz and substance abuse: Road 

to creative genius or pathway to 

premature death. International 

Journal of law and Psychiatry, 

30,530-538 

http://www.time.com/time/ 

magazine/article/0,9171,826388,00. 

html 

http://everything2.com/title/ 

Drugs+in+Jazz 


Heroin+and+jazz 

www.bps-research-digest.blogspot. 

com/2008/01/would-jazz-greatshave-been-so-great.htm 

en.wikipedia.org/wiki/ 

Charlie_Parker 


Billie_Holiday 

en.wikipedia.org/wiki/Miles_Davis 

Table 1. Caudal approach 

Caudal During procedure After Procedure 

NO ECG 19 / 47 (40%) 6 / 47 (13%) 

NO NIBP 26 / 47 (55%) 6 / 47 (13%) 

NO SpO2 12 / 47 (25%) 8 / 47 (17%) 

No intravenous access 17 / 47 (36%) 

Table 2. Lumbar approach 

Lumbar During procedure After procedure 

NO ECG 18 / 45 (40%) 9 /45 (20%) 

NO NIBP 23 / 45 (51%) 7 / 45 (15%) 

NO SpO2 12 / 45 (27%) 10 / 45 (22%) 


Table 3. Transforaminal approach 

Transforaminal During procedure After procedure 

NO ECG 14 / 37 (38%) 6 / 37 (16%) 

NO NIBP 22 / 37 (59%) 5 / 37 (13%) 

NO SpO2 9 / 37 (24%) 6 / 37 (16%) 


and the discussion following the 

publication of the recent NICE 

low back pain guidelines was the 

heterogeneity of the interventional 

pain practice. Many of us agree 

that interventional treatment 

procedures form an important 

facet in pain management. Whilst 

there are several hurdles in 

bringing uniformity to the practice 

due to the multiple variables in 

the nature of the patients we deal 

with and the available resources, 

still efforts must be taken to 

standardise our practice as much 

as we can. To survive in a world 

of evidence based medicine, 

focus should be on establishing a 

guideline development group to 

bring consistency to our practice. 

REFERENCE 

1. http://www.britishpainsociety. 

org/epi_inj.pdf 

2. Spinal Diagnostic & Treatment 

Procedures 2004, International 

Spine Intervention Society 

(ISBN 0-9744402-0-5) 

PAI N N E W S S U M M E R 2010 3

Editorial 

Mike Basler 

Editor, Pain News 

Hurt 

I hurt myself today to see if I still feel 

I focus on the pain the only thing that's real 

The needle tears a hole the old familiar sting 

Try to kill it all away but I remember everything 

What have I become my sweetest friend? 

Everyone I know goes away in the end 

And you could have it all my empire of dirt 

I will let you down I will make you hurt 

..................... 

If I could start again a million miles away 

I would keep myself I would find a way 

Extract from “Hurt” by Trent Reznor, sung by Johnny Cash 

Trent Reznor, a reformed heroin 

addict penned the song “Hurt" in 

1994 but it was only when it was 

covered by Johnny Cash in 2002 

that the song came to prominence. 

It was the last hit for Cash before 

his death and the music video is 

now generally recognized as "his 

epitaph," receiving both critical 

and popular acclaim. It is worth 

watching. 26 million people have 

already done it on Youtube alone. 

Music videos often promote a 

hedonistic lifestyle, a dopamine 

induced high of fame, wealth, 

sex, glamour and fantasy, to take 

people away from the realities 

of the pain and grind of life. 

This video is anything but that. It 

shows Cash, fragile and frail from 

the ravages of age and chronic 

illness (and neuropathy), dimly 

lit, playing piano and guitar, in his 

memorabilia-stuffed home. The 

footage is mixed with glimpses of 

the flood-damaged and decaying 

House of Cash museum and 

archival footage of the country 

legend as a young man and drug 

addicted hell raiser. Ultimately it 

is a song of regret and really a 

reflection of a loss of his health and 

the love of his live, his wife of many 

years, June Carter Cash. 

Cash was no stranger to pain both 

pain and addiction. In 1965 he was 

arrested by a narcotics squad in El 

Paso, Texas after being suspected 

of smuggling heroin from Mexico, 

but it was prescription narcotics 

and amphetamines that the singer 

had hidden inside his guitar case. 

Due to his excessive work schedule 

he had resorted to both narcotics 

and amphetamines to maintain 

function and the fact that the 

drugs had been legally prescribed 

was the only reason he escaped a 

custodial sentence. Eventually these 

drug problems lead to the famous 

drug fuelled suicide attempt in 

Nickeljack cave where he had his 

epiphany. After this Cash cleaned 

up his act and went to have a 

successful career becoming an 

elder statesman of both country 

and more recently popular music. 

His famous “Man in Black” persona 

was supposed to be a gesture of 

solidarity on behalf of the poor and 

hungry, on behalf of "the prisoner 

who has long paid for his crime" 

and on behalf of those who have 

been betrayed by age or drugs. 

He never quite escaped pain 

and opiates. In 1983, in a bizarre 

incident, after being kicked in 

the stomach by a pet ostrich, he 

became readdicted to narcotics. 

This led to his refusal to take any 

analgesia after his cardiac bypass 

in 1988. As well as this he suffered 

from both neuropathic pain from 

diabetes as well as Parkinsonism. 

Interestingly, as his health failed, 

his musical output and popularity 

seemed to increase. 

The term "narcotic," is derived 

from the Greek word for stupor, 

originally referred to a variety 

of substances that dulled the 

senses and relieved pain. Today, 

the term is used in a number of 

ways. Some individuals define 

narcotics as those substances that 

bind at opiate receptors while, in 

a looser parlance, there is a vague 

association between “narcotics” 

and illicit substances. Therein lies 

the damoclean sword of opiate 

prescribing, which, in BMJ articles, 

IASP newsletters, journal editorials 

(talking of caution and flying 

blind) and BPS seminars, once 

again has risen to prominence. In 

some quarters the increased use 

of opiates has been described as 

a "public health tragedy" and, in 

some countries, it may be that 

we are about to enter a more 

stringent regulatory phase. This 

should not surprise us. Opiate 

prescription cycling, from boom to 

bust, has been with us for a very 

long time. Opium has been used 

for both pain relief, and relief from 

depression, anxieties and other 

mental illnesses throughout history. 

Its medical use is cemented in the 

most important medical texts of the 

ancient world, including the Ebers 

Papyrus and the writings of Galen 

and Avicenna. Its psychotropic use 

has been known for thousands of 

years and in the 1700s and 1800s 

it had become a popular overthe-counter 

drug that was used 

not only to help calm a person's 

nerves, but also used in many 

children's elixir's to relieve crying 

fits or tantrums. Recreational use 

of the drug began in China in the 

fifteenth century, but was limited by 

its rarity and expense. The opium 

trade became more regular by the 

seventeenth century, when it was 

mixed with tobacco for smoking, 

and addiction was first recognized. 

Opium prohibition in China began 

in 1729, and this was followed by a 

century of exponentially increasing 

opium use. A massive confiscation 

of opium by the Chinese led to 

two Opium Wars in 1838 and 

1860. Britain won the right to trade 

opium to every part of China, until 

more than a quarter of the male 

population was addicted by 1905. 

In comparison, look at this recent 

quote in an IASP publication - “In 

some surveys, rates of prescription 

opioid abuse in the United States 

have overtaken those of illicit 

opioid abuse as addicts have 

increasingly favoured prescription 

drugs because of their purity, 

relative safety, and easy availability”. 

The potent wealth generation of 

opiates is also not new. In the 

mid 1880's, opium was one of 

the most valuable commodities 

moving in international trade. 

Each year, export opium leaving 

Calcutta and Bombay averaged 

over 90,000 chests containing 

more than 5,400 metric tonnes. 

This poured 93.5 million rupees 

(£9.4 million), approximatley 16% 

of total Indian revenue, into the 

Government of India. Once again 

there are resonances with today. 

In the last 10 years the increase 

in use of well known opiate 

preparations has increased from 

between 200-1000% in the USA 

and it is no wonder that many of 

the pharmaceutical companies are 

amongst the stock markets elite. 

Global regulation of opium began 

with the stigmatisation of Chinese 

and Indian immigrants and opium 

dens, leading rapidly from town 

ordinances in the 1870s to the 

formation of the International 

Opium Commission in 1870s, to 

the formation. During this period 

the portrayal of opium in literature 

4 

PAI N N E W S S U M M E R 2010

ecame squalid and violent. Opium 

was prohibited in many countries 

during the early twentieth century, 

leading to the modern pattern of 

opium production as a precursor 

for illegal recreational drugs or 

tightly regulated legal prescription 

drugs. Further International 

regulation took place in 1961 and 

1988. Illicit opium production, now 

dominated by Afghanistan, has 

increased steadily in recent years 

to over 6600 tons yearly, nearly 

one-fifth the level of production in 

1906 despite the efforts of many 

to limit it. 

The right to analgesia, like opium, 

is a sensitive and charged issue 

and for many there are no easy 

answers. It is so sensitive that the 

pain faculty of ANZCA produced 

a document of rights and 

responsibilities, PS45, that has an 

addendum that states – “A “right 

to pain relief” does not imply that 

all pain can or will be treated 

successfully, that all patients will 

be free from pain, or that any 

analgesic treatment will necessarily 

be provided on demand, including 

the prescription of opioids. That 

right requires that the professional 

response be reasonable and 

proportionate to the level and 

character of the pain experience 

and that the assessment and 

management of a patient’s pain 

be appropriate to that patient”. 

Are we to dream like the American 

Pain Society that we can alleviate 

pain? If we cannot alleviate it, can 

we therefore say, however noble, 

that pain relief is a human right? 

Will the dumbing down of this 

sentiment and just cause lead to 

the medical nihilism of yesteryear 

when many chronic pain patients 

were just ignored and passed off 

as “malingerers” or “depressed”, 

and given an even lower priority. 

The clinical difficulties of managing 

a pain to total alleviation may 

inadvertently lead to the use of 

opiates as a last resort. This is just 

as wrong as failure to use them 

as a first resort when it is obvious 

that they are both efficacious and 

necessary. Once again we still 

have many unanswered questions 

and we work in a system where 

long-term, non pharmaceutically 

sponsored, clinical based research 

is both impossible financially and 

technically and ethically difficult. 

Is it no wonder that the poor pain 

clinician, after years of just trying to 

improve his service on the back of 

arid support, gives up when faced 

with a 64 page ethics form and the 

competing interests of managerial 

targets and ever demanding 

patients. The research base has 

many unanswered questions 

and clinical judgement, rightly 

or wrongly, has less clout than 

previously. When was the last time 

you heard a patient with a chronic 

headache or severe rheumatoid 

pain declare a persistent clinical 

transformation on the back of 

sustained release opiates? We still 

have to make difficult and uncertain 

decisions. In 1996 the Drug and 

Alcohol Unit in New South Wales 

reviewed the official records 

of opiate prescribing for non 

malignant pain in Australia from 

1986-1996. Even then there were 

concerns of dose escalation and the 

use of “opiates in poorly defined 

medical problem in patients 

where the presence of social and 

emotional problems was noted”. 

The “quality and thoroughness of 

medical information documented 

in the health department files was 

very limited”. This is in country, that 

in the early 1990's and beyond, 

where every time a potent opiate 

is prescribed for anything but 

palliative care, the local health 

authority has to be notified. As 

well as this regular auditing of 

these patients took place. Is it not 

time that, in response to these 

concerns we attempt something 

similar in the UK? A comprehensive 

multicentre audit at least. Then we 

can get an idea of both good and 

bad practice out there. 

To quote an IASP clinical update 

the "marked change in prescribing 

habits, related in large part to 

the advent of “designer” opioids 

(new long-acting formulations) 

producing heightened commercial 

interest and to the increasingly 

active sponsoring of pain advocacy 

by the pharmaceutical industry” 

has not produced a new dawn. 

Neither will opiophobia. We need 

an open debate, we need more 

evidence and as pain physicians 

we need to admit when we are 

faced with intractable clinical issues. 

Intractable pain problems have not 

and should not be an open door to 

potent medications otherwise pain 

clinicians may lead all, patients, 

medical staff and pharmaceutical 

companies to an “empire of dirt” 

and that would be to no ones 

benefit. Dr Cathy Stannard hosted 

an excellent seminar at the ASM in 

Manchester where some of these 

difficulties were aired. We have an 

excellent document that has just 

been produced. We are publishing 

an excellent document on cancer 

pain. It is up to us to help to “find a 

way”. It will not be easy but, as pain 

clinicians, it is both our challenge 

and our burden to both help and 

prevent “Hurt”. 

Mike Basler 



From the President 

Professor Richard Langford 

In my opening remarks to my 

first President’s message, I would 

like to express heartfelt thanks on 

behalf of the BPS to Sir Michael 

Bond for his selfless act in 

agreeing to be Interim President. 

At a time of such disquiet, we 

were most fortunate to have a 

steadying hand on the tiller, and 

we collectively owe him a great 

debt of gratitude. Sir Michael, we 

are well aware that, in your case, 

the term retirement is euphemistic, 

but we will try not to disturb you 

again as you continue to pursue 

your many projects for both pain 

medicine internationally and for 

the University of Glasgow. 

Other notables have also left 

Council, particularly William 

Campbell and Peter Evans, who 

have been exemplary in their 

roles as Secretary and Treasurer, 

respectively. 

William contributed greatly to 

safely steering the Society through 

a challenging time, and as Chair 

of the Education Committee 

oversaw the very successful rolling 

programme of Study Days. His 

calm, unflappable and unassuming 

manner camouflaged a steely 

determination to deliver, and his 

charm ensured that nobody ever 

declined one of his requests! I can 

speak with personal conviction 

on this. I do however hope that 

he will continue in his role of BPS 

Photographer. 

Peter has been a fine custodian 

of our funds, and even in a 

prolonged period of recession 

and record low interest rates our 

balance sheet is healthier than 

when he took over. I’m sure we’ll 

all agree - a quite remarkable feat! 

Of course, we welcome their 

replacements, Pat Schofield 

and John Goddard to their new 

executive roles as Honorary 

Secretary and Honorary Treasurer, 

and wish them well. 

I would also like to congratulate 

and welcome our three new 

elected Council members, Suzy 

Williams, Andrew Baranowski and 

Austin Leach. 

Ordinarily, this post 2010 ASM 

message would also include 

farewell thanks to the Immediate 

Past President, but I am delighted 

(and relieved) to say that Joan 

Hester has very kindly agreed 

to serve for another year in this 

capacity, as I settle in. 

We also owe considerable 

thanks to the three elected 

Council members who have 

completed their three year 

terms of office: John Goddard, 

who remains on Council as 

Honorary Treasurer, and who has 

contributed greatly and highly 

diligently to a large number of 

submissions to DoH, NICE etc; 

Eloise Carr, another stalwart 

of the Society, with particular 

acknowledgement of her 

chairing of the Communications 

Committee, which has achieved 

a new level of professionalism 

in its procedures, and further 

landmark publications under her 

stewardship; and, Dave Counsell, 

with his notable contributions to 

the BPS website, the NAP3 audit 

and championing the cause of 

acute (in-patient) pain medicine. 

Of course, I am writing this soon 

after the highly successful ASM in 

Manchester, which together with 

Liverpool and Sandown make up 

the triple for Chris Eccleston, who 

steps down as Chair of the the 

Scientific Programme Committee. 

Chris brought great flair and 

panache to the meetings, as well 

as a galaxy of international and 

local speakers – and who will ever 

forget his innovation of the ASM 

Fun Run! 

We owe Chris and the Secretariat 

a great deal for these, the flagship 

events of the BPS, which combine 

science, education and recreation 

so effectively. Ultimately, the ASM 

is the sum of its many parts, and 

it was a pleasure to witness the 

commitment and enthusiasm 

of so many contributors and 

participants. 

The Year Ahead: 

Of course, I refer to ‘the year 

ahead’ somewhat loosely, as the 

period until the next ASM and 

AGM, is in fact 14 months, as we 

next convene in Edinburgh in 

June 2011 (from 21st to 24th), for 

the combined meeting with the 

Canadian Society. I am pleased 

to say that this special event is in 

the highly capable hands of the 

new Co-Chairs of the the Scientific 

Programme Committee: Suellen 

Walker as the BPS representative 

and Jennifer Stinson representing 

the Canadians. We’ll bring you 

Edinburgh 

2011 ASM 

21-24 June 2011 

Diary note 

further details in future issues 

of Pain News, but meanwhile 

please note the dates in your 

diaries, and book the leave in your 

departments! 

Meanwhile, it’s business as 

usual, and since the last Pain 

News there have been significant 

developments regarding 

Interventional Pain practice, with 

respect to NICE who have now 

issued a statement (printed in this 

issue of Pain News), and plans to 

expand the evidence base. Simon 

Thomson and Tony Hammond 

convened a meeting, at which we 

reviewed the current evidence and 

developed a research strategy. The 

intention is to apply for research 

grants to develop a three-year 

programme. We would be very 

pleased to hear from you, if you 

wish to contribute to the protocol 

development and/or research 

recruitment. 

We are continuing to capitalise 

on the opportunities afforded 

by the Chief Medical Officer’s 

proposals, and allied to this work 

The Annual Scientific Meeting 2011 is in 

collaboration with the Canadian Pain 

Society and will take place in Edinburgh, 

Tuesday 21 June –Friday 24 June 2011 

6 


is the National Pain Audit (http:// 

www.nationalpainaudit.org), a 

partnership of the Healthcare 

Quality Improvement Partnership, 

the BPS and Dr Foster, with 

Stephen Ward as BPS Lead. It is 

important that the data collection 

is comprehensive and robust, so 

please do ensure that your clinic is 

registered and will be supporting 

this important activity. 

The BPS Strategic Review 

This was attended by Council 

members and held in February 

of this year, was one of the key 

activities led by my predecessor. 

It generated a number of themes 

and aspirations for the Society, two 

of which I would particularly like 

to highlight: 

We are seeking ideas for improved 

communication and greater 

involvement of members in the 

activities of the Society. One 

suggestion was that one of the 

senior Council members could 

attend regional pain meetings for 

Q & A sessions, and providing 

updates on issues of the day and 

an opportunity for discussion. 

Please do let us have your ideas 

and views. 

It was also felt that we should give 

thought to the composition of 

Council. By the time that you read 

this, the General Election will be 

a receding memory, but as I write 

this in early May, there is much 

talk of elections and proportional 

representation. This too was 

considered in the Strategic Review, 

and we will explore methods of 

ensuring Council representation 

for the major professional groups, 

which make up our membership. 

Chronic Pain declared a 

RCGP Clinical Priority for 

2011-2013 

This is very exciting news. Martin 

Johnson, our long time champion 

of pain in Primary Care is to be 

congratulated for succeeding in 

his application for approval of 

Chronic Pain as one of the four 

RCGP clinical priorities for three 

years from January 2011. This year, 

a number of key aims and clinical 

priority projects will be developed 

in association with the College’s 

Clinical Innovation and Research 

Centre. 

Primary Care SIG 

With perfect timing, and hard 

on the heels of the RCGP 

announcement, Val Conway and 

Cathy Price succeeded in their 

proposal for a Primary Care SIG, 

which was approved by Council 

at the meeting following the ASM. 

As the new SIG develops, there 

is obviously great potential for 

collaborative work with the RCGP. 

EFIC and EJP 

I had the pleasure of spending 

the May Day Bank Holiday at the 

annual EFIC (European Federation 

of IASP Chapters) Council 

Meeting, and wish to report on 

a couple of items. Just to remind 

you that all BPS members are 

automatically included in EFIC, 

and with this comes free access 

to the European Journal of Pain 

(EJP), one of the premier journals 

in our specialty, via http://www. 

europeanjournalpain.com and click 

on the EJP registration link. 

You will hear more about some 

other important areas and 

themes over the coming year, as 

we intend to focus also on the 

issues of Revalidation for doctors 

practising pain medicine, and on 

the specific needs and interests 

of full-time pain doctors. For the 

latter, we are reconvening the BPS 

Working Group, whose first task 

will be to identify this group. 

So, we are looking at a busy year 

ahead, and I look forward to 

reporting on our progress in future 

editions. Hopefully, I’ll be writing 

the next message while enjoying 

the ‘barbecue summer’ that is 

predicted! 

With kindest regards, 

Updated 

Understanding and 

managing pain: 

information for 

patients 

The British Pain Society’s revised edition of 

‘Understanding and managing pain: information for 

patients’ is now available. 

To download your free copy please go to the 

publications section on our website: www. 

britishpainsociety/pub_home. Hard copies can be 

ordered from the 

secretariat. 

The British Pain Society 

Understanding and managing pain: 

information for patients 

January 2010 

To be reviewed January 2013 


From the Honorary 

Secretary 

Dr Pat Scholfield 

This is my first report for Pain 

News so I would like to say hello 

to all and thank you to Dr William 

Campbell who has supported me 

in my year as Honorary Secretary 

Elect. I will try to maintain the 

excellent standard of updating 

members that has preceded 

my appointment. I have been 

on council before as an elected 

member, but things have moved 

on since then. A nurse academic 

by background, I am now based 

in Aberdeen and some of you 

may know me as being the chair 

of the Pain in Older People SIG. 

Therefore, you may guess that 

my particular interest is around 

pain in older people and I am 

currently carrying out research in 

Aberdeen on this topic. I have a 

home up north on the Moray Firth 

overlooking the sea and I love 

sailing. We live in Aberdeen during 

the week and stay up there at 

weekends and holidays. So that is a 

bit about me, now to the important 

business of updating you all on the 

work of council and the society. 

Annual Scientific Meeting 

Another ASM now over and 

already the plans for next year are 

underway. I personally enjoyed 

this year’s event. The venue 

was excellent and the range of 

speakers superb. Thanks must go 

to Prof. Chris Eccleston and the 

Scientific Programme Committee 

for maintaining the tradition of 

excellence. The numbers were 

slightly down this year, a sign of 

the times. But we did have over 

100 registrants sign up on site. 

I thought that there were some 

excellent plenary speakers and 

I am thankful that they have all 

now managed to return to their 

homes. The workshops too were 

very topical and interesting. I also 

found the lunches were good and 

noted many positive comments 

from registrants about this. Please 

remember to put the dates in your 

diary for next year and note that it 

will be in June as a joint ASM with 

the Canadian Pain Society. 

Membership 

At the time of writing this 

report, the membership stands 

at 1,461 and is represented 

by 713 Anaesthetists, 297 

Nurses, 97 Psychologists and 

79 Physiotherapists with other 

disciplines accounting for 303 

members. Other disciplines 

include occupational therapists, 

rheumatologists, neurologists, 

pharmacists, general practitioners 

and basic scientists. As usual we 

encourage members to promote 

our society to their colleagues 

and the prize for recruiting most 

members was awarded again to 

Dr Simon Davies. Information on 

joining can be found at http://www. 

britishpainsociety.org/join_home. 

htm and the benefits of joining are 

many. 

Election of Council Members 

As many of you know at the AGM 

we announced our new members 

and this year we appointed all 

new executive officers. We are all 

grateful to Professor Sir Michael 

Bond who stepped in as Interim 

President and maintained the good 

standing of the Society with his 

steady hand. We now have our 

new President; Professor Richard 

Langford. Dr William Campbell 

has stepped down to be replaced 

by myself with Dr Peter Evans 

(Treasurer) being replaced by 

Dr John Goddard. New council 

members include; Dr Andrew 

Baranowski (218 votes) Dr Austin 

Leach (200 votes) and Ms Suzy 

Williams (263 votes). 

Changes to Memorandum 

and Articles of Association 

A special resolution to amend the 

Articles of the Association was 

proposed as follows: 

To amend Article 19 as follows: 

19. Any motion that calls into 

effect the suitability or otherwise 

of an elected Officer or Officer 

Elect must be proposed and 

passed by the adoption of a 

Special Resolution to that effect at 

a General Meeting of the Society 

duly convened. (New provision) 

The Officers of the Society shall 

be the: 

19.1 President. The President 

shall normally be elected one year 

in advance of taking up office as 

President, and during that period 

shall be the President Elect of the 

Society. The Honorary President 

Elect shall only take up office as 

Honorary President if approved 

by the Council. The President 

will hold office for a period of 

two years (or such longer period 

as prescribed in Regulations), at 

the end of which he shall retire 

and not be eligible to stand for 

re-election to any office previously 

held by him but may be elected 

to another office. In the event that 

the President has had to resign 

or is no longer in office for some 

other reason, the procedure set 

out in the Regulations will apply. 

19.2 Immediate Past 

President. The Immediate Past 

President shall hold office for a 

period of one year immediately 

after his retirement as President. 

The Immediate Past President 

shall not be eligible to stand for 



to another office unless the 

Regulations provide otherwise. 

19.3 Honorary Secretary. 

The Honorary Secretary shall 

be elected one year in advance 

of taking up office as Honorary 

Secretary, and during that period 

shall be the Honorary Secretary 

Elect of the Society. The Honorary 

Secretary Elect shall only take 

up office as Honorary Secretary 

if approved by the Council. The 

Honorary Secretary will hold office 

for a period of three years, at the 

end of which he shall retire and 

not be eligible for re-election to 

that office. The Honorary Secretary 






In the event that the Honorary 

Secretary has had to resign or is 

no longer in office for some other 

reason, the procedure set out in 

the Regulations will apply. 

19.4 The Honorary Treasurer. 

The Honorary Treasurer shall 

be elected one year in advance 

of taking up office as Honorary 

Treasurer, and during that period 

shall be the Honorary Treasurer 

Elect of the Society. The Honorary 

Treasurer Elect shall only take 

up office as Honorary Treasurer 

if approved by the Council. The 

Honorary Treasurer will hold office 

for a period of three years, at the 

end of which he shall retire and 

not be eligible for re-election to 

that office. The Honorary Treasurer 






In the event that the Honorary 

Treasurer has had to resign or is 

no longer in office for some other 

reason, the procedure set out in 

the Regulations will apply. 

19.5 President Elect. The 

President Elect shall not be eligible 

to stand for re-election to any 

office previously held by him but 

may be elected to another office 

unless the Regulations provide 

otherwise. 

19.6 Honorary Secretary 

Elect. The Honorary Secretary 

Elect shall not be eligible to 

stand for re-election to any office 

previously held by him but may be 

elected to another office unless the 


19.7 Honorary Treasurer Elect. The 

Honorary Treasurer Elect shall not 

be eligible to stand for re-election 

to any office previously held by 

him but may be elected to another 

office unless the Regulations 

provide otherwise. 

8 


The first licenced intranasal Fentanyl 

spray specifically developed for 

Break Through Cancer Pain (BTcP) 1 

Start here for rapid 

control of BTcP 

Indicated for the management of breakthrough pain in adults already receiving maintenance opioid therapy for chronic cancer pain 

Instanyl®▼ 50, 100 and 200 mcg/dose nasal spray, solution (fentanyl) 

Prescribing Information (refer to Summary of Product Characteristics for full 

information). Presentation: Each 100 microlitre dose of the nasal spray contains 

50, 100 or 200 micrograms of the active ingredient fentanyl. The nasal spray also 

contains sodium dihydrogen phosphate dihydrate, disodium phosphate dihydrate 

and purified water. Indications: Management of breakthrough pain (BTP) in adults 

already receiving maintenance opioid therapy for chronic cancer pain. Patients 

receiving maintenance opioid therapy are those who are taking at least 60 mg of 

oral morphine daily, at least 25 micrograms of transdermal fentanyl per hour, at 

least 30 mg oxycodone daily, at least 8 mg of oral hydromorphone daily or an 

equianalgesic dose of another opioid for a week or longer. Dosage and 

administration: Intended for nasal use only. Treatment should be initiated by and 

remain under the supervision of a physician experienced in the management of 

opioid therapy in cancer patients. Physicians should keep in mind the potential of 

abuse of fentanyl. Patients should be individually titrated to the dose that provides 

adequate analgesia with tolerable adverse drug reactions. Patients must be carefully 

monitored during the titration process. Titration to a higher dose necessitates 

contact with the health care professional. Maximum daily dose: Treatment of up to 

four breakthrough pain episodes, each with no more than two doses separated by 

at least 10 minutes. Patient should wait at least 4 hours before treating another BTP 

episode with Instanyl during both titration and maintenance therapy. Adults: 

Initially one dose of 50 micrograms in one nostril, titrating upwards as necessary. If 

adequate analgesia is not obtained redosing of the same strength may be 

administered at the earliest after 10 minutes. Each titration step (dose strength) 

should be evaluated in several episodes. Once the dose has been established the 

patient should be maintained on this strength. Generally, the maintenance strength 

of Instanyl should be increased when a patient requires more than one dose per 

breakthrough pain episode for several consecutive episodes. Dose adjustment of 

the background opioid therapy may be required if the patient consistently present 

with more than four breakthrough pain episodes per 24 hours. Recommended to sit 

or stand in upright position when administrating Instanyl. Cleaning of the nasal 

spray tip is required after each use. Children and adolescents: Not recommended in 

children and adolescents below 18 years of age. Elderly: Limited data available for 

the use of Instanyl in patients above >65 years of age. Elderly patients may have a 

reduced clearance, a prolonged half-life and higher sensitivity to fentanyl than 

younger patients. In clinical trials elderly tend to titrate to a lower effective strength 

than patients less than 65 years of age therefore caution when titrating. Hepatic 

and renal impairment: Administer with caution to patients with moderate to severe 

hepatic or renal impairment (see section 4.4 of full SmPC). Contraindications: 

Hypersensitivity to fentanyl or any of the excipients. Use in opioid-naive patients. 

Severe respiratory depression or severe obstructive lung conditions. Previous facial 

radiotherapy. Recurrent episodes of epistaxis. Warnings and precautions: Patients 

and carers must be instructed to keep Instanyl out of the reach and sight of children. 

Ensure patients and carers follow instructions for use and know what action to take 

in case of overdose. Monitor closely during titration process. Ensure maintenance 

opioid therapy stabilised before Instanyl therapy starts. Clinically significant 

respiratory depression may occur with fentanyl, and patients must be observed for 

effects. In patients with chronic obstructive pulmonary diseases, fentanyl may have 

more severe adverse reactions. Administer with caution to patients with moderate 

to severe hepatic or renal impairment. Use with caution in patients with evidence 

of increased intracranial pressure, impaired consciousness or coma. Use with 

caution in patients with cerebral tumour or head injury. Administer with caution to 

patients with bradyarrhythmias, hypotonia and/or hypovolaemia. If the patient 

experiences recurrent episodes of epistaxis or nasal discomfort while taking 

Instanyl, an alternative administration form for treatment of breakthrough pain 

should be considered. Tolerance and physical/psychological dependence may 

develop upon repeated administration of opioids such as fentanyl. Withdrawal 

symptoms may be precipitated by administration of substances with opioid 

antagonist activity. Interactions: Fentanyl is metabolised by CYP3A4. Concomitant 

use of agents that induce CYP3A4 activity may reduce the efficacy of Instanyl. Use 

with strong inhibitors of the cytochrome P450 3A4 system (e.g. ritonavir, 

ketoconazole, itraconazole, troleandomycin, clarithromycin and nelfinavir) or 

moderate inhibitors (amprenavir, aprepitant, diltiazem, erythromycin, fluconazole, 

fosamprenavir and verapamil) may result in increased fentanyl plasma 

concentrations. Concomitant use of other central nervous system depressants, 

including other opioids, sedatives or hypnotics, general anaesthetics, phenothiazines, 

tranquilisers, skeletal muscle relaxants, sedating antihistamines and alcohol may 

produce additive depressant effects. Concomitant use of partial opioid agonists/ 

antagonists e.g. buprenorphine, nalbuphine and pentazocine is not recommended. 

Concomitant use of oxymetazoline or other nasal decongestants should be 

avoided. Not recommended for use within 14 days of use of monoamine oxidase 

(MAO) inhibitors. Pregnancy and Lactation: Studies in animals have shown 

reproductive toxicity (see Section 5.3 of full SmPC). The potential risk to humans is 

not known. Should not be used in pregnancy unless clearly necessary. Long-term 

treatment may cause withdrawal in the new-born infant. Do not use during labour 

and delivery, including caesarean section, since fentanyl passes through the 

placenta and may cause respiratory depression in the foetus. If administered, an 

antidote for the child should be available. Fentanyl is excreted into human milk and 

may cause sedation and respiratory depression in the breast-fed infant. Fentanyl 

should only be used by breastfeeding women if benefits outweigh the risks for both 

mother and child. Driving, etc: Opioid analgesics are known to impair the mental 

and/or physical ability required for driving or operating machinery. Patient should 

be advised not to drive or operate machinery if they experience somnolence, 

dizziness, visual disturbances or other adverse reaction which can impair their 

ability to drive and operate machinery. Undesirable effects: Typical opioid side 

effects are to be expected. The most serious adverse reactions are respiratory 

depression, circulatory depression, hypotension and shock and all patients should 

be closely monitored for these. The most commonly reported adverse reactions are 

somnolence, dizziness, headache, vertigo, flushing, hot flush, throat irritation, 

nausea, vomiting and hyperhydrosis. Please refer to full summary of product 

characteristics for other undesirable effects. Overdose: Immediate 

countermeasures should be started including physical or verbal stimulation of the 

patient. A patent airway should be established and maintained and ventilatory 

support if necessary. Adequate body temperature and fluid intake should be 

maintained. Consider the use of opioid antagonists. Pack size and Basic NHS Price: 

Instanyl 50µg/dose nasal spray (10 dose) £59.50, Instanyl 50µg/dose nasal spray 

(20 dose) £119.00, Instanyl 100µg/dose nasal spray (10 dose) £59.50, Instanyl 

100µg/dose nasal spray (20 dose) £119.00, Instanyl 200µg/dose nasal spray (10 

dose) £59.50, Instanyl 200µg/dose nasal spray (20 dose) £119.00. Legal Category: 

CD (Schedule 2), POM. Marketing Authorisation Number(s): EU/1/09/531/001- 

002, 004-005, 007-008. Marketing Authorisation holder: Nycomed Danmark 

ApS, Langeberg 1, DK-4000 Roskilde, Denmark. Marketed by: Nycomed UK Ltd, 

Three Globeside Business Park, Fieldhouse Lane, Marlow, Buckinghamshire, SL7 

1HZ. Further information is available on request from Nycomed UK Ltd Tel 0800 

633 5797 Email medinfo@nycomed.com 

Date of PI preparation: September 2009 

Adverse events should be reported. Reporting forms and 

information can be found at www.yellowcard.gov.uk. Adverse 

events should also be reported to Nycomed UK Ltd on 

0800 633 5797 

Reference: 

1. Instanyl, Summary of Product Characteristics, July 2009 

Date of preparation: May 2010 UK/INS/10/011b 



26.1 The Council may at any 

time appoint a person eligible 

under Article 22 to fill a vacancy 

in any Office, even if he has held 

that Office for the maximum 

term allowed under Article 19. 

Any person so appointed shall 

be deemed to be appointed 

on an interim basis and must 

then resign at the next following 

Annual General Meeting. Provided 

that any such person has not 

held the Office in question for the 

maximum term allowed, he shall 

be eligible for re-election. 

26.2 In the event that there is no 

Officer Elect able and willing to 

take on the vacancy in Office, the 

Council must have recourse to the 

procedure laid out in Regulations 

11.5 and 11.6. 


27 A person will only be eligible 

to be elected an Ordinary Council 

Member if he is an Ordinary or 

Honorary Member of the Society. 

This provision precludes the 

election of an Ordinary Council 

Member if he is an International or 

a Retired Member of the Society. 

To amend Article 50.1 as follows: 

The President or the Council may 

whenever he or it thinks fit call 

General 

Meetings and, on the requisition of 

10 percent of Ordinary Members, 

shall forthwith proceed to convene 

an Extraordinary General Meeting. 

(i) within 21 days from the date 

on which he or it becomes subject 

to the requirement; 

(ii) the meeting must be held on 

a date not more than 28 days 

after the date of the notice calling 

the meeting or with the consent 

of a simple majority of those 

members calling the meeting 

within such longer period as may 

be agreed by mutual consent 

provided such period does not 

exceed 56 days; 

(iii) if the requests received by 

the company identify a resolution 

either special or otherwise 

intended to be moved at the 

meeting, the notice of the meeting 

must include notice of such 

resolution whether special or 

otherwise; 

(iv) the business that may be 

dealt with at the meeting includes 

a resolution whether special or 

otherwise of which notice is given 

in accordance with section 303 of 

the Act. 

The Special Resolution was passed 

unanimously by 75% of the 

Members present and voting in 

person or by proxy. 

Updates 

Those who attended the ASM will 

know that the National Pain Audit 

for England and Wales – Phase I is 

about to launch. Information will 

arrive to you in November and the 

information should be collected by 

the Clinical Lead and signed off by 

the Chief Executive of your Trust. 

The information will be core data 

relating to the service composition 

and personnel involved in 

delivering the service. Phase two 

and three are case mix and patient 

outcome. Further information 

can be found on the BPS website 

http://www.britishpainsociety. 

org/members_sigs_clinical.htm . 

Another very important document 

has just been launched by the 

BPS – Opioids for persistent 

pain – Good Practice 2010. A 

consensus statement prepared on 

behalf of the British Pain Society, 

the Faculty of Pain Medicine of 

the Royal College of Anaesthetists, 

the Royal College of General 

Practitioners and the Faculty 

of Addictions, Royal College of 

Psychiatrists. This document can 

be downloaded from the website 

http://www.britishpainsociety.org/ 

pub_professional.htm#opioids . 

Or hard copies can be requested 

from the Secretariat. There is also 

information for patients leaflet that 

can be requested and members 

are entitled to two free copies. 

Finally, we have a new Special 

Interest Group forming (Primary 

Care SIG). I have also written 

an article about setting up a SIG 

in this edition to help with this 

process. 

Lay Chairman Vacancy 

The British Pain Society Patient Liaison Committee 

Do you know any patients or contacts 

who might make a good Chair for the 

Patient Liaison Committee? 

We are looking for a new Chair for our 

Patient Liaison Committee. The suitable 

applicant will be a lay person and must 

have an interest in the NHS and in how 

to make sure people get the best care 

from the health service, particularly 

people living with pain. Experience of 

living with pain or of a voluntary sector 

organisation linked to pain would be 

useful. 

Applicants must be available to Chair the 

committee meetings and attend council 

meetings within London for a minimum 

of eight days per year. The British Pain 

Society will reimburse travel costs. 

Interviews will be held at the British Pain 

Society Secretariat, London. 

Closing Date for Applications: 5pm, 

Monday 2nd August 2010 

For an application pack please contact 

Rikke Susgaard-Vigon, Communications 

Officer on 0207 269 7840 or email: 

rsusgaardvigon@britishpainsociety.org 

10 


Breakthrough Cancer Pain (BTcP)* 

Fast relief 

as early as 

10 minutes 1 

UK PRESCRIBING INFORMATION: 

Effentora ® ▼ 100 micrograms, 200 micrograms, 400 micrograms, 

600 micrograms, 800 micrograms fentanyl buccal tablet (fentanyl) 

Please refer to Summary of Product Characteristics (SmPC) before prescribing. 

Presentation: Effentora buccal tablet containing 100 micrograms, 200 

micrograms,400micrograms,600microgramsand800microgramsfentanyl. 

Indications:Treatmentofbreakthroughpain(BTP)inadultswithcancerwho 

are already receiving maintenance opioid therapy for chronic cancer pain. 

Patients receiving maintenance opioid therapy are taking at least: 60 mg 

oforalmorphinedaily,or25microgramsoftransdermalfentanylperhour, 

or 30 mg of oxycodone daily, or 8 mg of oral hydromorphone daily or an 

equianalgesic dose of another opioid for a week or longer. Dosage and 

Administration:SeeSmPCforfullinformation.Method:Placetheentiretablet 

inthebuccalcavity(nearamolarbetweenthecheekandgum).Alternatively, 

sublingually(seesection5.2ofSmPC).Retainwithinthebuccalcavitylong 

enoughforthetablettodisintegrate.Swallowanyremnantswithwaterafter 

30minutes.Adult:Treatmentundertheguidanceofaphysicianexperienced 

inthemanagementofopioidtherapyincancerpatients.Beawareofpotential 

abuseoffentanyl.Individuallytitratetoan“effective”doseprovidingadequate 

analgesia,minimisingundesirableeffects.Therequireddosemayincrease 

over time due to progression of the underlying cancer disease. A second 

doseofthesamestrengthmaybetakenifrequired.Afterasecondtablet, 

wait4hoursbeforetakinganother.Ifaseconddoseistakenseveraltimes 

in a row, consider adjusting maintenance dose. Children and adolescents: 

Notrecommendedforuseinpatientsbelow18yearsofage.Elderly:Patients 

over65tendtoneedalowerdose.Hepaticandrenalimpairment:Cautionin 

patientswithmoderatetoseverehepaticorrenalimpairment.Seesection4.4 

ofSmPCformoreinformation.Xerostomia:Drinkwatertomoistenthebuccal 

cavitypriortoadministrationofEffentora.Ifstillinadequatedisintegration, 

switchtherapy. Contraindications:Hypersensitivitytotheactivesubstance 

ortoanyoftheexcipients.Treatmentofacutepainotherthanbreakthrough 

pain. Patients not on maintenance opioid therapy (see SmPC section 4.1). 

Severe respiratory depression or severe obstructive lung conditions. 

Building Confidence in BTcP Treatment 

Warnings and Precautions: Keep all Effentora tablets out of the reach and 

sight of children. Monitor patients closely during the titration process. 

StabiliselongactingmaintenancetreatmentbeforeEffentoratherapybegins. 

Continue maintenance treatment whilst taking Effentora. Risk of clinically 

significant respiratory depression. Increase dose with caution. Particular 

cautionwhentitratingpatientswithchronicobstructivepulmonarydisease 

orothermedicalconditionspredisposingtorespiratorydepression.Extreme 

cautioninpatientssusceptibletointracranialeffectsofCO2retention,suchas 

increasedintracranialpressureorimpairedconsciousness.Cautioninpatients 

withpre-existingbradyarrhythmias,withhepaticorrenalimpairment.Care 

withpatientswithhypovolaemiaandhypotension.Interactions:Metabolised 

mainly via cytochrome P450 3A4 isoenzyme system (CYP3A4), therefore 

potential interactions with agents that affect CYP3A4 activity. Inducers of 

3A4activitymayreducetheefficacyofEffentora.StrongCYP3A4inhibitors 

ormoderateCYP3A4inhibitorsmayincreasefentanylplasmaconcentrations, 

potentiallycausingfatalrespiratorydepression.Additivedepressanteffects 

withconcomitantuseofothercentralnervoussystemdepressants(referto 

theSmPCforfulllist).Notrecommendedforusewithin14daysofreceiving 

MonoamineOxidaseInhibitors.Concomitantuseofpartialopioidagonists/ 

antagonistsnotrecommendedduetopartialantagonismofanalgesiaand 

potential withdrawal symptoms. Pregnancy and lactation: Not to be used 

in pregnancy unless clearly necessary. Use of Fentanyl may cause opioid 

withdrawalinthenew-borninfant.Useduringlabouranddelivery(including 

caesareansection)maycausefoetalrespiratorydepression,requiringready 

availabilityofanantidoteforthechild.Notbeusedbybreastfeedingwomen 

andnobreastfeedinguntilatleast48hoursafterthelastadministrationof 

fentanyl.Effects on ability to drive and use machines:Mayimpairmentaland/ 

or physical ability required for potentially dangerous tasks (e.g., driving a 

caroroperatingmachinery).Advisenottodriveoroperatemachinerywhile 

taking Effentora until reaction to Effentora is known. Undesirable effects: 

Please see the SmPC for complete list of adverse effects. Typical opioid 

undesirable effects. Serious adverse reactions: Respiratory depression 

(potentiallyleadingtoapnoeaorrespiratoryarrest),Circulatorydepression, 

Hypotension and shock. Monitor for these. Very common effects (>10%) – 

Nausea, Vomiting, Dizziness and Headaches, Application site reactions. 

Common(>1%-10%)–Weightdecreased,Tachycardia,Anaemia,Neutropenia, 

Dysgeusia,Somnolence,Lethargy,Tremor,Sedation,Hypoaesthesia,Migraine, 

Dyspnoea, Pharyngolaryngeal pain, Constipation, Stomatitis, Dry mouth, 

Diarrhoea, Abdominal pain, Gastro-oesophageal reflux disease, Stomach 

discomfort, Dyspepsia. Toothache, Pruritis, Hyperhidrosis, Rash, Myalgia, 

Back pain, Anorexia, Oral candidiasis, Fall, Hypotension, Hypertension, 

Peripheral oedema, Fatigue, Asthenia, Drug withdrawal syndrome, Chills, 

Depression, Anxiety, Confusional state, Insomnia. Tolerance, physical and/ 

orpsychologicaldependence.OpioidwithdrawalsymptomssuchasNausea, 

Vomiting, Diarrhoea, Anxiety and Shivering. Loss of consciousness and 

Respiratory arrest have been observed in the context of overdose. See 

fullSmPCforotherundesirableeffectsclassifiedasUncommon,Rareand 

unknown.Overdose:SeeSmPCforfullinformation.Immediatemanagement 

ofopioidoverdoseincludesremovalofEffentora,ensuringapatentairway, 

physicalandverbalstimulation,assessmentofthelevelofconsciousness, 

ventilatoryandcirculatoryassessment,andventilatorysupportifnecessary. 

Basic UK NHS Costs: Effentora all strengths x 4 £19.96. Legal Category: 

CD (Sch2), POM. Marketing Authorisation Numbers: EU/1/08/441/001-010. 

Marketing Authorisation Holder: Cephalon Europe 5 rue Charles Martigny 

F-94700Maisons-AlfortFrance.Date of SmPC:December 2009.Information, 

including SmPC, is available from Cephalon UK Limited, 1 Albany Place, 

HydeWay,WelwynGardenCity,Hertfordshire,AL73BTMedicalInformation 

ukmedinfo@cephalon.com).Freephone:UK08007834869 

Adverse events should be reported. Reporting forms and 

information can be found at www.yellowcard.gov.uk. Adverse 

events should also be reported to Cephalon UK Ltd on 0800 

783 4869 or ukmedinfo@cephalon.com 

DateofPrescribingInformation:21DEC2009CE/FE-09121 

©Cephalon UK Ltd. All rights reserved. ®Cephalon and Effentora are registered trademarks CE/FE-10008c/Jan10 

* For the treatment of Breakthrough Pain (BTcP) in adults with cancer who are already receiving maintenance opioid therapy for chronic cancer pain. 

1. Slatkin NE et al., Fentanyl Buccal Tablet For Relief of Breakthrough Pain in Opioid-Tolerant Patients With Cancer-Related Chronic Pain. J Support Oncol. 2007; 5(7): 327-334.

12 



NEWS - ASM 2010 

Citation for Dr Joan Hester 

Citation delivered by 

Dr William Campbell 

Dr Joan Hester carried out 

her undergraduate training in 

London, qualifying in 1969. 

Three years after obtaining her 

fellowship in anaesthesia she 

was appointed consultant in 

1976 based at Eastbourne. Within 

just 2 years she had founded the 

Eastbourne pain management 

service for both acute and 

chronic pain, and as director of 

these services she established 

a full multidisciplinary service, 

including a pain management 

programme. Over the following 

5 years, Joan then went on 

to establish the Eastbourne 

Macmillan service, co-founded St 

Wilfrids hospice in Eastbourne, 

and became its medical advisor. 

In recognition of her dedication 

and commitment to the hospice 

she was awarded the position 

of Vice President of the unit 

in 1993. In1998 Joan became 

Clinical Director of Theatres, 

Anaesthesia, ITU and Pain 

Management at Eastbourne, 

going on to become the Medical 

Director of the hospital until 

2002. Joan co-founded the South 

Eastern Pain Interest Group 

organising its biannual meetings. 

She was also principle organiser 

of the Pain Societies Annual 

Scientific Meeting in Eastbourne 

in 1995 and the South Thames 

Acute Pain Group 1999. 

However, it was her special 

interest in palliative care and 

cancer pain that led to her being 

invited to many countries to 

speak on the subject from 1997 

onwards including: - Romania, 

Dakhar, Mumbai, Sarajevo, 

Bosnia, Davos, Kiev and Grand 

Cayman. 

In 2004 Joan moved to London 

taking up a new post, as 

Consultant in Pain Medicine 

at Kings College, and shortly 

thereafter completed an MSc 

in Palliative Care. Over the 

following 5 years she became 

involved in research in sleep 

disorders and pain, novel 

analgesics and the effects of 

opioids on pituitary function. In 

addition she has written book 

chapters, co-edited a book on 

interventions for pain control in 

cancer pain management, as well 

as having multiple publications 

in journals such as Pain, Drugs, 

the British Medical Journal and 

the European Journal of Pain. 

Joan was elected Honorary 

Assistant Treasurer of The Pain 

Society in 1996, then becoming 

Honorary Treasurer in 1999 and 

holding this office for 2 years. In 

2005 she was became President 

Elect of the British Pain Society, 

then President from 2006-2009, 

followed by the position of 

Immediate past President from 

2009 until now. Overall 10 years 

as an Executive officer of The 

Society to date. 

During Joan’s period as 

President she has been – 

A founding member of the 

Board of the Faculty of Pain 

Medicine of the Royal College of 

Anaesthetists. 

An invited member of the 

Department of Health’s 

18 week co-ordinating 

group (orthopaedics and 

musculoskeletal medicine, as 

well as for chronic pain). 

Worked with the Royal College 

of General Practitioners 

to develop guidelines and 

competencies for practitioners 

with a special interest in pain 

management 

She was also a council member 

of the European Federation of 

Chapters of the International 

Association for the Study of Pain. 

This was in addition to working 

with many organisations through 

the British Pain Society such as: 

Help the Aged, Long term 

conditions alliance, The Patients 

Association, The Chronic Pain 

Policy Coalition, Medicines and 

Healthcare Products Regulatory 

Authority, National Institute for 

Clinical Excellence , The Scottish 

Cross-party group for pain 

management. 

This illustrates her life-long 

interest in cancer pain control 

and her international reputation 

for work in promoting education 

and understanding in pain 

management. 

Throughout her career, Dr Joan 

Hester has illustrated her tireless 

dedication to pain management 

and the British Pain Society. She 

has responded constructively to 

nearly every email over the past 

6 years – no mean task. 

Over the years she has been 

most supportive to Council and 

the secretariat, and this together 

with her wisdom and clarity 

of decision making have been 

invaluable - very much to The 

Society’s benefit. 

There is life beyond pain – Joan 

enjoys art, opera, cookery and 

last but far from least choral 

singing and conducting. 

It is most fitting that Dr Joan 

Barbara Hester is awarded 

Honorary Membership of The 

British Pain Society. 

14 



Citation for Professor 

Troels Staehelin Jensen 

Professor Jensen was President of 

the Scandinavian Association for the 

Study of Pain from 1988 to 1984 

and President of the International 

Association for the Study of Pain 

(IASP) from 2005 to 2008. Currently 

he is the IASP Liaison for WHO, 

the World Federation of Neurology 

and the South East Asian Chapters 

of IASP. Professor Jensen has made 

significant contributions to the 

publication of scientific papers as a 

section editor for the journal PAIN 

from 1999 to 2002 and currently 

he is a Field Editor for the journal 

PAIN, the Clinical Journal of Pain, 

the Journal of Pain Symptom 

Management and the Scandinavian 

Journal of Pain. He is a founding 

member of the IASP Special Interest 

Group for Neuropathic Pain (NeuP 

SIG). 

From this brief review of Professor 

Jensen’s busy life and his major 

contributions to the basic science of 

pain and its clinical management, it 

is clear that he is a physician of great 

distinction and I have no 

hesitation in proposing that he be 

made an Honorary Member of the 

British Pain Society. 


Professor Sir Michael Bond 

Troels Jensen is a neurologist of 

distinction, a world authority and 

leader in pain research and pain 

management. He is a professor 

of experimental and clinical pain 

research at Aarhus University in 

Denmark and also head of the 

Danish Pain Research Centre. 

Professor Jensen received his MD 

and DMSc degrees at Aarhus 

University and his postgraduate 

training in neurology took place 

in Paris, at the Mayo Clinic in the 

United States and in his home 

country. 

Professor Jensen’s research 

interests have centered upon 

various forms of chronic pain, 

their neurophysiological basis and 

their management especially by 

pharmacological means. His work 

and that of his colleagues has 

been the investigation of a range 

of disorders and diseases of the 

nervous system including phantom 

limb pain, post stroke pain, 

multiple sclerosis, facial and oral 

pain and polyneuropathies. This 

has lead to a focus which was, and 

has remained, the mechanisms 

causing neuropathic pain and 

exploration of its treatment. In 

association with his work, Professor 

Jensen has played a major role in 

defining, classifying and assessing 

neuropathic pain. The work of 

his group has involved a series of 

studies of a range of pharmaceutical 

agents as analgesics for neuropathic 

pain and, in particular, the newer 

anticonvulsant drugs such as 

Gabapentin. Professor Jensen’s 

work can be summarised as 

the neurophysiology and the 

neuropharmacology of pain, and 

the translation of basic nociceptive 

sciences into clinical practice. 

Professor Jensen's work has resulted 

in over 300 peer review papers and 

reviews and he has been awarded 

several visiting professorships 

including ones in Denmark, the 

United States and Germany and a 

number of major awards. The latter 

include the Patrick D Wall Medal 

and Lectureship of the British Pain 

Society in 2009. 


Poster Prize presentations, 

2010 ASM 

1. The impact of pain severity, 

as defined by the EQ-5D 

index, on personal economic 

circumstances: findings from 

the England Health Survey 

Chris Ll. Morgan, Peter 

Conway, Craig J. Currie 

(Winning Poster) 

2. Opioid induced androgen 

deficiency (OPIAD): is it a 

problem? 

Deepak Ravindran, John 

Lee 

3. An examination of acceptance 

and values at the interface of 

primary and secondary care in 

adults with chronic pain 

Kevin E. Vowles, Julie 

Ashworth, David Beachill, 

Carol Graham, Jon 

Packham, Gail Sowden & 

Nicky Stanyer 

4. Acute pain in medical 

inpatients – time to stop 

suffering in silence 

Dr Mark Rockett 

5. The interruptive effect of pain: 

an examination of seven tasks 

of attention 

David J Moore, Edmund 

Keogh, Christopher 

Eccleston 



Citation for 

Ms Heather Muncey 


Ms Heather Cameron 

Heather Muncey began her 

working life as a psychiatric nurse 

before choosing to pursue a career 

in physiotherapy, graduating as 

a Chartered Physiotherapist in 

1979. After gaining experience in 

various settings she was appointed 

as the Lead Physiotherapist in the 

Bristol Pain Management Service 

in 1989. There she was part of an 

interdisciplinary team which aims 

to facilitate patients to develop 

coping skills and self-management 

of their long term pain problems. 

Heather is particularly interested 

in secondary prevention of painassociated 

incapacity; acting as site 

Supervisor in a “Back to Work” 

study aimed at returning people 

with low back pain to work. 

Heather also has 9 years 

experience as a Service 

Improvement manager in the 

NHS across both Primary and 

Secondary Care. As well as her 

Physiotherapy role, Heather is 

currently the Project Manager in 

Bristol for the Co-creating Health 

Initiative. This 3-year multi-centre 

Programme funded by the Health 

Foundation aims to improve self 

management support for people 

with long term conditions, including 

musculoskeletal pain. Patient 

involvement at all levels of care is a 

key feature of the design. 

Working within the pain field, 

Heather quickly realised that there 

was a lack of understanding of 

pain management within the 

physiotherapy profession; whilst 

pain mechanisms featured heavily 

in most undergraduate programme, 

pain management did not. 

Physiotherapy was a profession that 

was very focussed on a medical 

model. Heather Muncey has been 

one of the most influential people 

in changing these attitudes. 

In early 1994, Heather wrote a 

letter to the journal ‘Physiotherapy’ 

asking if there was anyone out 

there interested in pain; she had 

32 replies. Later that same year 

at the National Pain Management 

Conference in Bristol (which was 

later to became the conference 

of The British Pain Society Pain 

Management SIG) Heather 

proposed setting up a specific 

interest group for physiotherapists 

interested in pain. 

The group became the 

Physiotherapy Pain Association 

(PPA) with Heather becoming 

inaugural chair and under her 

leadership ( within two years) the 

PPA became an officially recognised 

Clinical interest group of the 

Chartered Society of Physiotherapy. 

Today it boasts as membership of 

over 600 physiotherapists. Not a 

bad growth rate from the initial 32! 

Heather was the first 

physiotherapist to be elected onto 

the Pain Society’s council. She was 

part of the Society’s working group 

that published the Standards for 

Pain Management Programmes. 

She was also one of the British 

Pain Society members advising the 

Department of Health in the area 

of pain management including the 

2000 Clinical Standards Advisory 

Group on Pain (CSAG) and was 

the lead for the Chartered Society 

of Physiotherapy Standards for 

Physiotherapists working in Pain 

Management Programmes. 

Heather was also one of the 

instrumental figures in convening 

an informal meeting of 

Physiotherapists at the IASP 8th 

World Congress in Vancouver to set 

up a network that later developed 

into the IASP SIG “Pain and 

Movement.” 

Heather has lectured extensively 

and delivered many workshops 

both nationally and internationally 

including Chartered Society of 

Physiotherapy Congresses, British 

Pain Society Annual Scientific 

Meetings and also at International 

Association for the Study of Pain 

World Congresses. She has 

designed and delivered postgraduate 

education and training 

programmes based in clinical 

practice settings on the use of the 

cognitive-behavioural approach 

to the management of pain in 

physiotherapy. 

Heather has also published 

extensively, including chapters 

in the “Topical Issues in Pain” 

series covering areas from the bio 

psychosocial assessment of pain 

to the management of change in 

clinical practice. These books have 

become key texts in undergraduate 

physiotherapy programmes both 

here in the UK and internationally. 

She has been a pioneer in the field 

of pain management, in particular 

her influence on the introduction 

of a biopsychosocial approach 

in physiotherapy and as an 

advocate for the multi disciplinary 

membership of the British Pain 

Society. 

Heather also has a life outside of 

pain! She is widely travelled and 

a keen hill walker, the latter being 

particularly enjoyed when there is 

a pub at the end. She has found 

time to study politics with the Open 

University and apparently has an 

indulgent streak – I understand she 

bathed in champagne at a recent 

‘special’ birthday celebration. 

Heather is not flamboyant nor 

is she a show woman, she is a 

discrete influencer; she is gently 

persuasive. When Heather speaks 

however people listen; she herself 

also has that rare gift of listening, 

truly listening as evidenced by 

her responses – these may be a 

question, may be an answer, or 

maybe just a thought provoking 

statement. Always it is something 

that others wish that they 

themselves had thought of. 

In Heather we have an insightful 

and innovative individual, someone 

who empowers others and has a 

unique ability to spot and nurture 

potential in colleagues, a dedicated 

and committed clinician. She has 

given of both her time and her 

talent generously on behalf of our 

speciality of pain and importantly 

on behalf of the patients we seek 

to help. It is both my pleasure and 

my privilege to deliver this citation 

for Heather for the richly deserved 

award of honorary membership of 

the British Pain Society. 

16 


NEWS - ASM 2010 NEWS - ASM 2010 

A personal experience of 

the ASM 

British Pain Society ASM – 

Manchester 2010 

Dr Fiona Duncan 

Blackpool Victoria Hospital 

Bursary recipient 

To all at the BPS, thank you for 

the bursary to attend the Annual 

Scientific Meeting (2010) in 

Manchester. The meeting was a 

great success, and I do appreciate 

the many months of preparation 

by Professor Eccleston and the 

scientific programme committee. 

The venue, catering and general 

atmosphere were excellent. You 

even organised good weather, 

a satellite political debate, and 

amazing sunsets, showing 

Manchester at its best! 

Each and every one of the 

plenary speakers was informative 

and inspiring. Professor Aziz 

explained mechanisms of central 

sensitisation so clearly, that I 

could relate this to patients I see 

in clinical practice. I particularly 

enjoyed learning more about 

using ketamine as an adjuvant 

in the postoperative setting. 

The cautions were useful too, 

especially as it seems to be the 

‘trendy’ drug to prescribe, often 

by fairly junior anaesthetists. 

Professor Langford’s summary 

of progress in inpatient pain 

management over the past 20 

years was thought provoking, 

the way forward is definitely 

both education and establishing 

national databases. I look forward 

to participating in both. 

It was good to have the 

opportunity to present 2 

posters, and spend time with 

other presenters. I particularly 

appreciate the CD provided with 

the abstracts. I also think it was 

a good idea to present abstracts 

alphabetically rather than dividing 

by acute/chronic etc. 

A highlight is always meeting 

up with colleagues from around 

the UK, discovering that we all 

have similar problems and I left 

enthused with new ideas. I do 

appreciate attending SIG meetings 

in particular. It was a useful forum 

to hear about both local and 

national initiatives to which we can 

all contribute. 

The drinks reception was fun, 

although one roving anaesthetist 

with a camera made a very strange 

request – he wanted to take a 

picture of three of us, but from the 

back! We must have been looking 

very jaded after an extremely busy 

conference! Edinburgh is in my 

diary now for 2011. 

Dr. Claire Goodchild 

Institute of Psychiatry 

London 

Bursary recipient 

I would like to thank the British 

Pain Society for providing me 

with the opportunity to attend this 

year’s Annual Scientific Meeting 

at Manchester Central in April. I 

presented a poster concerning 

negative pain-related beliefs 

and attitudes about sleep and 

enjoyed talking to other health 

professionals and researchers 

about the role of psychology 

in chronic pain and insomnia. 

I found both the plenary and 

parallel sessions interesting and 

insightful. 

I found the plenary session given 

by Professor Main enlightening 

in terms of the contributions 

that psychology has made to the 

management of chronic pain 

over past decades and future 

avenues for further improving 

pain management. Dr Palermo’s 

presentation of her team’s work 

on psychological management 

of paediatric chronic pain was 

also very interesting. Working 

in research involving cognitive 

behavioural therapy for painrelated 

insomnia myself, I was 

especially interested in their 

computer-based interventions to 

overcome barriers to the access of 

therapies, which is also a problem 

in the UK. 

I also enjoyed the short 

presentations given by the 

researchers nominated for 

this year’s poster prize. It was 

a refreshing way to promote 

contemporary research and 

is a strategy that I think more 

conferences should employ. 



Reports from the SIG 

Chairs meeting in 

Manchester 

The SIG had 3 main activities last 

year, the workshop at last year’s 

ASM, the bi-annual conference in 

Newcastle (see Dr Paul Wilkinson’s 

report in this edition) and the 

New Committee. The bi-annual 

meeting went very well with good 

speakers and content and the 

conference helped generate funds 

for the continuing work of the 

SIG. The new committee has been 

surveying the membership for 

ideas for the SIG. 

The PMP Guidelines are due for 

an update and the SIG are looking 

to play an active role in this and 

have contacted all those involved. 

regional representatives. Dr Foster 

will support and guide these 

representatives. 

To date 190 hospital sites 

throughout England and Wales 

have registered for the audit and 

have submitted their base line 

data. 

People who are uncertain if they 

are signed up can contact Dr 

Foster and enquire. 

It is planned that when the audit 

begins hospitals will be able to 

observe their results as live feed 

back for sites. 

Special Interest groups provide 

a useful forum for new ideas to 

spring up, contacts to be made 

and ultimately, like different 

varieties of the same plant, help 

the BPS to flourish. The annual 

SIG’s meeting took place at the 

ASM in Manchester this year. 

The following are summaries 

of the reports given by the SIG 

chairs. If there is any area of pain 

management that interests you 

after reading please look at the 

BPS website SIG section or contact 

the secretariat to get further 

information. Your area of interest 

and SIG needs you! 

Philosophy and Ethics SIG 

The SIG continues as it has been, 

holding a successful annual 

meeting with a hardcore of 

regular attendees and a constant 

influx of newcomers. Currently 

we have been using Rydall Hall 

in Ambleside in the Lake District. 

Most attendees have been very 

enthusiastic about the style of the 

meetings. 

Willy Notcutt thanked Peter 

Wemyss-Gorman who continues 

to do much of the day to day 

running and organising the 

annual meeting. He produces a 

transcript of the presentations in a 

booklet form each year, which is 

an excellent digest of the material 

presented and discussed. He also 

ensures that many of these appear 

in Pain News. Peter is still working 

to produce a book of a collection 

of essays from past meetings. 

The workshop at the ASM this 

year had about 60 attendees and 

was one of the most successful 

we have had. This was principally 

due to the quality of the 

speakers, Daniel Sokol and Jayne 

Molodynski on the topics of Deceit 

and Consent. 

Ethics in acute pain was a topic 

at the National Acute Pain 

Conference in 2009 and other 

such activity is being planned. 

There is no long term planning 

within the SIG which is a concern 

as is the matter of succession 

planning for both Willy and 

Peter. We are concerned of the 

effect study leave cuts will have on 

the attendance and the delegate 

mix at the meetings. This matter is 

being discussed and will be taken 

forward at the next AGM in June. 

PMP SIG 

The SIG has a new committee 

which has taken over in the last 2 

months, Frances Cole is the new 

chair. 

The SIG will possibly be holding 

an outcomes consensus meeting 

in the autumn regarding what 

PMP’s should/needs to be 

addressed. 

Clinical Information SIG 

Barbara Hoggart has taken over 

as the chair of the SIG, with 

Mike Bailey taking on the role of 

secretary. 

The SIG is very busy with the 

National Pain Audit which is a 

shared collaboration between the 

Pain Society and the Dr Foster 

group. The partnership with 

Dr Foster is working well The 

committee comprises Dr Foster 

representatives the SIG officers 

(Dr Barbara Hoggart, Dr Ola 

Olukoga and Dr Mike Bailey) with 

Cathy Price and Stephen Ward 

also on the committee ( The full 

committee also has psychology, 

lay person, faculty representative 

and HQIP representative.) 

Phase 1 of the audit is almost 

complete, the data that is to be 

collected was presented at a 

workshop at the ASM. 

The pilot audit is starting in 

May to test the system for 

patient collection of data with 

4 questions for the healthcare 

professionalwith a patient who will 

then contacted by an automated 

telephone system after the initial 

appointment and then at 6 and 

12 months. There will be 12 Pilot 

sites which will be lead by the 

The Audit was presented at the 

ASM workshop and well received. 

Next year the SIG will hold a 

workshop to feed back results. 

To ensure the success of the 

audit a great deal more publicity 

and information needs to be sent 

to all the hospitals and ideas 

would be welcome on how to 

achieve this. 

Pain Education SIG 

The SIG is now 3 years old 

and has held a seminar and a 

workshop at the ASM each year, 

it has 7 working groups. The SIG 

currently awaits the outcome of 

the BPS/Faculty of Pain Medicine 

joint submission to the DH for a 

national e-learning project. The 

SIG will be responsible a) for the 

development of the curriculum; 

b) for the development of a 

publication working group 

(Chaired by Dr Nick Allcock) 

to develop an undergraduate 

pain education curriculum and 

competencies/capabilities for all 

health care professions and c) 

educational initiatives related to 

GP pain education. The outcomes 

of the UK Survey have been 

mentioned in the Chief Medical 

Officer’s Annual Report (2010). 

The SIG is hopeful that it will 

provide an impetus for change in 

pain education. It will hold its 3rd 

seminar at Churchill House on 

November 23rd 2010. 

18 


Internationally the SIG 

is active with Eloise 

co-chairing IASP Satellite 

Conference in Toronto, August 

26-27th with Professor Judy 

Watson (Canada) and several 

SIG Committee and members 

presenting. 

http://bloomberg.nursing.utoronto. 

ca/PainSymposium.htm. 

It is anticipated that there will be 

a joint workshop between the 

Canadian and the UK SIGs at the 

2011 joint ASM. 

Neuropathic Pain SIG 

The Neuropathic Pain SIG held its 

AGM at Manchester. This particular 

SIG has a large membership 

but has trouble engaging with it. 

This could possibly be achieved 

through an interactive SIG 

members section on the BPS 

website. 

It held a well attended and very 

interactive workshop at the 

ASM on the NICE Neuropathic 

guidelines. It is felt that this 

community has a lot of meetings 

already so there is no need or 

demand that the SIG run meetings 

outside of the ASM, although it 

was involved in the Neuropathic 

Pain Study Day last year. There 

could also be the possibility of 

a joint meeting with the Primary 

Care SIG (in the process of being 

created at the time of this meeting, 

since passed by council). 

Two topics on which the 

membership could be engaged 

with would be monitoring and 

auditing the NICE Guidelines and 

also Research. The latter will be 

better defined after the Audit and 

Research survey of BPS members 

is completed. 

Pain in Older People SIG 

The SIG has held workshops at 

the ASM and there will also be 

a workshop at IASP. The group 

still has concerns regarding the 

assessment of pain in older people 

guidelines which do not appear to 

be taken up. The group continues 

to work on the management of 

pain guidelines which will be 

available early in 2011. 

Interventional Pain Medicine 

SIG 

The SIG's annual meeting in 

Manchester was well attended, 

and at the meeting it was decided 

that there was the need to form 

a research group to find out what 

evidence there is and to plan 

future research. The research 

group had its first meeting on the 

23rd March 2010. 

The SIG has formed a best 

practice guidelines committee for 

interventional procedures. The SIG 

would like to produce a newsletter 

for its members. 

The SIG reported the impact of 

the NICE guidelines were not 

uniform across the country and 

that in some areas they had been 

used as a reason for stopping 

procedures 

Acute Pain SIG 

The SIG holds no additional 

scientific meetings outside of 

the ASM there being several 

recognised acute pain meetings 

held already around the UK but 

has met informally alongside the 

National Acute Pain Symposium in 

Chester in September. 

The issue of future training for 

people dealing solely with acute 

pain is still unresolved with 

the Faculty, the situation being 

complicated by the Royal College 

of Anaesthetists who have put 

together a package for acute pain 

training as part of core anaesthetic 

training. This training will not be 

adequate for fellowship of the 

Faculty of Pain Medicine. 

Next year the SIG is going 

to launch a two phase audit 

project under the banner National 

In-Patient Pain Survey (NIPPS). 

Phase 1 is a survey of current 

practice via the NIPPS website 

which is due on-line soon 

(www.nipps.org.uk). Around 

300 hospitals will be invited 

to complete an on-line survey 

describing their service and its 

resources to give a comprehensive 

and constantly updateable view 

of UK wide acute pain provision, 

the results of which will be 

available on the website in due 

course. Passwords for the website 

will be distributed in the near 

future. Phase 2 of the audit is to 

establish a quality benchmarking 

system for In Patient Pain similar 

to the ICNARC system for Critical 

Care. 20 pilot sites have been 

identified which are currently 

collecting the minimum dataset as 

a test of feasibility. This work has 

been undertaken alongside Mela 

Solutions who have developed a 

software package allowing easy 

bedside data collection. The 

plan is to provide twice yearly 

performance statistics for each 

participant hospital against the 

average of all participants as a 

means of ensuring quality and 

driving continual improvement. At 

present participation requires the 

purchase of the Mela Solutions 

Acute Pain Audit software but 

it is hoped that in due course 

other portals for participation will 

become available. 

Pain in Children SIG 

The SIG elected a Vice-Chair at 

its 2010 business meeting, Gwen 

Porter, who will take over as 

Chair next year. Christina Liossi, 

on behalf of the SIG, consulted 

widely and contributed a section 

which has been included in the 

soon to be published Cancer Pain 

guidelines. 

In September, the Royal College 

of Nursing guidelines on The 

Recognition and Assessment 

of Acute Pain in Children was 

published. John Goddard (SIG 

Chair), representing the BPS, 

was a member of the guideline 

development group. The guideline 

has been endorsed by the 

BPS; also by the Association of 

Paediatric Anaesthetists and the 

Royal College of Paediatrics and 

Child Health. 

Led by Diabetes UK, a consortium 

of medical children’s charities 

is campaigning for statutory 

provision of support in schools 

for children with chronic health 

conditions. The SIG is a members 

of this consortium. A high profile 

“question time” event occurred in 

Westminster on October 27th with 

a panel of shadow ministers and 

Sheila Shribman, National Clinical 

Director for Children. A patient 

and parent represented the BPS 

SIG at this event. The SIG will 

also be contributing views on this 

matter to Sir Ian Kennedy’s review 

of NHS services for children. 

The working party on 

Recommendations for the 

management of complex noncancer 

pain in children and young 

people has been active throughout 

the year. 

The SIG has also been successful 

in obtaining an unrestricted 

educational grant from Grünenthal 

to support a clinical nurse 

specialist in capturing national data 

on the pediatric use of Lidocaine 

medicated plasters. 


NEWS 

BPS and NICE joint 

statement 

Professor Sir Michael Bond and 

Professor Peter Littlejohns 

In November 2009, Professor 

Sir Michael Bond and four 

representatives from the British 

Pain Society (BPS), Dr Joan Hester, 

Dr Stephen Ward, Professor Chris 

Main and Ms Heather Cameron, 

met with Professor Peter Littlejohns 

of NICE to discuss the Society’s 

concerns with the NICE guideline 

on Low Back Pain (CG088 - Early 

management of persistent nonspecific 

low back pain). 

At the meeting It was agreed 

that the BPS should consult their 

members on all the relevant issues 

and present a synthesis of these at 

a joint workshop with NICE. This 

subsequently took place on 11 

February 2010 and the proceedings 

of the workshop are available on 

the Members section of the British 

Pain Society website: http://www. 

britishpainsociety.org/secure/ 

members_articles_submenu.htm 

During the workshop small 

groups focused on providing 

suggestions for clarifying the 

guidance and what further 

implementation support 

documents should be 

developed. They also outlined 

a research agenda to address 

the uncertainties in the current 

evidence base. 

The guidelines have been written 

to aid the management of nonspecific 

low back pain i.e. tension, 

soreness and/or stiffness in the 

lower back for which a specific 

cause has not been identified, that 

has lasted for more than 6 weeks 

but less than 12 months. It does 

not include radicular pain from 

nerve root compression. 

There is evidence that the 

exclusion of radicular pain and 

pain duration of non specific 

low back pain as defined 

in the guidelines has been 

ignored or overlooked by some 

commissioners of health services, 

leading to discontinuation of 

injection therapies to all back 

pain patients, no matter what 

the diagnosis or duration of their 

symptoms. To our knowledge 

these patients have not been 

offered any alternative therapy, 

specifically a combined physical 

and psychological programme as 

recommended in the guidelines. 

The role of facet joint injections 

as a diagnostic procedure has not 

been explored in the guidance. 

It is acknowledged by NICE that 

the potential cost savings from 

stopping all injection therapies are 

based on estimates; these figures 

will be re-assessed by a working 

party from NICE and BPS. The 

implementation support tools 

will be re-examined after this has 

taken place to ensure that they 

present realistic view of what costs 

PCTs should bear to achieve the 

optimum configuration of services 

for the period covered by the 

guidelines. 

There is a need to consider 

providing further information on 

the definition of CPP in terms of 

patient selection and length of 

treatment, bearing in mind the 

need to make it cost effective. 

Further clarification is required 

over the role of a multidisciplinary 

pain assessment after initial 

treatments and CPP and before 

surgery. 

Potential Research 

In the light of concern expressed 

about the quality and strength of 

evidence used in the guidelines 

further research in certain areas is 

recommended. 

1) A careful examination of the 

diagnostic and therapeutic 

value of facet joint injections 

during the period covered by 

the guidelines. 

2) The RCTs quoted to 

support acupuncture and 

spinal manipulation as 

treatments reached 

significance but the effects 

were small. The data 

underpinning these 

treatments should be 

revaluated. 

3) The role of education in the 

management of non - specific 

low back pain. 

4) Is CPP a suitable treatment 

for all patients with 

non specific low back 

pain? The characteristics 

of those who are likely to 

respond to it should be 

defined. 

5) The cost effectiveness of the 

full service delivery should be 

examined. 

Next Steps 

The next steps are now for NICE 

and the BPS to discuss and agree 

the content of the implementation 

support documents and to 

encourage researchers and 

research funders to take up the 

research priorities identified. 

The Way Ahead 

The guidelines will be reviewed 

three years after their publication, 

which is in May 2012. This 

will involve consultation 

with stakeholders and the 

establishment a refreshed 

or new Guidelines Development 

Group, either of which which will 

definitely include a pain medicine 

specialist. 

20 



NEWS 

Clinical Excellence Awards 

update 

Dr Douglas Justins 

Dean of the faculty of Pain Medicine 

Nominating Officer for the British 

Pain Society 

Work has commenced on the 

2011 Clinical Excellence Awards 

round. The date for final online 

submission to ACCEA in England 

is 5pm on Friday 10 December 

2010. Specialist Societies such as 

the British Pain Society are asked to 

submit a ranked list of candidates 

to ACCEA by the same date along 

with a citation for each candidate. 

The closing date for electronic 

submission of forms to the BPS 

is Friday 24 September 2010. 

Please DO NOT send paper copies. 

Medical Colleges and other specialist 

societies will have separate closing 

dates. The closing date for the 

Royal College of Anaesthetists is 

Wednesday 1 September 2010. The 

Faculty of Pain Medicine takes part 

in the RCoA process and will not be 

submitting a separate list so please 

DO NOT send forms to the Faculty. 

The BPS Sifting Committee will meet 

in mid October 2010 after all the 

applications have been scored using 

the uniform ACCEA scoring system. 

Candidates must submit their 

own online forms to ACCEA by 

the closing date in December. The 

forms must have been signed off 

by your Trust. The BPS will only 

submit a ranked list along with a 

citation for each candidate. You 

are strongly advised to enter your 

College process as well because 

College support, if obtained, is very 

influential. 

Welsh candidates should submit 

their forms to the BPS. They will be 

ranked along with all the candidates 

from England and Wales and the 

BPS will provide a citation to the 

separate Welsh Secretariat. Welsh 

candidates must submit their final 

online forms to the Welsh Secretariat 

by the same closing date of 5pm 

on Friday 10 December 2010. 

Candidates from Scotland and 

Northern Ireland have separate 

arrangements. 

ACCEA expects the results of 

the current (2010) round to be 

published by the end of July 2010. If 

this happens it will certainly save a 

lot of unnecessary effort. ACCEA is 

expecting to launch the 2011 online 

application system on 1 September 

2010. Please check the ACCEA 

website for updates at http://www. 

dh.gov.uk/ab/ACCEA/index.htm .A 

set of the forms can be obtained 

from the BPS Secretariat if they are 

not available online from ACCEA. 

[info@britishpainsociety.org] 

It is likely that ACCEA will continue 

with the arrangements introduced 

for previous rounds with separate, 

optional, forms for (i) Research 

and Innovation (ii) Teaching and 

Training and (iii) Leadership and 

Management. Please read the 

instructions on the ACCEA website 

so that you submit the correct forms. 

Also please read the instructions so 

that you apply for the correct award. 

Pain specialists and anaesthetists 

often fail to progress in the awards 

process because their forms are 

poorly prepared and do not reflect 

accurately the work that they 

actually undertake. Please read 

very carefully the advice provided 

by ACCEA so that you understand 

fully what it is they are seeking. 

Please ask for advice from current 

award holders or people such as 

the Regional CEA Co-ordinators for 

the Royal College of Anaesthetists. 

At the BPS sifting committee, and 

at every step thereafter, the ranking 

process will be conducted by a mix 

of medical and lay people. Almost 

certainly, many of them will not be 

familiar with your reputation and 

achievements. The only way that 

you can make a case for yourself in 

this competitive process is through 

the forms that you submit. Therefore 

Clinical Excellence Awards update continued 

care and attention to detail is vitally 

important. 

Friday 24 September 2010 

Closing date for electronic 

submission of forms to BPS. 

[accea@britishpainsociety.org] 

NEWS 

Friday 10 December 2010 

Closing date for electronic 

submission of forms and 

citations to ACCEA. 

New Audit into the impact 

of migraine and headache 

in children and young 

people 

A National charity, Migraine Action, 

which has been supporting people 

with migraine for over 50 years, 

is launching a new survey for 

children and young people. The 

survey has ethical approval and 

it is hoped the results will help 

results plan awareness campaigns 

and decide what action is needed 

to help young people with 

migraine. The survey hopes to gain 

at least 2,000 completed surveys 

from both children and young 

people with and without migraine. 

The survey is a web based 

multiple-choice questionnaire and 

only takes children a few minutes 

to complete. 

Surveys can be completed online 

at www.migraine.org.uk/surveys or 

you can contact Migraine Action 

to request hard copy surveys to 

be posted to you. All hard copy 

surveys are accompanied with 

pre-paid envelopes so the child 

can return them to us in the post 

at no cost after seeking parental 

permission. 

The closing date for surveys 

is end of October 2010 and if 

anyone is interested in helping 

can you contact Migraine Action 

on 0116 275 8317 or emailing 

demelzaburn@migraine.org.uk 

22 


Pain 

controlled 

Constipation 

restrained1 

T0045 Date of preparation of item: January 2010. 

By harnessing the synergistic effect of 37.5 mg tramadol and 325 mg 

paracetamol, 1-4 Tramacet delivers the same level of analgesia as 30/300 mg 

co-codamol – with 46% less constipation. 1 When patients can’t tolerate 

co-codamol, consider Tramacet – and now there’s a new presentation, 

Tramacet effervescent tablets. 

TRAMACET 37.5 mg/325 mg, film-coated and effervescent tablets. Refer to 

the Summary of Product Characteristics (SPC) for full details on side effects, 

warnings, contra-indications and overdose before prescribing. Presentation: 

Each film-coated and effervescent tablet contains 37.5 mg tramadol hydrochloride 

and 325 mg paracetamol. Film-coated tablets are pale yellow. Effervescent tablets 

are orange flavoured round shaped flat with bevelled edges, off white to slightly 

rosy coloured with some coloured speckles. One effervescent tablet contains 

0.4 mg sunset yellow and 179.4 mg sodium. Indication: Symptomatic treatment 

of moderate to severe pain; in patients whose moderate to severe pain is 

considered to require a combination of tramadol and paracetamol. Dosage and 

method of administration: Oral use. Film-coated tablets must be swallowed 

whole (not be broken or chewed) with sufficient liquid. Effervescent tablets should 

be taken dissolved in a glass of drinking water. Adults, elderly and children over 

12 years: Initial dose of two tablets; additional doses (not less than 6 hours 

interval) up to 8 tablets (300 mg tramadol and 2600 mg paracetamol) per day. 

Treat no longer than necessary, otherwise monitor. Children below 12 years: 

Not recommended. Renal insufficiency: Not for use in patients with severe 

insufficiency (creatinine clearance < 10 ml/min). Increase dosing to 12-hourly 

intervals in moderate insufficiency (creatinine clearance between 10 and 30 

ml/min). Hepatic insufficiency: Not for use in severe impairment. Consider dosing 

in moderate impairment. Contra-indications: Hypersensitivity to ingredients, 

acute intoxication with alcohol, hypnotic medicinal products, centrally-acting 

analgesics, opioids or psychotropic medicinal products. Current treatment with 

monoamine oxidase inhibitors (MAOIs) or within 14 days of use. Severe hepatic 

impairment. Epilepsy not controlled by treatment. Special Warnings and 

precautions: Not recommended in cases of severe respiratory insufficiency, 

severe renal insufficiency, and severe hepatic impairment. Paracetamol 

overdosage may cause hepatic toxicity. Use with caution in patients susceptible 

to seizures or being treated with medication to lower seizure threshold, especially 

selective serotonin re-uptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), 

antipsychotics, centrally acting analgesics or local anaesthesia, due to the risk of 

convulsions. Concomitant use of opioid agonists-antagonists is not recommended. 

Use with caution in patients who have cranial trauma, biliary tract disorders, 

in a state of shock, in an altered state of consciousness, with respiratory 

dysfunction, or with an increased intracranial pressure. Tramadol cannot suppress 

morphine withdrawal symptoms. Tramadol can cause withdrawal symptoms, 

dependence or abuse. Avoid using during light planes of anaesthesia. In addition 

for the effervescent tablets: Sunset yellow E110 may cause allergic reactions. 

Sodium content to be taken into consideration by patients on a controlled 

sodium diet. Interactions: Concomitant use is not recommended with alcohol, 

carbamazepine and other enzyme inducers, and opioid agonists-antagonists. 

Consider concomitant use with serotoninergic medicines such as SSRIs and 

triptans, due to risk of Serotonin Syndrome. Other opioid derivatives (including 

antitussive drugs, substitutive treatments), benzodiazepines and barbiturates 

may increase the risk of respiratory depression. Other central nervous system 

depressants (anxiolytics, hypnotics, sedative antidepressants, sedative 

antihistamines, neuroleptics, centrally-acting antihypertensive drugs, thalidomide, 

baclofen), can increase the risk of central depression and medicines such as 

bupropion, SSRIs, TCAs and neuroleptics can increase the risk of convulsions. 

Evaluate prothrombin time periodically if given with warfarin like compounds. 

Other drugs known to inhibit CYP3A4 (ketoconazole and erythromycin), 

might inhibit the metabolism of tramadol (N-demethylation) and the active 

O-demethylated metabolite. Concomitant use with metoclopramide or 

domperidone may increase the absorption of paracetamol and cholestyramine 

may reduce the absorption. In limited cases, use of ondansetron increased 

tramadol requirement in postoperative pain. May affect ability to drive or 

operate machinery; effects are enhanced by alcohol or other CNS depressants. 

Pregnancy and lactation: Do not use. Undesirable effects: Very common 

( ≥1/10): dizziness, somnolence, nausea. Common ( ≥1/100,

NEWS 

Creating a Special Interest 

Group 

Dr Pat Schofield 

BPS Honorary Secretary 

The British Pain Society currently has 

a number of special interest groups 

(SIG). These are small subsidiary 

groups who share a particular 

interest in a topic or theme. For 

example we have groups related 

to pain in older people; acute 

pain; education; neuropathic pain; 

intervention and many more. These 

special interest groups provide 

workshops for the ASM, stand 

alone study days and expert advice 

to council or other representatives 

on topics related to the SIG focus. 

Another activity that a SIG may lead 

on is the development of guidelines, 

for example, the older people SIG 

has helped to produce guidelines 

for the assessment of pain in older 

adults and we are leading on the 

development of guidelines for the 

management of pain in older adults. 

There are certain criteria that must 

be met before setting up a SIG: 

Members will only be eligible for 

approval as an Affiliated or Society 

Special Interest Group if: 

• its sole purpose is to carry out 

the Society's objects within its 

specialist area 

• it consists of at least twenty five 

(25) Ordinary and/or Honorary 

and/or Retired Members of the 

Society 

• all its members are members of 

the Society 

• it is open to more than one 

professional group or area of 

discipline - its interest will be in 

one subject area and it has a 

governing document in force 

How the SIG runs is totally 

dependent upon the membership 

of each SIG and there is some 

variation between the SIG’s currently 

in place. For example, a SIG may 

operate with a chair, treasurer, 

secretary and council members in 

a similar format to the current BPS 

council. Alternatively, they may have 

members who lead on particular 

aspects such as education, policy or 

research. This will be influenced by 

the SIG being a Society or Affiliated 

SIG. 

Affiliated or Society SIG’s 

There are two types of SIG within 

the BPS: 

• Affiliated SIG 

• Society Special Interest Group 

Both are subject to similar regulations 

with the exception of funds and 

liability insurance. An affiliated SIG 

may have its own funds in place and 

must have a governing document 

and liability insurance in place. An 

Affiliated Special Interest Group may 

open and maintain a bank account in 

its own name for the receipt of funds 

which shall be under the control 

of the Group. All assets and funds 

acquired or received by or under 

the control of an Affiliated Special 

Interest Group belong to it (subject 

to any third party rights) and are 

under its control. The Society has 

no entitlement to any of those assets 

and funds (except as may otherwise 

be agreed between the Society and 

the Affiliated Special Interest Group). 

However, the SIG in this case is 

liable for its own debts and liabilities. 

In contrast the Society SIG does 

not have the right to open its own 

bank account or have its own funds. 

Any income must be agreed by 

council and be as the result of a 

comprehensive business plan put 

forward to the treasurer. So for 

example in running a study day any 

income and expenditure should be 

demonstrated. 

Setting up a SIG 

So how can you set up a SIG? As 

stated above - A SIG must contain 

25 members, these can be ordinary 

members, honorary members or 

retired members of any discipline as 

long as they are current members 

of the BPS. 

The written application should be 

submitted to the honorary secretary 

of the society with the following 

information: 

• the name of the proposed 

Society Special Interest Group; 

• the name of its proposed 

chairman and other officers; 

• a description of its proposed 

activities and scientific focus; 

• such other information as the 

Council may require. 

It is not necessary for all applicants 

to sign the same letter. If approved, 

by council, the SIG may be formed 

and would be incorporated into the 

society. As such, the group is subject 

to the control of the society. 

In order to become an Affiliated SIG 

the following are required: 

• the name of the proposed 

Affiliated Special Interest Group; 

• the names of all its members; 

• the names of its officers; 


activities and scientific focus; 

• details of any professional 

indemnity/public liability 

insurance; 


funding; 

• a copy of its governing 

document; 

• such other information as the 

Council may require 

If approved by council this type of 

SIG is an independent organisation 

from the society and An Affiliated 

Special Interest Group may describe 

itself as "a special interest group 

affiliated to The British Pain Society”. 

The application form can be 

downloaded from the BPS website 

http://www.britishpainsociety.org/ 

SIG_Application_form.pdf 

Benefits of being a SIG 

Both SIG’s can describe themselves 

as a “special interest group of the 

society” or “affiliated SIG of the 

society”. They can also both be 

listed in the Society’s Directory of 

members and dates and places of 

their meetings can be listed free 

of charge in both the newsletter 

and website. Subject to approval of 

council the society’s mailing lists and 

facilities to publicise forthcoming 

events may be used. Scientific or 

business meetings may also be held 

by both SIG’s at the ASM subject 

to approval by the chairman of the 

courses and meetings committee on 

a space available basis. 

Requirements of the SIG 

When approved by council, a 

council link person will be allocated 

to the SIG and will act as liaison 

between the SIG chair and council. 

The SIG will be expected to update 

council of any developments or 

plans and as such will be invited to 

produce a report which is presented 

at each council meeting. The SIG 

24 


will also be expected to produce 

an annual report and give a verbal 

presentation at a SIG chairs meeting 

scheduled for the ASM. 

At the Manchester ASM this year a 

new special interest group of the BPS 

was formed. 

The Primary Care SIG's aim is: 

• To push forward the pain 

agenda in primary care under 

the stewardship of its chair Ms 

Val Conway and co-chair Dr 

Cathy Price. The BPS council 

liaison member is Dr Joan 

Hester. 

Further information on setting up 

a SIG can be down loaded from 

the BPS website. http://www. 

britishpainsociety.org/members_sigs. 

htm 

NEWS 

Formation of New Special 

Interest Groups 

• To encourage better linkage 

and understanding between 

primary care and hospital pain 

services and to promote best 

practice for pain management in 

primary care. 

• To encourage research 

into pain management in 

primary care and to develop 

a consensus as to skills and 

competencies needed to 

manage pain in primary care. 

A webpage for primary care 

is hoped to be hosted on the 

BPS website. 

Further work of the SIG will 

involve organising meetings, 

seminars and workshops on 

aspects of pain management in 

primary care. 

For further information please contact 

val.conway@ekht.nhs.uk 

Plans are also afoot to form a Pain 

in Developing Countries SIG 

(PDCSIG). This SIG plans to explore 

the issues of inadequate pain relief in 

the developing world and methods 

by which this situation can improve. It 

is hoped that health links, education, 

advocacy and pain research can 

occur and the group hope to dovetail 

their work with the IASP Developing 

world group who are about to embark 

on a new workstream programme. 

There was considerable interest at 

the scoping meeting held at the 

Manchester ASM and currently the 

proposed chair of the SIG is Dr Mike 

Basler and the co secretary is Dr 

Clare Roques. Further interest in this 

project is welcome and if anyone has 

any information of currently existing 

projects and links please contact Dr 

Mike Basler at michael.basler@ggc. 

scot.nhs.uk. It is hoped that a first 

seminar will occur at next year's ASM. 

Pain in Developing 

Countries SIG 

The Pain Relief Foundation 

A registered charity funding research and education in chronic pain 

CLINICAL MANAGEMENT OF CHRONIC PAIN COURSE 

1-5 NOVEMBER 2010 

An advanced practical course in clinical pain management for those with some experience of 

treating chronic pain. Limited to 30 participants at The Pain Relief Foundation, Liverpool, UK 

Demonstration Clinics • Practical Pain Imaging • PMPs—How to assess and treat patients 

Managing common pain problems • The Pain Clinicians Role in Palliative Care 

Implants for Chronic Pain • Practical Pharmacology • Demonstration Theatres 

Case Presentations • Setting up and running a pain clinic & PMP • Course dinner 

Contact: 

FEE £750 - 2006 price held 

Mrs Brenda Hall, Pain Relief Foundation, Clinical Sciences Centre, University Hospital Aintree, 

Lower Lane, Liverpool L9 7AL UK. Tel +151 529 5822 or b.hall@painrelieffoundation.org.uk 

www.painrelieffoundation.org.uk 

Registered Charity Number: 277732 

In association with The Walton Centre for Neurology & Neurosurgery NHS Foundation Trust 


NEWS 

Update from Wales 

Continued improvements are 

occurring in pain services in Wales. 

The Welsh Pain Advisory Board 

has now completed the evidence 

based Pain management pathway 

for NHS Wales as agreed in 

previous Wales service directive for 

chronic non malignant pain which 

was published in 2008 (http:// 

www.wales.nhs.uk/documents/ 

chronicpaine.pdf). This large 

evidence based piece of work has 

been pushed on by the board. 

Ms Ann Taylor has been a driving 

force in its design and inception. A 

successful audit process in Wales 

has also been completed. A letter 

from the minister of health and 

social services, Ms Edwina Hart 

has been sent to all the NHS Chief 

Executives in Wales urging them to 

continue to improve pain services 

and resources. 

of Medicine project. http:// 

www.mapofmedicine.com/. 

The Map of Medicine is a visual 

representation of evidence-based, 

practice-informed pathways. The 

project is run in conjunction with 

NHS Evidence and is meant to be 

a key tool for clinically-led service 

improvement programmes. There 

is some evidence to show that the 

Map improves patient outcomes 

and lowers healthcare delivery 

costs. 

Above is an outline of the new 

Welsh project. If anyone wishes 

further information they may 

wish to contact Ms Ann Taylor at 

the Department of Anaesthetics, 

Cardiff University, CF14 4XN. 

This pathway has been also 

integrated into the new Map 

26 


NEWS 

Napp Awards for Chronic 

Pain Management 

Listen to 

Airing Pain 

The radio show for 

people in pain 

At an Awards Ceremony at 

Downing College, Cambridge, Pain 

Concern, based in Tranent, East 

Lothian, were awarded first place 

in the Napp Chronic Pain Awards’, 

receiving a grant of £10,000 to 

develop a radio programme aimed 

at those suffering from chronic 

pain. The Napp Awards in Chronic 

Pain is a national competition 

to allow individuals and units 

working in the area of pain to be 

recognised for their commitment 

to improving patient care and the 

management of pain. 

Pain Concern in association with 

Able Radio is developing a new 

programme specifically designed 

to meet the needs of those who 

live with chronic pain. Using the 

novel concept of Internet Radio 

people living with pain can share 

their experiences and discuss 

pain issues on the radio airwaves, 

for the wider benefit of fellow 

chronic pain sufferers listening in. 

Able Radio has a regular health 

programme which has reached 

communities not only within 

the UK but also internationally 

across several countries including 

Australia and USA , Pain Concern's 

programme aims to reach 

specifically those individuals living 

with pain. 

Heather Wallace from Pain 

Concern, stated “The best thing 

about receiving the award is that 

the project has been recognized 

as a worthwhile venture. We were 

the only patient group in the final 

three and we are delighted that we 

now have the potential to reach 

those with persistent pain, through 

the radio waves.” 

Alison Bliss and The Children’s 

Pain Service at Leeds were 

awarded 2nd place and £5,000 

for their project to develop a 

web-based decision support 

system (“decision tree”) for the 

management of bone cancer pain 

in children and young adults. 

The team from NHS Birmingham 

East and North Multidisciplinary 

Pain Service led by Eve Jenner 

were awarded 3rd place and 

£2,000 for their project to improve 

access to a Multidisciplinary Pain 

Service in Primary Care for a 

diverse range of communities in 

Birmingham. 

The independent judging 

panel, a group of experts in 

pain management, was very 

impressed with all the projects 

and the commitment they show 

to those suffering pain. They were 

particularly impressed with the 

innovation behind the ideas and 

that they could reach such a wide 

audience. 

The Napp Awards in Chronic Pain 

is a major awards programme in 

pain management sponsored by 

Napp Pharmaceuticals Limited. 

This is the fourth year the Awards 

have been run and there has been 

a huge amount of interest. 

Topics include: 

• How you can live with pain 

• Evidence-based treatment 

and pain management 

• Pain as a condition in its own right 

Plus anything and everything that 

matters to people in pain 

From August 2010 

A 30-minute programme every fortnight 

On the internet, as a podcast, on CD 

www.ableradio.com 

www.painconcern.org.uk 


NEWS 

New document on Over the Counter Medicines 

management of pain 

The Proprietary Association of 

Great Britain (PAGB) represents 

the manufacturers of over-thecounter 

medicines and food 

supplements in the United 

Kingdom. The PAGB and the 

British Pain Society Document on 

managing pain effectively with 

over the counter medicines has 

recently been published and a 

copy of it is presented here. As 

BPS members know a committee 

of MPs has published the results 

of an inquiry into the misuse 

of over the counter (OTC) and 

prescribed medication. The 

investigation by the All Party 

Parliamentary Drug Misuse Group 

(APPDMG) was launched in 

summer 2007 and the final report 

was published in January 2009. 

The document is a response to 

this. The document can also be 

downloaded on the BPS website. 

What side effects do painkillers have 

and what are the risks of taking 

painkillers in the long-term? 

Side effects 

All medicines can cause unwanted side effects. 

Used in the short-term these are not generally 

troublesome but if painkillers are used long-term, 

then the extent and severity of side effects can 

increase. If you have any unwanted side effects 

or if you have any concerns, you should seek 

advice from your doctor, pharmacist or other 

healthcare professional. 

Paracetamol is a safe drug, except in overdose 

when the liver can become damaged, sometimes 

permanently. 

High doses or long-term use of NSAIDs may lead to 

indigestion, bleeding from the gut, kidney 

problems, high blood pressure, fluid retention, and 

slight increased risk of heart attack and stroke. They 

may also affect blood clotting and worsen asthma 

in about 10% of asthma sufferers. Aspirin must not 

be given to children under 16 years because of a 

very rare illness called Reye’s syndrome which 

can be fatal. 

Prolonged use of painkillers containing codeine or 

dihydrocodeine can lead to constipation, “chronic 

daily headache” and addiction. 

Chronic daily headache 

If you are taking painkillers for 15 days or more 

a month you run the risk of getting daily or 

near-daily headaches that last, on average, for 

more than four hours. These headaches are 

often linked to overuse of painkillers. Unless the 

overused painkillers are completely discontinued, 

the chronic daily headache is likely to continue. 

If you suffer from this then you need to see your 

doctor who can help you. 

This leaflet is available to 

download from www.pagb.co.uk 

and www.britishpainsociety.org 

i 

ADDICTION 

Although, addiction to codeine and dihydrocodeine 

is rare, if it does occur it is a serious problem. 

Never take painkillers containing codeine or 

dihydrocodeine for longer than three days 

without medical advice. 

You may find it helpful to read ‘Pain and substance 

misuse: improving the patient experience’ published 

by the British Pain Society which can be downloaded 

from www.britishpainsociety.org 

How do I know if I am addicted? 

Ask yourself: 

• Do you feel that you need to take the 

codeine/dihydrocodeine products for longer 

periods of time than instructed on the pack? 

• Do you find yourself buying more and more pills? 

• Do you feel the need to take more than the 

recommended dose? 

• Do you feel very unwell when you stop taking the 

medicine but you feel better if you start taking 

the medicine again? 

If you answer “yes” to any of these questions then 

you need help in managing your symptoms and it is 

important that you talk to your doctor. If you take 

the medicine according to the instructions on the 

pack, it is unlikely that you will become addicted to 

the medicine. 

Managing your pain effectively 

using “Over the Counter” 

(OTC) Medicines 

We all know what pain is. Sometimes we hardly notice it. However, other times it is so 

severe that we ask a doctor or pharmacist for help. Sometimes we take a painkiller 

(analgesic) to lessen the pain until it goes away. 

Short-term (acute) pain relief 

Most of us have had occasional headaches, 

muscle or joint pain, or in women, period pain. 

Short-term pain does not last long and tells 

the body that something is wrong. 

Short-term pain can be treated by painkillers 

that can be bought “over the counter” (OTC) 

either from a pharmacy or other shop, such 

as a supermarket or corner shop. 

Long-term pain relief 

Long-term pain, sometimes called chronic or 

persistent pain, is present everyday or comes and 

goes. Some people with long-term illnesses need 

to take painkillers everyday to manage this. 

You may find it helpful to read ‘Understanding 

and Managing Pain’ published by the British Pain 

Society which can be downloaded from 

www.britishpainsociety.org 

produced by the Proprietary Association of Great Britain and the British Pain Society 

28 


i SAFE USE OF PAINKILLERS 

• When taken at the right dose, OTC painkillers are safe and effective medicines. 

• When you have short-term pain it may be best to take the painkiller as recommended on the pack to 

stop the pain from building up and becoming intolerable. 

• If you need to take painkillers for longer than three days you should see your doctor or pharmacist 

for advice. 

• If you feel the dose of a prescription medicine isn’t enough, don’t ‘top up’ with painkillers bought over 

the counter - Talk to your doctor or pharmacist. 

• Speak to your doctor or pharmacist if you need advice. 

i 

MANAGE YOUR PAIN EFFECTIVELY AND SAFELY 

WITH OTC MEDICINES 

Diclofenac 

Naproxen 

• Dihydrocodeine in combination 

with paracetamol 

• Paracetamol 

• Aspirin 

• Ibuprofen 

• Codeine – only available as a 

combination with paracetamol, 

or aspirin, or ibuprofen 

Always read the instructions and do not take two products containing the same active ingredient. Codeine 

or dihydrocodeine containing painkillers should only be used for short-term treatment of acute, moderate 

pain which is not relieved by paracetamol, ibuprofen, naproxen, diclofenac, or aspirin alone. Some OTC 

painkillers can only be used to treat specific conditions. 

i ALWAYS READ THE INSTRUCTIONS AND 

INFORMATION IN THE LEAFLET AND PACK 

• It can be dangerous to take more than one painkiller with the same active ingredient. Make sure you 

know the ingredients of the products that you are taking. 

• If you have conditions like asthma, any stomach problems or if you are taking certain medicines, then 

some painkillers may not be suitable for you and you should speak to your pharmacist or doctor about 

which painkiller would suit you best. Always read the instructions and information in the leaflet and pack. 

• Some people may have side-effects when taking medicines. You can help to make sure that 

medicines remain as safe as possible by reporting any unwanted side-effects via the internet at 

www.yellowcard.gov.uk or through your pharmacy. 

i UNDERSTAND WHAT YOU ARE TAKING 

• Keeping a pain and medicine diary can ensure that you are using your painkillers most effectively. 

• Never take painkillers more frequently than it says on the instructions on pack or in the leaflet. 

• Always read the names of the ingredients and information on the leaflet and pack. 

• Never take another product sooner than you should. 

Your pharmacist and their assistants can advise you on an appropriate choice of product. 

You do not always need painkillers to 

relieve pain 

• Applying heat to the skin can help some types 

of pain. Use compresses or products such as 

sprays, creams, ointments, gels and patches to 

help swelling and inflammation. 

• Support from bandages or compression hosiery 

can help with sprains and strains. 

• Acupuncture or Transcutaneous Electrical Nerve 

Stimulation (TENS) are alternatives to 

medication for pain control. Ask a healthcare 

professional about these treatments. 

• Rest if your body tells you to. 

• Exercise gently as soon as you are able to. 

Ask yourself what is causing the pain. If you do not 

know, if the pain persists for more than three days, 

or if you are unwell, always seek medical advice. 

What kinds of pain can be helped by 

OTC medicines? 

• Headache, migraine 

• Toothache 

• Period pain 

• Minor injuries, strains and sprains 

• Backache, muscle aches, joint pains 

How do different painkillers work? 

Aspirin, ibuprofen, diclofenac and naproxen 

come from a group of drugs called nonsteroidal 

anti-inflammatory drugs (NSAIDs). NSAIDs work by 

changing the body’s response to pain and swelling. 

They are particularly helpful for acute strains and 

sprains, muscle and joint pains. 

Codeine and dihydrocodeine are similar to, but 

weaker than morphine, and work by blocking pain 

messages in the brain and spinal cord. 

Paracetamol works in a different way to NSAIDs 

and codeine. It is particularly helpful in reducing 

fever and relieving pain. 

Because each type of painkiller works in a 

different way to relieve pain, there are some 

products available that contain more than 

one type of painkiller. For example aspirin, 

paracetamol or ibuprofen can be combined 

with codeine and/or caffeine. 

What do the other ingredients do? 

Some painkillers contain caffeine as it may improve 

pain relief. Caffeine, also in coffee and tea, is a 

stimulant. It increases blood pressure and speeds up 

the heart. There is about 75 mg caffeine in a small 

cup of coffee and about 50 mg in a small cup of 

tea, similar amounts to some OTC painkillers. 

Increasing caffeine intake may increase the 

risk of nervousness and dizziness. 

Doxylamine, a sedating antihistamine, has 

muscle relaxing properties thought to be 

beneficial in headache. 

Does your pain affect your life? 

Long-term pain can often affect your quality of life. 

Ask yourself: 

• Do you need to take this medicine continuously 

for more than three days? 

• Do you have low moods? 

• Do you suffer from a lack of sleep? 

• Are you tired and irritable often? 

• Do you find it difficult to concentrate? 

• Does the pain make it difficult for you 

to exercise? 

If you answer “yes” to any of these questions 

then you need help in managing your symptoms 

and it is important that you talk to your doctor. 

Although it may not always be possible to get rid 

of pain completely, there is a range of different 

treatments available. 

! 

BEWARE! MEDICINES HAVE 

MORE THAN ONE NAME 

A brand name is the name chosen by a 

manufacturer (e.g. Panadol®, Nurofen®, Voltarol®, 

Feminax®). Each drug may have several different 

brand names. The “active ingredient” describes the 

drug (e.g. paracetamol, ibuprofen, diclofenac and 

naproxen). Always read the instructions and 

do not take two products with the same active 

ingredient. Make sure you know the ingredients 

of the products that you are taking. These will be 

clearly marked on the pack. 

NEWS 

Economics and Utility of 

Diamorphine Use 

In November of 2009 the Drugs 

Licensing and Compliance Unit 

of the Home Office released 

a consultation paper on the 

Oxycodone import policy of the UK 

government. 

The Government regulates the 

possession, supply, production and 

international trade in controlled 

drugs. Long-standing government 

policy has been to allow the import 

of controlled drugs from outside 

the EEA only if those drugs are not 

available from within the European 

Economic Area (EEA). This policy 

applied to oxycodone in the same 

way that it applied to all other 

controlled drugs. In 2008, following 

representations from within the 

UK pharmaceutical industry that 

this policy was too restrictive, the 

Government amended its policy 

to allow oxycodone imports from 

outside the EEA provided that all 

imports were re-exported. However, 

in 2009 the Government decided to 

revert to its previous policy on the 

grounds that import for re-export 

posed an unacceptable risk to the 

UK’s access to diamorphine. A 

consultation process has occurred 

with the home office and interested 

parties have made submissions 

including the BPS. A review of the 

utility of diamorphine is presented 

at a later point in this edition. 

NEWS 

House of Commons debate 

into Musculoskeletal 

Conditions 

On Tuesday 19 January 2010 in the 

House of Commons a wide ranging 

and informative debate into the 

management of musculoskeletal 

conditions (MSK) occurred. As many 

will know the Department of Health 

has published a framework for 

managing musculoskeletal conditions. 

This debate was brought by Paul 

Rowen, Liberal MP for Rochdale. 

The debate had contributions from 

many MPs and The Parliamentary 

Under-Secretary of State for Health 

Ann Keen MP responded on behalf of 

the government. 

Key issues discussed were: 

• The need for better co-ordination 

and integration of services for 

patients with musculoskeletal pain. 

• The variability of services across 

the country and the need for 

more robust PCT commissioning. 

• The importance of patients being 

able to access a multidisciplinary 

team. 

• The need for better education and 

training, particularly for GPs, in 

MSK conditions. 

It was proposed that a post of clinical 

director for musculoskeletal conditions 

(tsar) could be considered to 

coordinate this work. The Chronic Pain 

Policy Coalition (CPPC) in conjunction 

with other stakeholders is working 

hard to arrange for a UK Pain Summit, 

similar to the recent Australian Pain 

Summit, to occur soon. 


Dr J Edmund Charlton 

9th October 1942 - 3rd 

April 2010 

Dr Chris Wells 

Ed was a giant in the emerging 

field of pain relief medicine. He 

qualified in Durham in 1965 and 

had obtained Consultant status by 

1973. He spent four of the next 

six years in Seattle, working with 

John Bonica and his colleagues, 

Bill Fordyce, John Loeser and 

Terry Murphy. This fostered his 

long-term interest in chronic pain 

management and also regional 

blockade, both of which were 

rarities in the UK at that time. He 

became one of the trusted few 

to administer pain relief blocks to 

Bonica, who had sustained injuries 

in his pre-medical career as a 

wrestler. These were usually done 

in the living room of Bonica’s 

magnificent home overlooking the 

Puget Sound. 

He developed the Newcastleupon-Tyne 

Pain Management Unit 

with John Thompson, becoming 

Director in 1990 and staying until 

his retirement in 2003. 

During his career he was an 

innovator and a mentor. He was 

a great administrator, committee 

man, speaker and writer. He 

spoke and wrote with wit and 

pithy humour, always to the point, 

and said things that others would 

not dare! His wisdom and advice 

helped many He made things 

happen. 

His greatest love in his work was 

the British Pain Society and he 

was a Council member from 1986 

onwards for twelve years, serving 

as President from 1997 to 1999. 

He edited the website for four 

years in the late nineties and was 

still working on the history of the 

Pain Society up to his death. He 

was also Editor of Anaesthesia 

News from 1992 to 1999, which 

was eagerly awaited by his 

colleagues for its sharp content 

and witty commentaries. 

In the wide world of pain, he was 

an eminent and well-respected 

man. He was Secretary of the 

International Association for the 

Study of Pain (IASP) from 1993 to 

1999, surprising the administrative 

secretary by being the first to want 

to actually write the Minutes. He 

served on numerous committees 

of IASP from 1990 onwards, 

through to 2005, and he was 

the Editor of Clinical Notes, Pain, 

from 1993 until 2005. He gave 

numerous lectures and wrote 

many papers, chapters and books, 

as well as editing "The Relief 

of intractable Pain" with Mark 

Swerdlow in 1989 - at 

that time one of the 

very few textbooks 

on pain. He was the 

Founder Member of 

NeuPSIG, a Special 

Interest Group of IASP; 

he collected signatures 

for this in 1999 and 

was the first Secretary 

of the group, moving 

it forward to its present 

respected position. 

He suffered poor 

health in his retirement, 

but maintained his 

immense interest in 

pain medicine, and 

he continued to be involved in 

meetings, education and medical 

politics. He was a major influence 

in the development of the IASP 

core curriculum. Outside work 

Ed was a bon viveur, raconteur 

and friend. At meetings, he 

could always be found dispensing 

advice and libations in equal 

quantity far into the night. He 

was a keen rugby player and then 

rugby referee and was an ardent 

observer of both international 

rugby and cricket. He leaves 

behind his wife Laura, from 

Seattle, and their two children 

John and Danielle, many grateful 

patients and a host of friends 

throughout the world. 

30 


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® 

(tramadol) 

ONCE DAILY AT BEDTIME 

When you need continuous 24 hour pain relief, 

when short acting tramadol dosing is not optimal .... 

Before prescribing controlled drugs 

consider 


® 

200 mg* 

* The starting dose is one 100 mg tablet. The usual dose is one 200 mg tablet. The maximum dose is 400 mg daily. 

TRADOREC ® XL prolonged-release tablets 

tramadol hydrochloride 

ABRIDGED PRESCRIBING INFORMATION 

Refer to Summary of Product Characteristics (SPC) 

before prescribing 

Adverse events should be reported. Reporting 

forms and information can be found at 

www.yellowcard.gov.uk. Adverse events should 

also be reported to Merck Sharp & Dohme Ltd 

(tel: 01992 467272). 

PRESENTATION 

Prolonged-release, white, round tablets containing 100 mg, 200 mg or 

300 mg tramadol hydrochloride. 

USES 

Treatment of moderate to severe pain. 

DOSAGE AND ADMINISTRATION 

The tablets should be swallowed whole with or without food, with a 

suffi cient quantity of liquid and not divided or chewed. Adults and 

adolescents (12 years and over): Starting dose 100 mg orally, once 

04-11 TRA.10.GB.49160.Jg 

daily. The usual dose is 200 mg once daily preferably in the evening. 

Dosage can be increased to 300 mg or to a maximum of 400 mg once 

daily. Elderly: No adjustment of daily dosage is required in patients 

up to 75 years. Not recommended for patients over 75 years. 

Children (under 12): Not recommended. Use in renal or hepatic 

dysfunction: Use with caution in moderate hepatic or renal 

impairment. In general, the lowest effective dose should be chosen. 

Should not be used longer than absolutely necessary. If continued 

treatment is necessary, careful regular surveillance should be carried out. 

CONTRA-INDICATIONS 

Hypersensitivity to tramadol or any ingredient. Acute intoxication or 

overdose with CNS depressants. Concomitant treatment with MAO 

inhibitors or within 2 weeks. Concomitant treatment with linezolid. 

Severe hepatic or renal impairment. Uncontrolled epilepsy. Breastfeeding 

for more than 2-3 days. 

PRECAUTIONS 

Alcohol consumption or concomitant treatment with carbamazepine is 

not recommended. Tolerance and psychological/physical dependence 

may develop with long-term use. Caution in patients at risk 

of respiratory depression, epilepsy, patients with head trauma or 

shock. Not suitable as a substitute for opioid dependent patients. 

Concomitant medications not recommended: mixed agonists-antagonists 

(buprenorphine, nalbuphine, pentazocine), naltrexone. Use with caution with 

morphine derivatives, CNS depressants, SSRI’s, other anti-depressants, 

mefl oquine, bupropion, venlafaxine, coumarin derivatives, e.g. warfarin. 

Pregnancy: Do not use Tramadol during pregnancy unless clearly 

necessary. Lactation: A single administration of tramadol does not 

usually require breastfeeding to be interrupted. If repeated administration 

is needed for several days, i.e. more than 2 to 3 days, breastfeeding 

should be suspended. If long-term treatment after birth is necessary, 

breastfeeding is contraindicated. 

SIDE EFFECTS Refer to SPC for complete information on side effects. 

The most commonly reported undesirable effects, nausea and dizziness, have 

been observed in more than 10% of patients. 

Cardiac disorders 

Uncommon (≥1/1,000,

® 

(tramadol) 


For continuous 24hr pain relief, type 

T R A D 

into your prescribing system 

Incorporating Contramid ® technology under licence from Labopharm 

recommended doses and in the case of concomitant administration of 

other CNS depressant medicinal products. Epileptiform seizures primarily 

occurred following administration of high doses of tramadol or following 

concomitant treatment with medicinal products that lower the seizure 

threshold or trigger seizures. 

Psychiatric disorders 

Rare (≥1/10,000,

PROFESSIONAL PERSPECTIVES 

A painful truth? 

Dr Des Spence 

General Practitioner and 

BMJ Columnist 

The work of doctors is to relieve 

suffering. All of us, bar a few rogue 

elements, work to the best of our 

abilities, earnest, well intentioned 

and continually striving to do the 

right thing for our patients. When 

I recently criticized the wider 

pain management community 

in relation to the use of strong 

opioids in the BMJ, it was neither 

intended to be disrespectful or 

offend. My motivation was to 

reflect on changes in practice 

that I had observed over the last 

decade, in the use of opioids 

and opiates, particularly in the 

wider community. As a General 

Practitioner I am one of the 

“canaries in the coalmine” of 

care, and have anecdotally 

witnessed increasing problems 

with prescribed opioids; from 

dependence and drug seeking 

behaviour, to the diversion of 

prescriptions into the black 

market. Anxiety, by myself and 

many colleagues, is also now 

expressed by the creep of strong 

opioids into non-malignant pain 

syndromes which too many seem 

often poorly defined diagnostically 

and of contentious and uncertain 

aetiology. Recently the promotion 

of opioids in the elderly for early 

osteoarthritis (OA) has also caused 

concern. This condition (OA) is 

notoriously intermittent and the 

wholesale introduction of potent 

medications, on the back of any 

guideline, may lead to problems in 

a vulnerable group. 

Opiate prescribing trends report 

a 70% increase since 2003 with 

the trajectory relentlessly upwards. 

Indeed some countries have 

experienced a 5 fold increase 

in 2 decades. [1] Such a rapid 

change in potent opioid use 

cannot be explained by changes 

in pathology but only by changing 

clinical practice. Concern has also 

been raised about the power 

and lobbying of pharmaceutical 

companies (“Big Pharma”). It is 

now recognized unequivocally, 

that worldwide these companies 

have close educational and 

financial links with many leading 

medical organisations, and pain 

specialists and medical charities 

are not excluded. My point was to 

challenge these changes, especially 

on behalf of general practitioners 

who are responsible for the vast 

majority of prescriptions, so that 

we might avoid the evolving 

disaster of the US experience 

of opiates and chronic pain 

management. 

Background 

There is an argument that pain has 

been under treated for decades. 

Anecdotally this is certainly true 

and many doctors were ignorant 

in the use of strong opioids and 

consequently weary of their 

use. Both palliative care and 

pain communities have been 

actively involved in improving this 

situation. This success, coupled 

with some limited research 

evidence, informally led to the 

more widespread use of opiates 

in non malignant pain syndromes. 

Over the last few decades NSAIDs 

fell from favour as a mainstay for 

chronic painful disorders, due to 

a strong research base showing 

significant and occasionally 

lethal side effects. Initial research 

suggested that when opioids were 

used therapeutically they were 

not associated with significant side 

effects nor addiction. Furthermore 

short small studies suggested 

opioids improved the quality of 

life of sufferers .It seemed logical 

that opioids should be more 

widely used. The acceptance 

of opioids first started in the 

pain clinic but soon became 

common clinical practice in the 

community, following education 

and promotion by pharmaceutical 

companies. Superficially this 

seemed like enlightened medicine. 

Figure 1 

34 


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Indeed, dissenters have become 

increasingly marginalized branded 

“opiophobes” a term that to me, 

smacks of intolerance, but also 

of ignorance. (When I choose to 

raise concerns many felt I merely 

needed to be better educated). 

Research and time, however, have 

cast doubt over the low addictive 

potential with some estimates as 

high as 50% in chronic users. [2] 

Likewise more recent research 

questions whether opioids actually 

improve patients functioning and 

quality of life. [1] 

"Pain is whatever the 

patients says it is" 

There is a prevailing mantra that 

"pain is whatever the patients 

says it is" and this has been 

widely accepted as part of patient 

centeredness. Although the 

concept of “pain is whatever the 

patients says it is" seems both 

reasonable and logical - this 

obviously cannot be the case. Self 

reporting is notorious fraught, for 

what people say, and what they 

do are two quite separate entities. 

Also in the field of pain there are 

numerous contraindications in 

respect to pain. A WHO report into 

the incidence of persistent pain 

in primary care pain generated 

extreme variation – women’s 

reporting of persistent pain in 

Chile is 40% while is only 3.9 % 

of Italian men [3] . How can this 

be so? These large differences 

have no robust pathological or 

physiological explanation. The only 

conclusion, as everyone knows, 

is that pain clearly has a strong 

cultural, gender and personal 

perspective - pain is not one 

entity. All doctors know that pain 

clearly has strong psychological 

components and is a manifestation 

of many different interactions 

of physical and non physical 

mechanisms. I doubt therefore, 

that anyone truly believes that 

“pain is whatever the patient 

says it is”. The unspoken truth 

is we promote complementary 

and alternative medicine because 

we understand its importance as 

placebo in pain management. 

How have we dealt with some 

of the risks of potent opiate 

prescription? It is argued that 

proper assessment with the use 

of validated tools can screen 

out patients with drug seeking 

behaviors, personality disorders 

and psychological issues. This 

patently is not the case. Why 

else is there such variation 

between pain clinic and doctors 

who administer these and again 

reflect the dangers of relying on 

self reporting. I believe these 

questionnaires are both crude 

and clumsy with a low specificity 

and large rates of false positives 

(especially when used out with a 

research environment) But worse 

still, questionnaires undermine 

that most important clinical 

tool – clinical judgment. This 

is even more of a risk with the 

newer government trend towards 

a protocol based generic chronic 

care model that will inevitably be 

delivered by the least expensive 

option possible. 

Opioids have both a physical and 

psychological effect therefore 

many patients with psychological 

issues do respond to medication. 

Applying "pain is whatever the 

patients says it is” has lead to an 

irrefutable over-diagnosis of pain. 

These potent forces have, in my 

opinion, conspired to produce 

a significant cohort of opiate 

dependent patients who are 

“stuck” and unable to engage in 

any meaningful functional activity 

or rehabilitation. Would they be 

better off if they had not been 

prescribed these medications? 

The Land of the Free 

But these arguments against the 

widespread use of opiates are 

not new. In the Victorian period 

opium was widely abused and 

lead to the controls over its use. 

Indeed the backlash against abuse 

likely limited its legitimate use in 

medicine. 

In 1873, an English physician 

noted: “...Amongst the three 

millions and three-quarters 

[people in London] there are to 

be found some persons here 

and there who take [opium] 

as a luxury… began under 

medical advice. The genuine 

opium-eating districts are the ague 

and fen districts of Norfolk and 

Lincolnshire. There it is not casual, 

accidental, or rare, but popular, 

habitual, and common…. You 

offer money, and get opium as a 

matter of course. This may show 

how familiar the custom is.... In 

these districts it is taken by people 

of all classes, but especially by the 

poor and miserable, and by those 

who in other districts would seek 

comfort from gin or beer.” 

Today, we do not need to look 

too far to see the potential harms 

associated with opioids - namely 

the USA. A potent cocktail 

of consumerism and free 

marketeering, "pain is whatever 

the patients says it is" , political 

lobbying, direct to consumer 

advertising , doctor shopping, 

private practice with wealth 

through health and a lack of 

integrated records has caused a 

prescription addiction to a wide 

range of prescription medicines 

and has coined new terms such 

as “hillbilly heroin” And we need 

to look beyond the high profile 

deaths of Michael Jackson, Heath 

Ledger and others celebrities . 

In Washington state there has 

been a 10 fold increase in death 

associated with opioids over a 

decade (450 in 2007) – a change 

that mirrors prescribing patterns. 

[4] The USA is now seeking to 

control this over prescription 

medication which might see 

draconian restrictions. Consider 

this statement from the U.S. 

Centers for Disease Control and 

Prevention (CDC) - “CDC said that 

while automobile crashes remain 

the top cause of accidental death 

nationally, drug-related incidents 

caused more deaths in 16 states 

-- double the number of states in 

2003. In 2006, 45,000 Americans 

died from car crashes, while 

39,000 died from drug-related 

causes” Most of the deaths were 

due to overdoses, especially of 

opioid analgesics like methadone, 

Vicodin, OxyContin, and Fentanyl.” 

But this of course could not 

happen in the UK! I have spent 

15 years in general practice and 

encountered widespread drug 

seeking behaviour; commonly 

for benzodiazepines but more 

recently for opioids and opiates. 

The main abused medications 

are dihydrocodeine, cocodamol, 

codydramol and in recent years 

tramadol and oxycodone. In my 

practice we have had patients die 

from opioids overdoes, numerous 

examples of medication being 

diverted and even a patient who 

had fulminant liver failure from 

compound analgesics. But as these 

are prescription medication they 

receive little reporting. It is also 

very difficult to challenge patients 

about overuse of medication or 

dependence, as the medication 

has been legitimized through 

a diagnosis of pain. Medication 

is therefore often impossible to 

stop. This type of information is 

difficult to collect and collate but 

needs urgent research from a UK 

perspective. 

But rather than accept concerns 

over drug dependence there is 

a policy of medical denial. In a 

widespread cohort, explaining 

away addictive behavior as a 

“pseudo addiction” (as just a 

reflection of a patients need for 

pain relief) and not dependence 

or addictive behavior is a form of 

dangerous knight move thinking 

36 


that is completely counter intuitive 

to most non medical outsiders. 

Ultimately intractable pain, from 

whatever cause, many being non 

malignant, should never been 

seen as an absolute birthright to 

potent narcotics. 

Big Pharma and the real cost 

Pharma companies have been 

very active in promoting their 

medications. This has taken 

the familiar form of promotion 

masquerading as medical 

education. When was the last 

meeting that you attended that 

wasn’t sponsored? Many leading 

specialist have been paid to speak 

and to advise companies with 

the amounts paid undisclosed. 

International conferences, flights, 

and accommodation have been 

gifted widely to the medical 

community, including pain 

physicians and GPs. None of this 

over steps common professional 

boundaries but has lead to a 

dominance of therapeutics in the 

mind set of the pain community 

and undoubtedly increased the 

uptake of new medications. 

I could quote corporate billions 

but this is difficult to conceptualize. 

So in table 1, I have set at the 

cost to the NHS for commonly 

prescribed opioids to illustrate 

the personal implications of our 

prescribing patterns. This explains 

why the industry is so benevolent 

with its money for education. 

Chronic medical conditions are 

industries golden geese. The more 

pain, the more medication and the 

more profit – this a simple and 

hugely effective business model 

– a monster goose. This is no anti 

pharma conspiracy but merely a 

statement of fact. 

The industry is active in all areas 

of public lobbying. But most 

insidiously with patient groups. 

Emotions drives health care, 

not science, and the emotion of 

suffering patients is marketing 

dynamite. The American Pain 

Society suggests no one should 

suffer pain and has a campaign 

“Dream no Small Dreams “. 

This same society has received 

$ 500,000 from a single 

pharmaceutical company. I wonder 

who is doing the dreaming? 

Always promoting the simplistic 

message on pain – that is it is 

both under diagnosed and under 

treated. Pharma money pollutes 

many patient charities and suffers 

to reinforce the medical model of 

care and the use of therapeutics. 

Harms 

But even if we assume that current 

practice does good, do we know 

if it does harm? Most pharma 

research is short by design for 

both efficacy and harms. Also 

study populations are carefully 

chosen to be the groups most 

likely to benefit and are often very 

different from general practice 

populations. This research is then 

applied inappropriately to different 

and unrepresentative populations 

e.g. research in a group of 300 

attending a pain clinic is quite 

different from a general practice 

population. Lastly, because pain 

has such a wide cultural variation, 

research should be country 

specific. Good critical appraisal 

skills are essential- don’t always 

believe the research at face value. 

Opioids are associated with 

tolerance and significant 

withdrawal when stopped. Once 

started opioids are difficult to 

stop and seem to be taken for 

decades. Opioids cause both 

a physical and psychological 

addiction. But what is the long 

effect on social functioning, like 

work, relationships and the rest? 

Key systematic and literature 

reviews highlight the “scarcity of 

evidence” [5] and huge variation 

in reported incidence of addiction 

of 0-50%. [2]. There is also little 

evidence to support better social 

functional and new evidence 

comments “it is remarkable that 

a opioids treatment of long-term/ 

chronic non-cancer pain does not 

fulfill any of the key outcomes 

of opioids treatment goals: pain 

relief, improved quality of life and 

improved functional capacity” [1] 

But other hard end point data 

is beyond refute - opioids 

are associated with abuse, 

unintentional overdose and 

deaths. The numbers dying in 

the UK are not known, but if we 

look to the USA, the increase 

in mortality mirrors increasing 

prescribing. So the doubling in 

prescriptions has likely doubled 

iatrogenic death. [4]. We need 

urgent UK research, not anecdote, 

to inform the issue of balance 

versus harm for the rapid and 

widespread use of opioids. 

The Future 

The pain community has been 

a great advocate for improved 

pain relief ( a problem often 

ignored) and they should be 

rightly proud of the improvements 

in care. The problem is those 

pain clinics are detached 

from the community and lack 

continuity. In recent times many 

GPs complain that pain clinics 

purse a policy of inconsistent 

polypharmacy, new medicines 

and rapid dose escalation. There 

are new regional pain syndromes 

that many are skeptical of. And 

despite the assertion of pain 

clinic are multidisciplinary with a 

broad view of pain - intervention 

seems dominated by therapeutics. 

The pain community needs to 

acknowledge these concerns for 

they are the key opinion leaders. 

Table 1 

Medication* Monthly Cost * Real 10 year Cost 

Butrans 10 Patch £32 £3,840 

Patch Oxycontin 40mg £101 £12,120 

Durogesic 100 £163 £19,560 

*as per BNF 

GPs need better guidance and 

monitoring of prescribing activity. 

There also needs to be serious 

consideration from both pain 

clinicians and GPs as to whether 

they need to distance themselves 

from the Pharma industry due 

to the huge financial conflicts 

of interest. At the very least the 

amounts paid to leading specialists 

needs full disclosure and a 

move away from the traditional 

sponsored educational events. 

How we do this is a thorny issue 

but transparency is key. We must 

monitor the prescribing trends 

and halt the rate of rise. Lastly, 

we need to redefine the notion 

that “pain is what the patient says 

it is” for this is clearly not the 

case and rebalance the doctor 

patient relationship. I maintain 

that the rapid increase in opioids 

prescribing in non malignant pain 

is generating significant iatrogenic 

harm, is bad for patients and is 

bad medicine. 

References 

[1] Eriksen J et al. Critical 

issues on opioids in chronic 

non-cancer pain: an 

epidemiological study. Pain 

2006;125:172-179 

[2] Hǿjsted J, Sjǿgren P. Addiction 

to opioids in chronic pain 

patients: A literature review 

European Journal of Pain 

2007;11:490-518 

[3] Oye Gureje, MBBS, PhD, 

FWACP; Michael Von Korff, 

ScD; Gregory E. Simon, 

MD, MPH; Richard Gater, 

MRCPsych Persistent Pain and 

Well-being A World Health 

Organization Study in Primary 

Care JAMA. 1998;280:147-151. 

[4] http://www. 

agencymeddirectors.wa.gov/ 

Files/AGReportFinal.pdf 

[5] Ballantyne J and LaForge 

KS. Opioid dependence 

and addiction during opioid 

treatment of chronic pain. Pain 

2007;129:235-25 



Opioids for Persistent 

Pain: a personal view 

Dr Joan Hester 

BPS past president 

The revised 2010 consensus 

guidance on good practice for the 

prescription of opioids for persistent 

pain, recently published by the 

British Pain Society, Faculty of Pain 

Medicine, Faculty of Addiction 

Medicine and the Royal College 

of General Practitioners is an 

excellent up-to-date overview and 

should be widely read and used 

effectively 1 . The authors should be 

congratulated, especially Dr Cathy 

Stannnard, who has drawn it all 

together. 

The main thrust of the guidance is 

that, yes, opioids can and should 

be prescribed for persistent pain, 

but if they cannot be demonstrated 

to reduce pain intensity they should 

be stopped, not next year or the 

year after, but soon, after a trial of 

a few weeks. Escalating the dose 

beyond an equivalent daily dose 

of 120-180mgs morphine is very 

unlikely to be beneficial. 

What other drugs with an incidence 

of 80% side effects, some serious 

in the longer term, continue to be 

prescribed, and taken, so readily 

even when they are ineffective? 

Narcosis indeed, the very presence 

of them numbs the senses to 

reason. There should also be 

careful selection of the patient with 

persistent non cancer pain for an 

opioid trial, carefully monitoring 

and managing anyone with a 

previous history of substance 

misuse or a psychiatric disorder. 

The Americans go further with 

this and rule out anyone with a 

history of criminal behaviour. It is 

time for closer working with our 

colleagues from psychiatry and 

addiction medicine, and indeed, 

with our colleagues in primary 

care. Experience dictates that it is 

possible to manage pain without 

strong analgesics, this is more 

difficult as it requires a greater 

investment of time, but surprisingly 

possible. Are we treating 

psychological distress by acceding 

to requests for stronger analgesia? 

It is certainly more difficult to say 

no. However, if you witness first 

hand the emergence of a patient 

from an opioid-induced cloud, 

slurred speech, and constant fatigue 

enhanced by hypogonadism 2 , 

and if you see the transformation 

back into a functioning and alert 

human being, you will change your 

practice. 

Will this wise guidance change 

prescribing behaviours? 

Lance McCracken, Consultant 

Psychologist, has recently surveyed 

GPs’ prescribing habits 3 and finds 

that approximately 60% never 

read guidelines on analgesia use, 

let alone change their practice as a 

result. We know that prescribing of 

opioids is highly variable; we see 

an increasing number of patients 

who are on large doses of strong 

opioids, escalated up from lower 

doses perhaps, who have no 

improvement in quality of life or 

functional ability, but who are very 

reluctant to reduce or come off 

them. We may also see a patient 

on codeine or tramadol whose life 

could be enhanced by a sustained 

release strong opioid, whose 

doctor is very reluctant to prescribe 

for fear of addiction, or possibly 

personal retribution. We know that 

the overuse of oxycodone in US 

has led to a generation of opioid 

dependent patients with, in our 

eyes, consumption of huge doses 

of a variety of drugs of addiction: 

diazepam, temazepam, cyclizine, 

ketamine as well as opioids. The 

Veterans Association in US has run 

an intensive campaign to reduce 

the oxycodone bills, but also to 

improve quality of life. The result 

of this campaign is predictable, a 

third stop taking oxycodone, a third 

stay on the drug but at a lower 

dose, and in a third the attempt is 

unsuccessful. We also know of well 

publicised and unpublicised deaths 

from prescribed opioids. 

Surely we must stop the UK going 

in the same direction? You will 

say “the UK is different, we do 

not have the problem”, but we 

do, on a lesser scale maybe, but 

my observations from working 

in a central London hospital, 

indicate that we do indeed have 

the problem, it is increasing in 

size as the number of narcotic 

prescriptions increases, and it will 

continue to increase unless we 

all lead a local campaign in our 

communities to educate healthcare 

professionals into good prescribing 

practice. We must read every word 

of the guidance and deliver the 

message, every day, in our working 

practice, by letters to other doctors, 

by lecturing at every possible 

opportunity, by making sure that 

the “Accountable Officer” in our 

workplace or PCT has a copy of the 

guidance and by helping him/her 

to act on it. Dissemination of the 

guidance in itself is not enough. 

Opioids have an essential role in 

the management of acute pain, 

and in cancer pain, though the 

doses used in cancer pain often 

seem too high to me. Are cancer 

patients offered a real “choice” in 

deciding between escalating doses 

of opioids, or the use of other 

agents, or even the presence of 

an acceptable level of pain? Has 

the nature of cancer pain changed 

so much that such high doses 

are required? When I first worked 

in cancer pain in the 1980s the 

average daily dose of morphine 

was 30mgs and it seemed to be 

effective in the majority of cases. 

What has happened in the ensuing 

years that we now see patients with 

breakthrough doses of oxycodone 

of hundreds of milligrams given 

on demand? Would perhaps a 

less vigorous initial titration have 

prevented the onset of tolerance? 

Is hyperalgesia recognised and 

managed? Are the long term side 

effects, such as hypogonadism, 

even acknowledged in cancer 

pain? There are many unanswered 

questions. 

These are my own 

recommendations for changing 

prescribing practice that we can 

easily achieve in our workplaces: 

• Make definite 

recommendations for 

the tapering of opioids in 

secondary care after surgery; 

restrict take-home supplies to 

one week with written advice 

for primary care follow up 

and ensure that short acting 

opioids such as oramorph are 

not allowed to continue. 

• Build up an integrated acute/ 

chronic secondary care pain 

service which serves medicine 

as well as surgery 

• Educate all healthcare 

professionals, but particularly 

F1 and F2 doctors in 

hospital, GPs, and consultant 

colleagues, promoting 

educated prescribing and 

referral to the Pain team for 

38 


advice in uncertain or complex 

cases. 

• Use case history examples 

of good and poor practice to 

illustrate your points (some 

examples will be available 

from BPS this year) 

• Contact the Accountable 

Officer in your Trust or PCT 

• Work with your pharmacy 

department to promote good 

practice. 

These are some simple practical 

ideas; good practice is explained 

in the guidance. As pain specialists 

we are also opioid specialists, 

referred to by NICE in this context 

in both the Low Back Pain guidance 

(CG88) 4 and Neuropathic Pain: 

pharmacological management in a 

non-specialist setting (CG96) 5 . 

This is our opportunity to 

disseminate our knowledge and 

to prevent problems for future 

generations. 


References 

End of Life Choices? 

Following the attempt by Jeremy 

Purvis to introduce a Member’s 

Bill on assisted dying interest in 

Scotland, prominent MSP Margo 

MacDonald has introduced an 

“End of Life Choices (Scotland) 

Bill” into Scottish Parliament. Ms 

MacDonald with the assistance 

of Christina Chen, Peter Warren 

1. Opioids for persistent pain: 

good practice. http://www. 

britishpainsociety.org/ 

pub_professional.htm#opioids 

2. Katz N, Mazer N. The 

impact of opioids on the 

endocrine system. Clin J Pain 

2009;25(2):170-175 

3. McCracken L, Vellerman 

SC, Eccleston C. Patterns of 

prescription and concerns 

about opioid analgesics for 

chronic non-malignant pain 

in general practice. Primary 

Health Care Research and 

Development 9 (2008):146-156 

4. Early management of persistent 

non specific low back pain. 

http://guidance.nice.org.uk/ 

CG88 

5. Neuropathic pain: the 

pharmacological management 

of neuropathic pain in adults in 

non-specialist settings 

http://guidance.nice.org.uk/ 

CG96 

and the Scottish Parliament’s 

Non-Executive Bills Unit, has the 

support of 18 MSPs to introduce 

this bill. The Bill is currently being 

investigated and scrutinised by the 

Scottish Parliament but may have 

wider implications for the greater 

NHS. 

The proposal of the bill is that 

persons who wish to decide when 

to end their lives should be able to 

do so, legally, with the assistance 

of a registered physician. This 

has come about because of 

the experiences of people with 

degenerative conditions, terminal 

illnesses and those who become 

entirely dependent on others 

following a trauma. 

Of interest is the fact that all of the 

examples given in the consultation 

document are patients who have 

non malignant illnesses, terminal 

or not. It is not unreasonable to 

assume that some of the illnesses 

will chronic non malignant pain 

and distress. As such it is probable 

that this issue will become more 

and more likely to be in the 

domain of all multidisciplinary 

pain professionals. 

What follows are articles by both 

Ms Margo MacDonald MSP and 

Baroness Ilora Finlay, a prominent 

palliative care physician and 

Professor of Palliative Medicine, 

presenting opposing views of 

the key points of this important 

debate. 

Margo MacDonald MSP puts 

forward the arguments for 

the End of Life Assistance 

Bill Scotland 

“Recently, one of the faith-based 

groups opposed to the End of Life 

Assistance Bill (Scotland) assured 

people there is no need for the 

Bill currently being considered by 

the Scottish Parliament because 

“up to 95%” of those who might 

suffer a painful death avoid such 

a distressing end to their lives 

because of the much improved 

understanding of pain relieving 

drugs. 

Even taken at face value, that’s 

hardly reassurance for the 5%. In 

Scotland, the calculation is that 

between 50 and 60 deaths per 

year might be assisted, because 

the people concerned are unlikely 

to see any benefit in prolonging 

their agony at the very end of 

life. It should also be stated 

that people with irreversible, 

progressive degenerative 

conditions tend not to cite their 

fear of pain as the reason for 

wanting the legal right to seek 

assistance to end their lives, but 

emphasise instead their fear of 

losing dignity, and their ability to 

exercise choice over the last acts 

of their lives. 

The End of Life Assistance 

Scotland Bill, (“The Bill”), is 

now into the most important 

part of the process whereby it 

may become law in Scotland, 

and possibly, influence the law 

on assisted suicide south of the 

border. From the start, it should be 

emphasised that the Bill has not 

been constructed as a ubiquitous 

answer to the dilemmas posed 

by people going to Switzerland 

to bring about their own deaths. 

Nor has it been conceived out of 

sympathy for people such as Dr 

Anne Turner who brought about 

her own death perhaps earlier 

than she might have in order to 

comply with Swiss law. Neither 

was it prompted by the experience 

of two mothers, each of whom 

helped a much-loved child to die, 

but whose actions were judged 

quite differently by the English 

courts. 


The mother who admitted having 

assisted her daughter to commit 

suicide, a crime under English law, 

was given a deferred sentence. 

She helped her daughter die after 

her unsuccessful attempt to end 

her own life. The Court recognised 

her autonomy to end a life she 

found intolerable. 

In the second case, there was no 

proof that had the young man 

been able to exercise autonomy; 

he would have sought to end his 

life, with or without his mother’s 

assistance. She was found guilty of 

Murder and sentenced accordingly. 

This mother’s love and 

compassion weren’t challenged by 

the court. But without proof, the 

decision to end his life was judged 

to be hers, alone. 

If my Bill becomes law, patient 

autonomy will be the legal norm. 

The attitude in England and Wales 

may be influenced by this, and 

the law on Assisted Suicide may 

be changed during the course of 

the Parliament. In addition, the 

interest in and support for the 

high-profile testimonies of Terry 

Pratchett and other prominent 

figures may persuade new MPs to 

support the idea. But without the 

acceptance of patient autonomy, 

whether assisted suicide is made 

legal according to my preference 

for professional assistance, rather 

than have assistance given by a 

relative or friend, the dilemma in 

the second case referred to above 

will be unresolved. 

I and my colleagues believe that 

helping someone to achieve a 

peaceful, dignified end to life is 

more likely to be accomplished 

by a willing professional, acting 

in accordance with the patient’s 

clearly expressed wishes. The 

“patient” will be known to this 

person, or to the nursing, social 

work etc care team. Also, specialist 

opinion must be obtained as to 

the patient’s competence and 

state of mind. Such professional 

intervention can prevent splits 

in families where siblings, for 

example, might disagree with a 

parent’s wish to bring their life to 

a close. Medical professionals are 

more likely to prevent something 

going wrong, a not uncommon 

occurrence; we have been assured 

by doctors and family members of 

patients who have tried to die. 

In Oregon and elsewhere, some 

patients have changed their mind 

and never used the prescription 

drug that would have ended their 

lives. This should be seen as proof 

of the feasibility of, and respect 

for, patient autonomy. 

Opponents of the Bill, who 

condemned it even before it was 

printed, claim it threatens elderly 

and vulnerable people who would 

ask for help to end their lives to 

save scarce public resources and 

that elderly people will be coerced 

by greedy relatives into asking for 

help to die. 

Whilst not agreeing with them, 

I have nevertheless attempted 

to meet such fears by defining 

the groups of people who might 

choose to seek help to die: 

those suffering from progressive, 

irreversible conditions, and 

patients who are classified as 

being terminally ill. 

Patients would initiate a request, 

witnessed by two people with 

nothing to gain from their death, 

to a medical professional, (likely 

to be a GP or hospital consultant, 

with Committee scrutiny of the 

Bill, I hope, might investigate a 

possible role for Nurse Specialists). 

The medical professional must 

arrange for an appropriate 

specialist in mental health to 

examine the patient. If the patient 

is suffering from depression, for 

example, this must be treated. 

Whether or not this is the 

outcome of the patient’s request, 

after a fortnight has elapsed, the 

request must be repeated. After 

two days, the patient could request 

help to drink, or to be injected 

with a fatal dose of drugs. 

The patient can change his or 

her mind at any point. There 

will be a strict requirement for 

record-keeping by the medical 

team involved. Post-mortem, the 

Procurator Fiscal ( the Scottish 

equivalent of the Coroner) will 

investigate such deaths as being 

“unusual.” Judging from the 

consistent numbers of assisted 

deaths recorded in the widely 

varying communities where they 

are legal, Scotland might expect to 

record annual totals of around fifty 

deaths. 

We are not alone in considering 

this question and it is my belief 

that, contrary to the fears of the 

church-based groups campaigning 

against the Bill, should it become 

law, it will not weaken the faith 

or beliefs of church-goers...or so 

many have told me. 

Baroness Ilora Finlay replies 

to her proposal 

Margo MacDonald has tabled 

in the Scottish Parliament a bill 

with the euphemistic title of the 

"End of Life Assistance" Bill. 

What it is seeking, however, is 

not end-of-life assistance but 

ending-life assistance. There's 

a world of difference between 

the two. End of life assistance is 

what palliative care physicians 

do now - work recognised as 

highly effective and completely 

within the law. The science of pain 

control has developed rapidly 

over the last 10-20 years, to 

the point where pain and other 

distress - psychological as well as 

physical - can usually be relieved. 

Pain is now recognised as a very 

serious problem, 'bad deaths' are 

much rarer now than they were 

20 or even 10 years ago and the 

situation is improving all the time. 

Euthanasia and assisted suicide are 

a blunderbuss solution to today's 

problems. 

Ms MacDonald constantly presents 

her bill as seeking to legalise 

assisted suicide. Yes, it does. But, 

much more important, it also 

seeks to legalise euthanasia - the 

administration of lethal drugs 

by a doctor to a patient rather 

than the provision of such drugs 

to the patient for self-ingestion. 

Anyone who doubts this should 

look at Section 1(2) of the bill. The 

evidence from abroad shows that 

the legalisation of euthanasia, as 

in Holland, leads to a considerably 

larger death toll than does assisted 

suicide. Yet Ms MacDonald 

continues to base her estimates 

of deaths rates in Scotland as a 

result of her bill on what happens 

in Oregon, where assisted suicide 

only has been legalised. She 

quotes figures of 50-60 deaths 

a year. But, if the experience of 

Holland (the closest analogue to 

her bill) is anything to go by, the 

number will be many times that - 

possibly as many as 1,000 a year. 

A House of Lords select committee 

five years ago estimated that 1 in 

every 38 deaths in Holland was 

the result of euthanasia. 

The assessment process provided 

for in this bill is also seriously 

flawed. There is no provision for 

an independent second medical 

opinion - the same doctor assesses 

the same patient twice over. There 

is no mandatory independent 

second psychiatric opinion. And 

the bill fails to set out clearly what 

sort of 'end of life assistance' is 

to be legal. Though a doctor is 

involved in assessing an applicant, 

there is no explicit requirement 

that the assistance with suicide or 

the euthanasia should be medical 

in nature. Just what is the Scottish 

Parliament being asked to legalise 

here! 

Then there is the bill's 'catchment 

area' - not merely people who 

are terminally ill but anyone 

whose physical incapacity makes 

it impossible for them to live 

independently. This applies to a 

large proportion of the population 

of Scotland - as it would of any 

country. The bill proclaims a clear 

message - if you need support 

from others to live, ending your 

life is not an unreasonable course 

of action for you to consider. Is 

this really the message that the 

people of Scotland want to send 

to the world! 

Ms MacDonald places much 

emphasis on patient autonomy. 

I would not quarrel with that: 

patient autonomy is a key element 

of medical care. But it exists to 

protect patients from having 

unwanted treatments imposed 

on them, not to require doctors 

4 0 


to carry out any treatment that 

a patient says he or she wants. 

Doctors sometimes refuse to 

prescribe antibiotics either because 

the patient doesn't need them 

or because over-prescription 

could lead to antibiotic resistance 

and put others at risk. Surgeons 

sometimes have to refuse to 

perform operations that patients 

say they want but which are 

considered futile or dangerous. 

Similarly, patients cannot require 

their doctors to kill them or to 

help them kill themselves. 

This bill has been designed around 

the wishes of a small minority 

of strong-minded and highlydetermined 

people, but it would 

put much larger numbers of less 

resolute people at serious risk of 

self-harm. It is not uncommon 

for seriously ill people to think 

in terms of 'ending it all' either 

because of transient depression 

or because they want to spare 

their families a care burden - or, 

in some cases, as a result of subtle 

coercion by others. The law as it 

stands protects them by putting 

assisted suicide or euthanasia 

safely out of reach. Responsible 

law-making has to consider the 

interests of the community as a 

whole, and especially of its most 

vulnerable members. 

Laws can and do affect social 

thinking. They provide a 

benchmark of right and wrong, 

indicating to many that 'if its 

legal it must be ok'. This Bill runs 

counter to suicide preventions 

strategies. The Scottish Parliament 

would be well advised to ignore 

the spin and the soft euphemistic 

wording and to read carefully what 

Ms MacDonald's bill actually says 

and to think about what it really 

means. 


Diamorphine Necessary or Not? 

The Home Offices recent Oxycodone consultation paper stated: 

“The UK is a world leader in palliative care. It is one of the few countries in the world to use diamorphine, a 

powerful opioid analgesic which has proved to have certain advantages over other painkillers. Diamorphine has a 

more favourable side effect profile than morphine, in that it may cause less nausea and hypotension. Diamorphine 

is also more soluble than morphine which means that effective doses can be administered in smaller volumes. This 

is important in palliative care where patients may be emaciated.” 

“It has a vital place in current clinical practice in the UK. The Government considers it essential that a suitable 

supply of diamorphine is maintained.” 

There has been an ongoing debate about the need to maintain diamorphine in the UK. This has been in part due 

to the episodic shortages of the drug due to its reliance on one UK manufacturer. Here 2 BPS council members – 

Dr Michael Platt and Professor Sam Ahmedazi put forward contrasting views on the evidence base for the need for 

the continued supply of diamorphine in the UK. 

Why diamorphine 

should be retained 

for pain management 

Dr Michael Platt 

Imperial College Healthcare NHS 

Trust 

Diamorphine was first synthesised 

some 136 years ago in 1874 

by Charles R. Alder-Wright at 

St Mary’s Hospital Medical 

School, following which it was 

re-synthesised and manufactured 

by Bayer, being released in the 

same year as Aspirin some 23 

years later 1 . Its brand name was 

‘heroin’, meaning ‘strong’. It 

has been used for the chronic 

cough of tuberculosis, for pain 

relief, breathlessness, cardiac 

ischaemic pain and more recently, 

intra-nasally for painful procedures 

in Accident and Emergency 2 . 

It is favoured by intravenous 

drug mis-users because of its 

potent and immediate ‘high’ or 

‘rush’, producing a potent state 

of euphoria. This phenomenon 

highlights its main advantage over 

morphine and other opioids, with 

its greater lipid solubility, 200 

times that of morphine 3 , due to 

its two acetyl moieties, enabling 

higher cell membrane transfer and 

rapid tissue penetration. 

It is used for pain management 

either systemically, via 

subcutaneous or intravenous 

routes, or spinally, via the epidural 

or intrathecal routes. In order to 

reach the mu receptors, in the 

dorsal horn of the spinal cord, 

opioids have to penetrate the dura 

and arachnoid layers and enter 

the cerebrospinal fluid, before 

penetrating the dorsal horn and 

binding to mu receptors (with 

lesser effects on delta and kappa 

receptors), producing analgesia 

via a G-protein coupling. When 

administered intrathecally these 

barriers are bypassed. Most 

epidurally administered opioids 

rapidly cross the dura, but the 

rate of penetration across the 

arachnoid mater is determined 

by lipid solubility. Drugs with low 

lipophilicity (e.g. morphine) cross 

the arachnoid slowly and have 

a slower onset of action; they 

are cleared slowly, resulting in a 

longer duration. Cephalad spread 

of drugs with low lipophilicity 

may result in delayed onset of 

nausea and respiratory depression. 

Drugs with higher lipid solubilities 

(e.g. fentanyl) have a faster 

onset, a shorter duration and are 

associated with fewer late-onset 

side-effects, but show more 

localised segmental action at area 

of spinal cord they are applied to, 

with less spread and penetration 

than diamorphine. 


Diamorphine is the di-acetylated 

analogue of morphine, its powder 

being highly soluble in water, 

but highly lipo-philic in-vivo. It 

is converted to acetylmorphine 

and morphine by esterases in the 

liver, plasma and central nervous 

system. Its physical properties, 

especially its relative lipid / water 

solubility make it highly efficient 

at crossing cell membranes, whilst 

allowing enough water solubility 

to allow an even spread across the 

length of the spine, more so than 

fentanyl or alfentanil, which have a 

far greater segmental action. There 

is also evidence that plasma levels 

of fentanil after spinal application 

may be just as important as CSF 

concentration, suggesting a more 

parenteral effect, even when given 

via the spinal route 4 . Oxycodone, 

although well-absorbed orally and 

even sub-cutaneously, is far less 

potent when given epidurally or 

intrathecally, than either morphine 

or diamorphine, by a factor of 8, 

possibly because it relies on active 

metabolites for its effect. 

Diamorphine is also especially 

suited to patients who require 

very high doses of opioids 

given systemically. 100mg can 

be dissolved in 1 ml of water 

or saline, allowing the giving 

of low-volumes but high doses 

parenterally or spinally. This is 

not possible with oxycodone or 

morphine, which need higher fluid 

volumes. 

By far the greatest advantage of 

diamorphine over all other opioids 

is its ability to give extremely good 

pain relief with fewer side-effects 

when given via epidural or 

intrathecal routes. It is ideal for 

patients on large doses of systemic 

opioids, but suffering significant 

side effects such as drowsiness or 

nausea. When given epidurally, 

only one tenth of the equivalent 

systemic dose is usually needed, 

and only one twentieth when 

given intra-thecally. Infusions are 

tailored to need, and tunnelling 

of the line allows for long-term 

infusions with relatively little risk 

of infection. When combined with 

a small concentration of a local 

anaesthetic such as bupivacaine, 

pain control can be greater. 

Neither oxycodone nor fentanyl 

are as good as diamorphine in 

this regard, as they seem to give 

less spread of analgesia, or else, 

especially with oxycodone, are 

more likely to cause significant 

side effects such as respiratory 

depression. 

In summary, diamorphine should 

be retained for pain management 

because it is a far more versatile 

and reliable opioid for the 

following reasons: 

It has high efficacy, with rapid 

onset, being twice as potent as 

morphine, with fewer side-effects, 

including nausea and sedation. 

Its high lipid solubility allows it 

to penetrate rapidly to the dorsal 

horn, with much quicker uptake 

than morphine from CSF, and less 

accumulation in epidural fat. 

It distributes more widely along 

the length of the spine for a 

given dose, than a single dose of 

fentanyl, when given spinally. 

It has less leakage out from the 

spine than other opioids, including 

morphine and fentanyl. 

It is safer when given epidurally or 

intrathecally, because it produces 

a much lower incidence of 

respiratory depression, compared 

to morphine, with less cerebral 

spread. 

It requires very low fluid volumes 

for its dilution, compared to other 

opioids, allowing greater flexibility 

in its application – especially 

for patients needing high dose 

regimes. 

None of the newer opioids, 

including oxycodone, 

hydromorphone, fentanyl, 

alfentanil, or sufentanil, have as 

great a versatility or potency in 

use, especially for epidural or 

intrathecal use, and I therefore 

propose that diamorphine should 

continue to be available for the 

management of pain. 

References: 

1 Walter Sneader. The discovery 

of heroin, The Lancet, Volume 

352, Issue 9141, Pages 1697 - 

1699, 21 November 1998. 

2 Kendall J.M. Latter V.S. 

Intranasal Diamorphine as an 

Alternative to Intramuscular 

Morphine: Pharmacokinetic 

and Pharmacodynamic 

Aspects. Clinical 

Pharmacokinetics, Volume 

42, Number 6, 2003 , pp. 

501-513(13). Adis International 

3 T.N.Calvey, N.E.Williams 

eds. Principles and Practice 

of Pharmacology for 

Anaesthetists, 4th Edn. 

Blackwell Science, 2001;196- 

228 

4 Yehuda Ginosar, Edward T. 

Riley, Martin S. Angst,. The Site 

of Action of Epidural Fentanyl 

in Humans: The Difference 

Between Infusion and Bolus 

Administration. Anesth Analg 

2003;97:1428-1438 

Diamorphine – does 

the evidence back up 

the continued beliefs? 

Sam H Ahmedzai 

Professor of Palliative Medicine, 

Sheffield 

I was reminded when the Home 

Office consultation on Oxycodone 

importation and the subsequent 

concerns about diamorphine 

availability came to prominence 

in early 2010, that it was only four 

years ago 2006 that the previous 

'diamorphine scare' burst open. 

This was the announcement that 

there would be a major shortage 

of the drug in the UK owing to a 

technical problem in the factory. 

The Department of Health and the 

Association of Palliative Medicine 

issued sensible guidance on 

alternatives. There did not seem 

to be any outcry at the time that 

patients were left in agony and it is 

my impression that many palliative 

care services went over to the 

alternatives (mainly morphine, 

oxycodone) and have stayed on 

them even after diamorphine 

stocks returned to normal levels. 

42 


I have to say that I can see no 

'good' reason to support the 

persistence of diamorphine 

usage in the UK. I put 'good' 

in apostrophes because I admit 

it's a value judgement (there’s 

no Cochrane-level review to 

fall back on, sadly), but I have 

tried to take a critical look at the 

evidence base for the choices, 

especially for palliative medicine. 

My overall impression is that many 

of the diamorphine aficionados in 

palliative care are, in my opinion, 

guided more by tradition and 

misplaced concept of familiarity 

taking precedence over innovation 

and evidence. So why does 

diamorphine hold this special 

place in palliative care? 

(There is also a case made for 

its use in British anaesthetics, 

but from my reading of that and 

discussion with anaesthetists 

both within the UK and outside 

it, the scientific arguments for 

continuation of diamorphine for 

the spinal route are not rock-solid 

– but more on that later.) 

The tradition/familiarity argument 

basically states that because 

we've been doing something for 

the last four decades, it must be 

right. In my opinion, this is a very 

poor reason to block progress 

in medicine and I can't see that 

principle being applied anywhere 

else than in (British) end of life 

care. Let’s go back to where it 

started. Diamorphine was the 

drug of choice at St Christopher's 

in the early 1970s until Dr Robert 

Twycross, even then, showed that 

it was no better than morphine. 

I quote from his seminal paper 

(one of the first randomised 

double-blind controlled trials 

in palliative medicine) – “A 

controlled trial of diamorphine 

(diacetylmorphine, heroin) and 

morphine is reported in which 

the two drugs were administered 

regularly by mouth in individually 

determined effective analgesic 

doses... 699 patients entered the 

trial and, of these, 146 crossed 

from diamorphine to morphine, 

or vice versa, after about two 

weeks using an oral potency ratio 

of 1.5/1 determined in a pilot 

trial... In the female crossover 

patients, no difference was noted 

in relation either to pain or the 

other symptoms evaluated. On 

the other hand, male crossover 

patients experienced more pain, 

and were more depressed, 

while receiving diamorphine.... 

It is concluded that, provided 

allowance is made for the 

difference in potency, morphine 

is a satisfactory substitute for 

orally administered diamorphine. 

However, when injections are 

necessary, the greater solubility 

of its hydrochloride gives 

diamorphine an important 

practical advantage over 

morphine, especially when large 

doses are required.” (Twycross 

1977) 

Thus, oral diamorphine was 

found to be equivalent to oral 

morphine – or actually worse for 

males – but because of its greater 

solubility (which is actually only 

important for large doses given 

by the parenteral route), it was 

recommended over parenteral 

morphine. Which could have 

been the final word on the 

subject – until alternatives to 

both morphine and diamorphine 

became available in the following 

decades. 

Twycross’ introduction reveals 

more fascinating insight into the 

thinking in palliative care in the 

1970s - “Moreover, diamorphine 

has been the strong analgesic of 

choice at St. Christopher's Hospice 

since its inception in 1967 on the 

grounds that it: (1) causes less 

nausea and vomiting; (2) often 

results in a return of appetite 

when given to patients with 

anorexia; (3) is less constipating; 

(4) enhances the mood of the 

patient whereas morphine not 

infrequently causes dysphoria; (5) 

results in a patient who is more 

alert, active and cooperative.” 

Oddly for such a well-researched 

paper, none of these assertions 

about the ‘advantages’ of 

diamorphine are referenced. 

So they probably represent the 

opinion of hospice workers 

amassed over the previous ten 

years – evidence grade IV, we 

would say now. And interestingly 

enough, reduced nausea is one 

of the advantages of diamorphine 

cited by the Home Office in its 

consultation document. I cannot 

find any authoritative source 

for that, or the other alleged 

advantages, apart from the greater 

water solubility. 

The only evidence I'm aware 

of, that diamorphine may do 

something ‘special’ as an opioid 

analgesic is from the laboratory 

of Gavril Pasternak in New York. 

(Rossi et al, 1996) This group 

identified a novel opioid receptor 

to which diamorphine appeared 

to be a direct ligand, that was 

distinct from the mu-opioid 

receptor (MOR) that was bound 

by morphine. However, this new 

splice variant of the MOR was 

also bound by fentanyl and the 

morphine metabolite M-6β-G, 

so even this was not a ‘unique’ 

property of diamorphine. As far as 

I know nobody else has replicated 

this finding and all the other 

evidence is that diamorphine only 

works when it is de-acetylated to 

morphine and then targets the 

classical MOR. With diamorphine 

we are therefore only using 

a rapidly absorbed version of 

morphine. 

The issue about water solubility 

is interesting. In the palliative 

care world the key issue is for 

use in subcutaneous injections 

and infusions. Sometimes it is 

both necessary and acceptable 

to use fairly high doses of opioid 

for these. (However, we would 

now frown on the patients who 

still occasionally turn up on 

‘thousands’ of milligrams per day 

of diamorphine or morphine – we 

now understand that in those 

cases, there is almost certainly 

a large degree of tolerance and 

probably also opioid-induced 

hyperalgesia, which ‘feed’ the 

vicious circle leading to ever 

higher doses. (Chu et al, 2006; 

Fallon, Colvin, 2008; Mao, 2008). 

Up till 2009, I could not argue 

against the superior solubility 

of diamorphine – and with 

heavy heart (!), I actually had 

to convert some of my patients 

from morphine or oxycodone 

infusions to diamorphine for 

just this reason. But since last 

year we have oxycodone in high 

concentration (50mg/ml) - and so 

that major argument in favour of 

diamorphine is now history. In the 

past year I have never had need to 

convert a patient to diamorphine 

for the sake of fitting the dose 

of opioid into a Graseby syringe 

driver. 

Admittedly the high strength 

oxycodone costs more, but in 

fact the current perverse situation 

caused by the monopoly of the 

manufacturer of diamorphine is 

that the latter is now actually more 

expensive than standard strength 

oxycodone or morphine. But even 

if oxycodone or morphine were 

more expensive than diamorphine, 

can we really justify saying that 

palliative medicine prescribing 

should be determined more by 

cost to the NHS/hospice charities 

than the quality of care? The 

outcome for patients may well 

be better with a more expensive 

drug - and there is good enough 

evidence that oxycodone causes 

less CNS adverse effects like 

hallucinations and sedation than 

morphine (Mucci-LoRosso 1998; 

Reid et al, 2006). In the final 

analysis, the cost of oxycodone 

concentrate for the last few days 

is insignificant in comparison to 

all the other costs that the health 

service and charities throw at 

patients in the last year of life. 

For the past 20 years we have 

course also been able to use 

fentanyl or alfentanil, both very 

potent drugs and with, at least for 

the former in its transdermal patch 

formulation, a very solid evidence 

base of superiority over morphine 

in terms of adverse effects, patient 

convenience and preference 

(Ahmedzai, Brooks 1997; Clark 

et al 2004; Tassinari 2008). Both 

drugs can also be given by the 

parenteral route, where they are 

acknowledged to be the safest 

opioids to use in renal failure, 

when diamorphine and morphine 

are in fact dangerous on account 

of their toxic metabolites. 


(www.palliativedrugs.com) 

So we have the odd situation 

where, for reasons of familiarity, 

it is considered unsafe to use 

alternatives to diamorphine for 

patients with working kidneys, but 

when the patient is in renal failure 

it suddenly becomes safer to use 

the unfamiliar alternatives. 

One argument for the persistence 

of diamorphine has been its 

usefulness in being dissolved 

in small volumes for prn or 

breakthrough pain management, 

when the oral route is not 

possible. However, we now 

have alternatives in the form 

of transmucosally absorbed 

fentanyl and alfentanil which 

can be taken by sublingual, 

buccal or nasal routes. And if an 

injection is really preferred, than 

as argued above, oxycodone 

concentrated solution (50mg/ 

ml) should suffice any patient for 

acute pain control, with reduced 

CNS side-effects compared to 

diamorphine/morphine. There has 

been a vogue of using intranasal 

application of diamorphine 

for trauma and acute pains in 

children.(Kendall et al, 2001) 

However, the new transmucosal 

fentanyl products now render 

even that specialist application 

of diamorphine to be redundant. 

(Borland et al, 2005) 

Perhaps the last - and most 

evidence-based - bastion 

of diamorphine usage is in 

very specific areas of British 

anaesthetic practice, notably for 

spinal analgesia and especially 

in obstetrics. I would not dare 

to venture into such specialised 

territory but would make the 

following observations: (a) the 

use of morphine and diamorphine 

in epidural analgesia has been 

challenged and supplanted by 

fentanyl and sufentanil in ALL 

other countries of the world, 

which do not I believe, have worse 

post-operative or obstetric pain 

results than the British; (b) even 

when a recent audit of British 

intrathecal diamorphine usage 

was undertaken recently, “only 

37.9% of patients given 300 µg 

of intrathecal diamorphine had 

a visual analogue pain score 

of 3/10 or less throughout the 

study”. This was compared to the 

Royal College of Anaesthetists’ 

postoperative audit target that 

90% of patients should have 

a pain score of no more than 

3/10. The authors concluded “We 

believe that this target is too 

arduous.” An alternative reading 

is that the drug was not good 

enough. 

Unfortunately in the real world 

of UK prescribing and recent 

history we need to think about the 

societal harms of diamorphine. 

Diamorphine was the 'Shipman 

drug' - precisely because it is so 

soluble, he was able to kill so 

many old people with relatively 

small volumes of injection. I 

am not in possession of the full 

facts but I suspect if he'd used 

morphine or (low strength) 

oxycodone, quite a few of the 

old folk he injected would still 

be alive, after a deep sleep. So it 

would be a good message to the 

British public, whose confidence 

in GPs and probably palliative 

care doctors took a dive after 

Shipman, to announce that we are 

abandoning that lethal drug from 

the legal armamentarium forever. 

In the end it comes down 

to something similar to the 

Coproxamol story, but for 

different reasons. I suspect that 

with passage of time only a small 

number of patients and physicians 

will notice the loss of Coproxamol 

and we have already had 

significant reductions in deaths 

from suicidal compound analgesic 

overdose. This time, it's not the 

evidence that dextropropoxyphene 

causes irreversible cardiac 

arrhythmias when taken in 

overdose with alcohol, but the lack 

of evidence that diamorphine does 

anything that current alternatives 

can't do as well, or even better. 

But because it's a free world and 

doctors still have (some) clinical 

freedom, many colleagues will 

regret the passing of old drugs 

and I suspect that sadly some 

patients may indeed, for a while, 

have a slightly worse time, until 

we all get familiar with using the 

modern drugs. But we've got to 

move on. The evidence to support 

diamorphine use in the 2010s 

is not good enough. We have 

evidence-based alternatives on 

which to formulate sound, safe 

practice - as the new BPS cancer 

pain document shows! 

References 

Ahmedzai S, Brooks D (1997). 

Transdermal fentanyl versus 

sustained-release oral morphine in 

cancer pain: preference, efficacy, 

and quality of life. J Pain Symptom 

Management, 13 (5) 254-261 

Borland ML, Bergesio R, Pascoe 

EM, Turner S, Woodger S. 

Intranasal fentanyl is an equivalent 

analgesic to oral morphine in 

paediatric burns patients for 

dressing changes: A randomised 

double blind crossover study. 

Burns, 2005; 31: 831–837. 

British Pain Society. Cancer Pain 

Management. A perspective from 

the British Pain Society, supported 

by the Association for Palliative 

Medicine and the Royal College of 

General Practitioners. 2010. ISBN: 

978-0-9551546-7-6 

Chu LF, Clark DJ, Angst MS. 

Opioid Tolerance and Hyperalgesia 

in Chronic Pain Patients After 

One Month of Oral Morphine 

Therapy: A Preliminary Prospective 

Study. J Pain, 2006; 7(1): 43-48. 

Clark AJ, Ahmedzai SH, Allan 

LG, et al. Efficacy and safety 

of transdermal fentanyl and 

sustained-release oral morphine in 

patients with cancer and chronic 

noncancer pain. Curr Med Res 

Opin, 2004; 20:1419–1428. 

Fallon M, Colvin L. Opioid-induced 

hyperalgesia: fact or fiction? Palliat 

Med 2008; 22; 5-6. 

Kendall JM, Reeves BC, Latter VS. 

Multicentre randomised controlled 

trial of nasal diamorphine 

for analgesia in children and 

teenagers with clinical fractures. 

BMJ 2001; 322: 261–5. 

Mao J. Opioid-Induced 

Hyperalgesia. IASP Pain Clinical 

Updates, 2008 Volume XVI, Issue 

2. 

Mucci-LoRusso P, Berman BS, 

Silberstein PT, Citron ML et al. 

Controlled-release oxycodone 

compared with controlled-release 

morphine in the treatment of 

cancer pain: a randomized, 

double-blind, parallel-group study. 

Eur J Pain, 1998; 2: 239-249 

Palliativedrugs.com. Strong 

Opioids. http://www. 

palliativedrugs.com/strong-opioids. 

html (last accessed 12 May 2010) 

Reid CM, Martin RM, Sterne JAC, 

Davies AN, Hanks GW. Oxycodone 

for Cancer-Related Pain. Metaanalysis 

of Randomized Controlled 

Trial. Arch Intern Med, 2006; 

166:837-843. 

Rossi GC, Brown BP, Leventhal 

L, Kang K, Pasternak GW. Novel 

receptor mechanisms for heroin 

and morphine-6β–glucuronide 

analgesia. Neuroscience Letters 

1996; 216; 1-4. 

Tassinari D, Sartori S, Tamburini 

E, Scarpi E et al. Adverse Effects 

of Transdermal Opiates Treating 

Moderate-Severe Cancer Pain 

in Comparison to Long-Acting 

Morphine: A Meta-Analysis 

and Systematic Review of the 

Literature. J Palliat Med, 2008; 

11(3): 492-501. 

Twycross RG. Choice of strong 

analgesic in terminal cancer: 

diamorphine or morphine? Pain, 

1977; 3: 93-104. 

Wrench IJ, Sanghera S, Pinder 

A, Power L, Adams MG. 

Dose response to intrathecal 

diamorphine for elective caesarean 

section and compliance with 

a national audit standard. Int J 

Obstetric Anesthesia, 2007;16: 

17–21. 

44 



Teaching your 

grandmother to suck eggs: 

the pain history (101) 

Professor Henry McQuay 

Oxford 

Teaching your grandmother to 

suck eggs means that a person 

is giving advice to someone else 

about a subject that they already 

know about (and probably more 

than the first person). Wikipedia 

suggests the origin was a Punch 

cartoon in the 1890s; "You see, 

Grandmama, before you extract 

the contents of this bird's egg 

by suction, you must make an 

incision at one extremity, and a 

corresponding orifice at the other." 

Grandmama's response is to the 

effect, "Dearie me! And we used 

to just make a hole at each end." 

Which sums up my trepidation 

at writing about the pain history. 

There seems to me no harm and 

a lot of potential good in revisiting 

the basics. If any of these are 

useful to you that’s terrific - if 

there are better questions then 

that would be a bonus. 

How much of the useful 

information in a new patient 

pain consultation comes from 

the history? Most of the time we 

work from the patient’s story and 

the referral letter, with no other 

records available. This may be an 

advantage, because you have to 

listen. If you can’t get an accurate 

story, because of language, 

special needs, deafness or speech 

difficulties, then you will really 

struggle, which just goes to show 

how important is the history. 

The questions you ask and the 

way you ask them change over 

time. You accrue questions you’ve 

heard your colleagues use. You 

drop things which don’t help, 

and grow those which help you 

distinguish. So why focus precious 

ink and paper on this topic, taking 

a pain history? Because of the 

way in which we are increasingly 

required to work, paid bum-onseat 

with minimal overlap with 

colleagues’ sessions and hence 

less interaction and conversation. 

This means that we have less of a 

professional memory on which to 

draw, with the threat that you ask 

the same questions thirty years on 

as you did at the beginning. My 

questions draw heavily on those 

instilled by our mentor John Lloyd, 

on my colleagues Chris Glynn and 

Tim Jack, and on the consultants 

from different specialties with 

whom we did joint clinics. Debt 

duly acknowledged. 

No matter how long you’ve been 

doing this job you can still have 

the consultation which runs away 

from you. Some of my worst 

have been with doctors and their 

families, where the plunge into 

the details of the most recent 

intervention for their problem, or 

the quest for the next, derails the 

consultation, and gives you the 

salutary warning that the structure 

of the history is really important. 

A blob of drug history, adverse 

effects and previous surgeries 

can otherwise leave you fifteen 

minutes in and none the wiser. 

The structure of the history is so 

crucial, and often the examination 

so peripheral, that we gently have 

to steer it back. 

Some logistic stuff first 

How should one arrange the 

room? 

This always going to be tricky with 

the need for wheelchair access, 

but should we be learning from 

others about desk and chair 

positions? Certainly at appraiser 

training it was apparent that 

there is a wealth of sociological 

information on this which I'd 

never heard before. 

Who else is present makes a 

difference 

The necessity for translation and 

the presence of translators which 

I alluded to above can create 

difficulties. With sons or daughters 

translating I'm sometimes unsure 

of whose agenda I'm dealing 

with. With outsiders translating 

a different set of queries arise. 

One Chinese patient crept back in 

when the translator left and said 

“I no come with her anymore. 

She no tell the truth.” With patient 

advocates the troubles may be 

different - hostile anti-doctor 

feelings can produce a runaway 

consultation. A third party in the 

room, a student or a trainee, can 

alter the conversation, with the 

patient directing remarks to the 

third party; for me this has been 

more of an issue with followups 

than with new consultations, 

perhaps because the dynamics 

change from the original 

one-on-one to a more diffuse 

arrangement. 

Going out to collect the 

patient 

John Lloyd used to watch the 

patients leaving the clinic from the 

window in his office. By walking 

with them from the waiting room 

to the office you can garner the 

same feel for disabilities. Always 

invite the accompanying person 

(but beware if it is simply the 

chauffeur), and beware too asking 

the older male (or female) patient 

if they’d like their daughter (son) 

to come too (yes I've done it). 

Where is the pain? 

Asking the patient to colour in 

which bit(s) hurt on a body 

sketch provides a baseline. The 

affected area can shrink over 

time (c.f. postherpetic neuralgia), 

so the serial chart can provide 

some reassurance that things are 

improving. In our old notes it’s 

common to see Chris Glynn’s 

turquoise ink just circling the entire 

body - the original ‘widespread’ 

pain graphic. Important too is to 

remember the corollary “Where 

doesn’t hurt?” 

If I've not asked it anywhere else 

then “Is it numb in the affected 

area?” should be included, 

and the necessary “Does it go 

anywhere else?” If the pain does 

go somewhere else then what 

provokes it to move? 

Another way of tracking change 

over time is to photograph the 

affected parts. Data protection 

gets in the way, but getting the 

patient to photograph the area on 

their mobile phone is an informal 

work-around. 

What sort of pain is it? 

Everybody struggles to describe 

their pain. Classically we are taught 

to ascribe burning and shooting 

descriptors to neuropathic rather 

than nociceptive pain, and that’s 

probably fair, but neither 100% 

specific nor 100% sensitive. 

It‘s common for there to be 

background pain (which may be 

dull) and flare (which may be 

sharp) [see below on background 

and flare], so one adjective is 

unlikely to suffice. Some feel for 

intensity is helpful too - “on a 

scale of 0 to 10 it’s a 12”. Again 

these numbers can be used in 

subsequent appointments to 

monitor progress. 

If it’s not already clear by this 

stage in the history then once 

again a primary focus of these 

questions is to help you decide 

if the pain is nociceptive or 

neuropathic, because this is such a 

huge distinction when it comes to 

treatment, one pharmacopeia for 

one and one for the other (well 

nearly). 


Timing 

How long have you had the pain? 

The answer ‘many years’ will 

inevitably lead to a chronology 

of the pain with lists of previous 

procedures and interventions. 

Don’t get too blown off tack. 

“What has changed?” or “What 

has led to you coming here after 

all this time?” may elicit useful 

information. 

How did it start? Out of the blue, 

gradually or after something 

happened? A precipitating cause 

may be obvious, the road traffic 

accident, the operation or damage 

due to a fall, or it may not. The 

distinction between an obvious 

precipitant and not is the rationale 

for the question. 

Constancy - is it there all the time 

or does it come and go? 

How many good (bad) days do 

you have each week? 

Is it better, worse or the same as it 

was e.g. last Christmas? 

If it’s worse is that more severe or 

more frequent (or both?) 

These questions about constancy 

are important for treatment. Using 

heavy duty analgesic prophylaxis is 

just a huge burden for the patient 

on the day(s) with minimal pain. 

Identifying and distinguishing 

background pain and flare pain is 

really important if prescribing is to 

be tailored effectively. 

The issue of whether or not the 

pain is deteriorating (worse on the 

better/worse/same question may 

colour attitudes and expectations. 

If it hasn’t got worse in five years 

then it’s unlikely to be fatal. 

That should be reassuring. The 

necessity, the urgency and the 

quest for further investigations 

may all be coloured by this 

answer. 

Pattern 

Does time of day have an 

influence or is it truly constant? 

Does it only hurt when you move? 

Have you got pain now just sitting 

there? 

What things make it better and 

what things make it worse? 

Does distraction help? Alcohol? 

I think there are two obvious 

patterns which we need to detect 

a movement-related pain, which 

takes you into musculoskeletal 

problems, and neuropathic 

pain. Distraction and alcohol as 

alleviating factors are mentioned 

commonly by patients with 

neuropathic pain. 

What have they told you to 

expect? 

I often use the question “What 

does your own doctor think?” You 

need to know what the patient 

has been told about the prognosis 

and treatment approaches. If 

they have a legal case on the 

go then the experts may have 

talked about prognosis and 

treatment verbally or in writing, 

and this is true obviously for 

other hospital doctors involved 

in the patient’s care. The concern 

is that expectations are wildly 

different from the reality. A simple 

example is when the patient has 

been referred with the request 

for a specific procedure, and you 

believe that is not feasible, won’t 

work or is otherwise inappropriate. 

It may take a lot more time to talk 

this through than it would to do 

the procedure. 

It’s important to emphasize the 

distinction between pain and 

disability. No matter how good the 

analgesia it is unlikely to have any 

effect on the disability - indeed 

greater activity may accentuate the 

disability. 

Somewhere in the consultation 

you need to gain a view on the 

patient’s expectations and beliefs 

about health. It may come in 

this section, or it may come 

elsewhere. This may be blisteringly 

obvious - the patient believes they 

have insects living in their painful 

knee, but the more subtle issues, 

for instance a family background 

of long periods of time off school 

and work for dubious medical 

reasons, may be just as relevant. 

Often this is the place where the 

conversation extends to myths 

about pain, and some of these 

continue to intrigue me. Many 

would be answerable if we had 

a collective prospective database, 

but we’ve failed to deliver that 

over thirty years. An example 

would be nerve damage. The 

general teaching is that if it’s 

not better in two years then it 

won’t get better. That’s perhaps 

realistic on average, but not true 

for all, as one might expect for 

an ‘average’ number. I see some 

people who continue to improve 

beyond the two year mark, so I 

am loath to cut off all hope of 

further improvement by an ex 

cathedra statement. Conversely 

the two years is useful when 

people are struggling at one year. 

Don’t be impatient, these things 

take time. A second example is 

the general view that amputation 

won’t help the pain. I've seen 

people with ankle damage who 

were undoubtedly better after 

amputation (but I still give the 

party line). A third example is 

our belief that all pains get better 

if treated early. I've never been 

sure of the basis for this wishful 

thinking. It may be that we are 

given to claiming success of our 

therapy when actually the natural 

history would have meant that 

the pain improved anyhow. My 

most optimistic colleague always 

used to say “If they don’t come 

back they’re cured”. The Dutch 

trial of epidural in shingles did 

not suggest any alteration of 

natural history by the intervention 

[The PINE study of epidural 

steroids and local anaesthetics to 

prevent postherpetic neuralgia: a 

randomised controlled trial. van 

Wijck AJ, Opstelten W, Moons KG, 

van Essen GA, Stolker RJ, Kalkman 

CJ, Verheij TJ. Lancet. 2006 Jan 

21;367(9506):219-24.] 

What are you using to help the 

pain? 

The information you need for each 

drug is the dose and timing, how 

long at that dose, adverse effects 

and percentage of relief. 

If it really isn’t clear which drug (if 

any) is helping then “Of all your 

painkillers which do you think 

works best (which is the one you’d 

least like me to stop?)?” may work. 

For previous procedures what you 

need to know is did a technically 

effective procedure succeed or fail? 

the success or failure may be easy 

to determine but is often difficult 

to know if the procedure was 

technically valid - did the relevant 

area go numb if local anaesthetic 

was used etc.? The issue is “Is it 

worth repeating?” 

What else have you tried which 

hasn’t worked? 

Again for each drug you need the 

dose and timing, duration, adverse 

effects and percentage of relief 

(rarely will you get all this). 

One of the tough questions to 

yourself is did this patient have an 

adequate trial of this medicine? If 

the patient says they had a week 

of amitriptyline at 25 mg at night, 

had no adverse effects and gave 

up because of lack of efficacy 

then that might argue for a trial 

of escalating dose. Conversely, 

repeated trials of strong opioids 

to dose levels of 500mg per day 

morphine equivalents with no pain 

relief and overwhelming adverse 

effects might suggest a poorly 

opioid sensitive pain. In between 

lies the more ambiguous territory. 

What other things have you tried? 

There’s a long list of potential 

candidates here, from simple 

hot or cold to TENS (or spinal 

cord stimulation), physiotherapy, 

chiropractic, acupuncture, 

and other alternative or 

complementary manoeuvres. Two 

I specifically check for are TENS 

and topical anti-inflammatories 

or capsaicin. TENS and capsaicin 

are still part of my initial thinking 

for neuropathic pain and so one 

needs to know if they have been 

tried or not. 

4 6 


Past Medical History 

This pain problem - just in case 

anything has been missed so far. 

Other operations 

Other illnesses 

Are you seeing any other hospital 

doctors at the moment? This I 

find helpful, particularly with the 

elderly who often have multiple 

appointments each month. You 

may get diagnostic clues, and 

you may be able to bow out if 

the pain end is already being 

dealt with. This redundancy 

sometimes happens if there is 

an unacknowledged ‘spray’ of 

referrals to different departments 

in response to a particular crisis. 

Previous mental health problems 

or previous substance abuse are 

highly relevant, and particularly 

so if long-term opioid analgesia is 

envisaged. 

Social 

This is where the impact, the 

burden, of the pain (and disability) 

should become apparent if not 

already so. Questions like who else 

lives with you? How do you spend 

your time? What can’t you do that 

you’d like to do? Exercise, or lack 

of, and how are you managing 

financially? needs to be asked. 

If still working then how does 

work fit with the pain, or is the 

work required always going to 

make the pain worse? What is the 

way forward? 

Has all that can been done to 

improve or maintain mobility been 

done? (House adaptations, rollator 

etc?). 

I was trying to avoid that abused 

word outcomes, but this part 

of the consultation is asking 

which bits of your life are or are 

not affected by the pain, and in 

follow-up any improvement can 

be assessed on these aspects. 

This is an informal version of what 

Danny Rutter did many years ago 

[Ruta DA, Garratt AM, Leng M, 

Russell IT, MacDonald LM. A new 

approach to the measurement 

of quality of life. The Patient- 

Generated Index. Med Care. 

1994;32 - Nov(11):1109-26.] and 

tested in low back pain. 

How are you sleeping? 

We were taught that patients 

with postherpetic neuralgia slept 

surprisingly well, given their bad 

day-time pain, and by and large 

that eyes-and-ears (as opposed 

to evidence-based) observation 

holds up. I have no idea how 

generalisable this is across 

neuropathic pain as a whole. If 

true it would be another clear 

distinction from nociceptive pain 

which commonly disturbs sleep as 

you turn. Of course you’d need to 

know that it wasn’t just the tricyclic 

antidepressants doing their job. 

Conclusion 

Is there anything about this pain 

that I've missed out? 

I'm acutely aware there are glaring 

omissions here, not the least of 

which is the ‘special’ questions you 

may need to ask for a headache. 

Last but not least two things I've 

come to late in life which I think 

are helpful are to dictate the clinic 

letter with the patient present 

and to copy the clinic letter to the 

patient. Both things would have 

caused eyebrows to go through 

the ceiling thirty years ago, but 

both (particularly the letter) are 

important as continuity of care 

becomes fragmented and intervals 

between appointments expand. 

So I finish in the hope that some 

of these clinical pearls that I 

have picked up over many years 

experience in the harsh and 

rewarding world of a pain clinic 

may indeed help you consult 

better as they have indeed done 

for me. 

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In adults one or two caplets every four hours as required should be given, do not exceed 4g of paracetamol (8 caplets in a day). In elderly a reduced dosage may be necessary. Children: Not recommended 

below the age of 12 years. CONTRAINDICATIONS: Hypersensitivity to either Paracetamol or codeine, or any of the excipients, severe renal or hepatic impairment; acute asthma, obstructive airway disease, 

respiratory depression, acute alcoholism, head injuries, raised intracranial pressure, after biliary surgery, and patients who have taken MAO inhibitors within 14 days. Codipar is contraindicated in patients for 

whom opiate medications are contraindicated. WARNING & PRECAUTIONS: Use with caution in patients with acute abdominal conditions, increased intracranial pressure, elderly, debilitated, 

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should be advised not to exceed the dose and not to take other products containing paracetamol or opiate derivatives while on Codipar and consult their doctor if symptoms persist. Tolerance to codeine can 

develop with continued use and the incidence of unwanted effects is dose related. Patients should be advised not to drive or operate machinery if Codipar causes dizziness or sedation. INTERACTIONS: Use 

of antihypertensive agents, diuretics, quinine, quinidine, CNS depressants, MAOI’s or tricyclic antidepressant, anticholinergics, antidiarrhoeal 

agents, antimuscarine drugs, metoclopramide, domperidone, cholestyramine, mexilitine, cimetidine, warfarin and other coumarins may interact with 

Codipar. Opiods may interfere with results of some laboratory tests and codeine may interfere with tests for gastrointestinal function. PREGNANCY 

& LACTATION: Not recommended. UNDESIRABLE EFFECTS: Most common are nausea, vomiting, light headedness, dizziness, sedation, 

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PAI N N E W S S P R I N G 2010 

47


The following three articles are summaries taken from the recent Philosophy & Ethics 

Special Interest Group Annual Meeting at Rydall Hall. Once again we are indebted to 

Dr Peter Wemyss-Gorman for his transcription and endless enthusiasm for all things Pain 

and Ethical! More will follow in the next editions and Dr Wemyss-Gorman has transcripts 

of the meeting available for a very modest fee. Further information can be obtained 

about this and any future meetings by contacting -peter.gorman@matmosonline.co.uk 

Images of Pain- 

Understanding pain 

related distress from the 

viewpoint of semiotics 

Dr Owen Hughes 

Consultant Clinical Psychologist Pain 

Management Centre, Bronllys, Brecon 

This article discusses some 

of the ways we develop our 

understanding of pain. We all have 

our ‘truth’ about what pain is and 

we ascribe our own meanings to 

it. I shall attempt to discuss some 

of the images used by patients and 

indeed by practitioners, as well as 

the placebo and nocebo effects of 

words and images. The meaning 

intended by a doctor’s words are 

often not what the patient hears 

and I want to reflect on how this 

process affects our interaction with 

patients in pain. 

There is some evidence that the 

foetus can feel discomfort. Any 

newborn’s early experiences may 

revolve around pleasure and 

discomfort and as such, they are 

preoccupied of finding means of 

gaining pleasure or alleviating pain. 

Newborn children are very good 

at telling people that they are not 

happy. Until they are at least a year 

old, they haven’t got words, and 

cannot put them together to help 

them understand what’s going on. 

Typically children don’t become 

fluent in language until they are 

two or three. They are going 

through the world and experiencing 

and understanding things as they 

become more adept at living in 

their environment. The question is: 

what are they using to process this 

information? I would suggest that 

they are probably using images. 

Not just visual pictures, but auditory 

and kinaesthetic pictures as well, of 

the world around them and how 

things work. I propose that we 

do not ever stop doing that. We 

go through our lives with a visual 

understanding of what’s going on. 

Paivio, a psychologist from Canada, 

put forward a dual processing 

model of how we understand the 

world. He postulated two separate 

pathways: the verbal and the 

visual. We use the verbal pathway 

to use and receive words. We 

take them in, check them against 

our own vocabulary, accept it as 

a reasonable coherent premise 

and move forward. When we 

are producing words there is a 

whole series of processes we go 

through before they come out 

of our mouths. Mostly this is a 

checking process that stops us 

saying anything inappropriate or 

things that we don’t mean to say. 

The visual pathway is very different 

because it doesn’t have the 

checking process that we need to 

produce language. It doesn’t have 

discrete symbols like words and 

there aren’t any grammatical rules. 

It’s an implicit thing and involves 

tacit knowledge. But it is quite 

concrete as regards the pictures 

that are formed. No checking, and 

concrete fixed images can lead to 

a very fast process cognitively, and 

it is a lot faster way of interpreting 

things than language. 

Pain and semiotics 

The word pain will probably 

produce, in most people, a similar 

image. When someone gives a talk 

on pain one of the first images that 

may come to mind is Descartes 

picture of the boy and the fire. In 

this situation, pain is the signifier. If 

we ask: what about back pain, what 

is the image that comes to your 

mind? Is it an anatomical structure? 

Or a type of person? For one of my 

patients it was a digestive biscuit. 

He came in walking very gingerly 

and when I asked him about his 

understanding of what was going 

on in his body he told me that the 

doctor said he had a crumbling 

spine. He visualised his back as 

like a stack of digestive biscuits 

and every time he moved a bit 

fell off. So he daren’t move! I’m 

fairly sure that that doctor didn’t 

have the signifier of digestive 

biscuits in mind when he told him 

that he had a degenerative spine. 

That’s the danger of using words 

without checking the picture that 

they generate in someone else’s 

mind. If you tell someone in their 

30’s or 40’s they have ‘a touch of 

arthritis’ then it is well known that 

for some, they may have an image 

of a granny in a wheelchair and 

think that’s going to be them. A 

lifetime of illness and dependence. 

This may represent loss of dignity 

and status especially if the doctor is 

seen as all powerful and someone 

whose instructions you have to 

follow. 

Is it worthwhile to check the 

images? If I ask patients to draw a 

picture of their pain or tell me if I 

were to take a picture of their body 

what would I see going on, such 

descriptions include “like being shot 

in the back”, “its as if the skin is 

being ripped off from the inside”, 

“my spine is being pulled apart”, 

“someone is sticking a knife in” 

"Men are 

disturbed, not by 

things, but by the 

view which they 

take of them" 

Epicetus 

48 


and “like having a blow torch on 

my skin”. I imagine you will have 

come across this sort of thing fairly 

commonly. But just take a moment 

to think about the words and what 

the pictures that go with them 

might be. Bear in mind that those 

pictures are going to be faster, 

unchecked and more powerful. 

If every time I have a pain I have 

one of these pictures that’s what 

I’m going to react to first and the 

anxiety kicks in and a whole lot of 

other things with it. 

Semiotic pain research revealed 

that there were five basic areas 

where the pain impacted on 

people. Firstly there was a huge 

impact on their self-image in 

terms of their personal worth, 

their strengths and their personal 

agency in life. Ideas about where 

the pain was coming from very 

rarely seemed to have any basis in 

fact. They constructed their images 

based on other experiences in life, 

with very little resemblance to any 

anatomical details or pathology. 

The issue of locus of control was 

always interesting with patients and 

as expected there was often the 

idea that, the doctor was in charge. 

Other people who had always felt 

they were in control found it very 

difficult to give up that control 

to other people. Patients can 

also express pain in kinaesthetic 

terms like different temperature, 

sensation, texture or weight – “my 

leg has become a lot heavier” - and 

visual ones such as being a 

particular colour or a particular 

shape. 

Using imagery in therapy 

At Bronllys we find it very useful 

to use images as ways of helping 

people to manage the experience 

of pain. If you can change the 

image you can change the 

experience, and this can have a 

very powerful impact. It is a very 

useful source of healing if we 

can give people a more adaptive 

meaning to their experience. 

People get some very strange ideas 

of how their bodies work: “you’ve 

got some notches in the middle of 

each side and that just locks up”, 

and misinterpret what doctors tell 

them: “Dr T, at the pain control, 

he said there’s so much where 

they’ve cut into the spine the nerve 

endings they’re just jumping”. Now 

I’m sure Dr T wouldn’t have said 

this but this was what was heard. 

Physicians have to use metaphors 

when explaining things to patients 

but the danger is that the metaphor 

becomes concrete for them. 

Imagery can be used to create 

a better understanding between 

clinician and patient. I find pain 

drawings very useful because 

they tell me so much about the 

patient’s experience and distress. 

Pain is very multidimensional not 

just in terms of words but also 

the visual elements for different 

individuals. Some images of pain 

can even introduce a spiritual 

element e.g. martyrdom and this 

may be a powerful dynamic for 

some. Historical perspectives on 

pain are fascinating in this respect. 

The concept of pain as in the hands 

of the Gods is probably the highest 

form of an external locus of control. 

Should we then be making a point, 

as part of clinical assessment, of 

asking people to describe their 

pain, not just in words but in 

pictures? Asking something on the 

lines of explain what I would see if 

I took a photograph of your pain or 

indeed one that represented your 

life? That is very effective shortcut 

to finding out a lot; people put their 

priorities into their ‘photographs’. 

Should we be making more out of 

pain diagrams than simply getting 

an idea of the distribution of pain? 

Should art play a greater part in 

pain clinics? Given that it has this 

immediacy for people and can be 

very therapeutic in itself. 

To quote Epicetus, the famous 

Greek Stoic philosopher: “Men are 

disturbed, not by things, but by 

the view which they take of them.” 

So pain may be what the patient 

says it is, what the patient sees it as 

or how they move with it. It is up 

to us to find out what that image 

really is and, if we can to use it and 

other images, for good. 

Painting over the 

cracks: creativity 

when art and medicine 

collide 

Dr Diana Brighouse 

Southampton General Hospital 

Throughout my career as a pain 

doctor and psychotherapist and 

now in my final year of a fine art 

degree I have been looking at 

medicine as a healing art. 

The Intertextual Space 

I would like to discuss the wider 

concepts of art and medicine and 

firstly I would like to explain the 

concept of the intertextual space. 

The intertextual space is sometimes 

called the interpersonal space but 

that’s not strictly accurate. To put it 

simplistically, the intertextual space 

is the third space where something 

is created in the interaction 

between subject and object. That 

subject and object might be two 

people, but might be a person and 

a piece of literature, music or visual 

art, or a landscape. That is the place 

where creativity occurs, where the 

healing art of medicine occurs, and 

where art and medicine collide. 

Public space art 

There is a difference between 

public space art and art therapy 

and these are quite different things. 

In the UK art therapy only exists 

as a tiny part of the mental health 

sector and in palliative care but 

is otherwise virtually unavailable. 

Public space art on the other hand 

is something we’re all exposed to 

every day. It’s not just the visual 

arts but includes architecture, the 

performing arts and music e.g. 

there is much literature about 

narrative and writing therapy – 

getting patients to write about bad 

experiences can be a powerful of 

way of getting into their world. 

Drama therapy is used quite a lot in 

adolescent mental health but not to 

my knowledge in any pain clinics. 

The most comprehensive body of 

knowledge about art in medicine 

can be found in the Arts Council of 

England 2004 report “Arts in health: 

a review of the medical literature” 

edited by Dr Rosalia Staricoff and 

reviews 400 papers. It is available 

online at 

http://www.artscouncil.org.uk/ 

publication_archive/arts-in-health-areview-of-the-medical-literature/ 

Some of the most compelling 

evidence put forward for the 

beneficial effect of “art” is in the 

study of the environment on 

rates of healing and recovery. 

The implications of this for the 

architecture, design, decoration and 

setting of healthcare facilities cannot 

be underestimated. There are some 

visionary examples of new hospital 

builds inspired by this principle 

but nearly all are in the US. We do 

have some purpose-built wards, 

one of the most famous being the 

Bart’s breast cancer unit. There 

is evidence of a reduced length 

of stay in medical wards just by 

changing the environment, with 

reduced analgesic requirements. 


In the mental health sector, if 

you abolish the old big asylum 

type wards with something more 

homelike you reduce patient 

aggression levels. Perhaps more 

surprisingly there are consistent 

figures to show that you reduce 

staff absenteeism and improve 

retention just by providing a 

better and more pleasant working 

environment. 

There is an organisation called 

Painting for Hospitals which leases 

and in certain circumstances gives 

out paintings for hospitals to 

improve their visual environment. 

The paintings are almost all 

provided on a charitable basis. 

Participation in art 

Participation in art is getting 

patients to participate in art 

projects and is not the same as 

art therapy. This may be what is 

used in palliative care. 95% of 

patients report that they are more 

relaxed and their minds lifted from 

other things. 93% of medical and 

surgical patients reported increased 

happiness and contentment and 

this was linked to early discharge. 

You may suggest these were fairly 

nebulous measures but we’re 

not dealing with easily quantified 

things. 90% reported improved 

mood and 48% that their pain and 

symptoms were relieved, reflected 

in decreased analgesic use and 

increased mobility. Another study 

showed that visual arts and live 

music reduced levels of depression 

by a third in patients undergoing 

chemotherapy. 

As well as thinking about the wider 

impart of art, on for example a pain 

clinic, another project of which I 

am interested in is asking patients 

to paint their dreams. In a project 

patients were asked to paint their 

dreams. Most participants found 

this difficult. They were worried 

about their lack of artistic ability but 

with help they were encouraged 

to see what happened when they 

tried with fascinating results. If you 

were a trained art therapist you 

would be doing one-to-one work; 

interpreting the painting, getting 

the patient to free associate with 

the images and so on. This unusual 

premise and technique may open 

new avenues with an otherwise 

“stuck” patient. Experimental 

subjects responding to a controlled 

pain stimulus looking at paintings 

or a blank panel rated the pain 

as 33% less intense when 

looking at paintings and this was 

confirmed by reduced electrical 

activity in the brain. Patients 

viewing art-work postoperatively 

demonstrated reduced blood 

pressure, lowered heart rate and 

reduced skin conductance, with 

reduced requirements for analgesic 

medication, and many other papers 

showed similarly positive results. 

There are clear economic benefits 

if you are sending patients home 

earlier and using less medication. 

Effects on staff 

Art is not just about the care 

environment or patient, it is 

also useful for the caregiver. 

When medical student training 

included visual arts, history and 

philosophy of art, semiotics 

and other more broad artistic 

subjects they demonstrated 

improved observational skills and 

an increased capacity for critical 

analysis. Neurosurgical trainees 

given life drawing classes were 

found to have improved 3D 

thinking and practice. In the mental 

health services staff exposed to 

similar training showed improved 

communication skills, and in 

nursing training an increased 

awareness and empathy with the 

emotional aspects of illness. 

Two quotations lend authority to 

my contention that there should be 

greater awareness of the value of 

art in health care: 

‘The arts can enrich all our lives 

but they are also a powerful force 

for healing. Arts in healthcare will 

inspire, inform and encourage new 

partnerships between healthcare 

professionals and artists of all 

disciplines. This new initiative 

represents a significant contribution 

from the arts to healthcare and the 

wider social inclusion agenda.’ 

Gerry Robinson, Chairman of the 

Arts Council of England 

“I would like to see the benefits of 

participation in the arts recognised 

more widely by health and social 

care professionals, particularly those 

involved in commissioning services 

for people with mental health 

problems. This is not some kind of 

eccentric add-on – it should be part 

of the mainstream in both health 

and social care.” 

Alan Johnson, September 2008 

So to summarise this brief sketch 

of the arts and medicine it is clear 

that there is a body of work that 

shows exposure to art can lead 

to both positive physiological 

and psychological changes in 

The Creative Arts in 

Palliative Care; 

the Art of Dying 

Nigel Hartley 

Director of Supportive Care, 

St. Christopher's Hospice 

“We emerge deserving of little 

credit; we who are capable of 

ignoring the conditions that 

make muted people suffer. The 

dissatisfied dead cannot noise 

abroad the negligence they have 

suffered” 

Professor John Hinton - Dying 

This article discusses how 

art enables human beings to 

communicate things. Things that 

cannot be said, or are difficult 

to say, with words alone. In 

doing so, we may find that the 

communication that does occur 

may be more profound and deep 

than any traditional interaction. 

Listening 

In a sense, the quotation from 

Professor Hinton summarises the 

motivation for Cicely Saunders 

to develop what we now call 

palliative care. Her insistence 

was that you matter until the 

last moment of your life and 

as well as mattering you can 

also communicate. A key area 

of interest for me is how do 

clinical outcomes, reduced drug 

consumption, shortened length 

of stay, increased job satisfaction, 

improved doctor-patient 

relationships, improved mental 

healthcare and development of 

empathy across gender & cultural 

diversity. So why isn’t more being 

done? The evidence is clear, the 

government awareness is there, 

but it doesn’t seem to be filtering 

down. 

“Doctors heal your body and mind; 

art heals your soul” 

The Central Louisiana arts and 

healthcare inc. 

we engage when listening to 

each other. Most of us learn to 

give a very good impression of 

conscientious listening. Let us face 

it, we all do it. We have to survive 

and protect ourselves, so I sit in 

a certain way and nod in all the 

right places and make eye contact, 

but in reality in my head I’m 

planning what I’m doing later in 

the afternoon. It is my contention 

that as we become automated 

at doing this, as we are taught 

“what is right” we are in danger 

of losing the possibility of taking 

risks with the people that we work 

with. Where would that be? It is 

in those times when we make 

a deep connection with another 

human being and for centuries art 

has moved us to recognise this. 

How we might articulate those 

experiences. These connections 

can be fleeting and uncomfortable 

and what we normally do is to 

pull back from it, this difficult 

interaction with a vulnerable and 

emotionally exposed patient. What 

happens if we actually stay with 

that moment? What possibilities 

does it make available? 

“Those who are unhappy have 

no need for anything else in this 

5 0 


world, apart from someone who 

is capable of giving them their 

attention…” Simone Weill 

Below I outline some examples of 

what is possible if you actually stay 

with that moment, and where it 

might lead you. 

A middle-aged lady with HIV/ 

AIDS had been abandoned and 

shunned by all her family and 

friends and was living in a flat on 

her own with practically no human 

contact. The medical consultant at 

the hospice suggested everything 

he could think of, like coming 

to the day hospital, to ease her 

isolation but she refused every 

offer. Eventually for some reason 

she consented to see me, and I 

saw her regularly for the last few 

months of her life. For much of 

this time she was totally withdrawn 

and refused to make any eye or 

any other contact. There were 

long periods of silence and her 

only words were yes or no. I tried 

everything, all my communication 

skills, even music, that I knew. 

Eventually she became very ill and 

was admitted. After a few days she 

was a little better and came to see 

me and I sat with her, in silence, 

for about an hour. At the end of 

this time I once again asked her if 

there was anything else she would 

like and suddenly she began to 

sing. I was completely shocked 

and pulled out of my comfort 

zone, but I started to play the 

piano very quietly with her. At first 

she sang without words and then 

she started to use the Brownies 

good night song: 

Oh Lord our God 

Thy children call 

Grant us thy peace 

‘til the sunrise… 

Goodnight…Goodnight 

(and then she started to speak)) 

Keep all our family in your care, 

Love us all, as we know you do. 

Still, Goodnight and God bless 

to friends, family and those that 

we love. 

(and singing again) 

Goodnight… Keep us in your 

care. 

Amen…Amen. 

It was almost as if she was using 

this as a ritual to say goodbye to 

her family. When she finished I 

looked at her and asked if she 

thought she would die soon and 

she said yes, very soon. In fact she 

died the following morning. Music 

was the catalyst to a resolution 

that no clinical skill could bridge. 

One of the things I think that 

music does well is that it forces all 

involved to listen. You can actually 

hear people listening which 

you can’t do in language: it’s so 

immediate, we’re doing it at the 

same time as each other – it’s a 

very different frame in which to 

be in relation to someone. I can’t 

pretend to listen to someone in 

this situation – I just have to listen 

acutely to every note she sings 

and improvise around that – we’re 

just making it up together. I think 

I would articulate that process, of 

my interaction with another being 

through music, as getting myself 

out of the way. When she started 

singing it was uncomfortable. I’m 

human and my first reaction was 

please don’t do that! But you can’t 

invite someone in and then tell 

them to stop. My craft ( a word we 

are in danger of losing in modern 

medicine) at that point was to use 

music. Once I started to hear her 

I played as I would with any other 

musician. I don’t know if it made 

a difference to the way she died. 

I think in asking that question, 

what was the evidence of benefit, 

we are in danger of losing the 

sense of the now and what’s really 

important – the health system we 

work in always wants to ask: did 

it make a difference. It certainly 

made a difference at that moment. 

There are three levels of listening: 

the first is personal. When I listen 

to someone my first response 

is always an intimately personal 

one: what you say makes 

me uncomfortable or makes 

me want to cry or laugh etc. 

Communication can be easy but it 

can also be problematic for some 

patients particularly those who are 

awkward, vulnerable or even those 

who produce negative emotions 

in you, the listener. But you do 

have a responsibility to them all, 

the vulnerable difficult people, to 

hold them and support them. As 

a professional that’s not a very 

good place to be in and often 

we want to get out of it as soon 

as possible, but we actually have 

to do something. If I stay in that 

first place, the easy clinical place 

a lot is going to be about me. So 

the next level is to listen to what 

someone is doing and when this 

lady started to sing, it gave me 

a world, a space, where I could 

join her. That was in music. I was 

listening on that level. In order 

to be there I had to pay attention 

to what is going on between us. 

Music lives in that space between 

us – as lot of the arts do. 

The arts can be used to help 

people tell their life story, or 

create a legacy they want to leave 

behind. Another story concerned 

an elderly blind Jamaican man 

coming to the end of his life in a 

care home. All his family were in 

Jamaica, he had no visitors so he 

was isolated in this bed and in this 

room, just waiting to die. One of 

our St Catherine’s team of artists 

went to see him and he asked 

her to set up a video to record 

himself. The video was to be sent 

to his family but also be seen by 

as many people as possible. The 

result was a moving account of 

his life as the “black kid in the 

corner.” It was also of a resilient 

human being who had managed 

to get through his life despite 

what society had done to him. 

There is an energy which comes 

at the end of life and the tendency 

for us to want to dampen it. The 

soft pastel walls of the hospice 

come crypt, the hushed tones 

of a peaceful death. Anything 

else is too uncomfortable. It is 

too uncomfortable if people get 

distressed. 

Another woman with advanced 

lung cancer, who I hadn’t met 

until the last two or three days of 

her life, had heard that I played 

the piano. She had terrible 

breathlessness. She asked me to 

take her to my room, where she 

indicated that she wanted me to 

switch on my tape recorder. She 

wanted to sing. She had the words 

on a piece of paper, and sang the 

whole of the song without oxygen. 

She also asked for a copy of the 

recording for her family. She died 

three days later. Her last will and 

testament was artistic. 

A while ago I overheard a 

conversation in the coffee area 

between four young women, all 

coming to the end of their lives, 

bemoaning the fact that they 

didn’t look good any more and 

never would – their clothes didn’t 

fit them because their breasts 

had been cut off or their weight 

fluctuated so much, they’d lost 

their hair etc. I contacted the 

London College of Fashion and 

described the conversation with 

one of their lecturers. He brought 

a group of students to meet the 

women. Each of them worked 

with the students to design their 

own outfit and choose materials. 

Then they went up to the college 

and made them. We decided to 

have a celebration: we invited all 

their families and got in a jazz 

band. The women came down a 

catwalk in their outfits and each 

of them spoke. Another example 

of how a visual and textual 

artistic programme gave space 

to an unwritten feeling or word 

that may never have been truly 

communicated and it lead to an 

uplifting experience. 



Narcotic Use in the 

Creative Era of Jazz 

Dr Aileen Clyde 

Pain fellow Glasgow 

“I think that trumpets and drugs 

have always gone hand in hand” 

Mark Ronson 

"I saw the best minds of my 

generation destroyed by madness, 

starving hysterical naked, dragging 

themselves through the negro 

streets at dawn looking for an 

angry fix, angelheaded hipsters 

burning for the ancient heavenly 

connection to the starry dynamo 

in the machinery of night, who 

poverty and tatters and holloweyed 

and high sat up smoking 

in the supernatural darkness of 

cold-water flats floating across the 

tops of cities contemplating jazz." 

Allen Ginsberg 

There was an epidemic of heroin 

addiction among jazz artists 

between 1940-1960. This period, 

also known as the “creative era of 

jazz”, saw the invention of styles 

such as bebop, cool jazz, hard bop 

and free jazz. 

Charles Parker, Billie Holiday, 

Miles Davies were some of the 

famous Jazz musicians who were 

addicted to narcotics. Some artists 

were from troubled backgrounds, 

had multiple social stresses and 

may have experimented with 

heroin as a form of escapism. 

Cocaine and other “uppers” were 

commonly used by these artists 

to aid their musical performance. 

Many would then turn to narcotics 

to act as “downers”. Others used 

the drug due to peer pressure or 

because their jazz heroes used 

the substance and they wanted to 

emulate their life and music. After 

experimenting with heroin, most 

became addicted and struggled 

throughout their career with their 

addiction. Often it had seriously 

negative effects on their career 

and would lead to trouble with the 

law, ill health and early death. 

Charles Winick, a Manhattan 

based Psychologist, studied jazz 

artists and their drug use. He 

commented that the benefits 

these artists thought they got 

from their heroin use were, a 

feeling of group excitement or 

“contact high”, release from 

their personal problems and a 

physical boost during long road 

trips. Some have postulated 

that drugs helped these artists to 

release their creative talents and 

cope with a disapproving society 

at the time. They often had to 

contend with segregation and 

discriminatory practices. However, 

the effect of drugs on these artists’ 

performance levels remains 

uncertain. 

The Extent of the Problem 

Charles Winick published an 

article in ‘Social Problems’ in 1957 

alluding to the extent of heroin 

use among jazz artists at the 

time. He had interviewed 357 jazz 

musicians on the habits of 2000 

fellow jazz performers and found 

that 53 % had tried heroin, 24% 

took it occasionally and 16% used 

it regularly. A survey conducted 

at the 1957 Newport Jazz festival 

of 409 New York Jazz musicians 

found a similar extent of the 

problem. 

Hipsters 

Jazz and heroin use were as 

closely associated as their 

terminology. The terms “hip” and 

“hipster” were derived from opium 

smoking, during which the addict 

would lie on one hip. 

Charles Parker (1920-1955) 

Saxophonist and composer 

Charles Parker was one of Jazz’s 

best known addicts. This addiction 

to narcotics started when Parker 

was a teenager after he and his 

first wife were involved in a car 

accident. He sustained significant 

injuries in this accident. Initially 

he started using morphine for its 

analgesic affect. He then started 

using heroin and quickly became 

addicted to it, an addiction that 

would trouble him until this death 

in 1955. 

In his early career he would miss 

gigs and at times busked in order 

to feed his habit. He even pawned 

his horn and would borrow fellow 

performers’ instruments. 

All aspiring young jazz artists 

looked up to Parker. Some thought 

heroin was the key to his success. 

They wished to copy his music 

and his lifestyle. 

Occasionally, Parker would go 

without heroin, for instance when 

he was living in California and it 

was in short supply. When the 

drug was scarce he would turn 

to alcohol. In 1946 his behavior 

became erratic due to excess 

alcohol and heroin use and 

eventually he has admitted to 

Camarillo state hospital. When 

he came out of hospital in 1947, 

Parker was initially clean from 

drugs and did some of the 

best recordings of his career. 

His famous tune Moose the 

Mooch was dedicated to his drug 

pusher. Parker recorded “relaxin 

in Camarillo” in reference to his 

hospital stay. 

In 1949 he is quoted as saying 

for downbeat magazine, “Any 

musician who says he’s playing 

better either on ‘tea’ (marijuana), 

the ‘needle’ or when he is ‘juiced’ 

is a plain straight liar” 

Parker eventually returned to New 

York and he started using heroin 

again. In 1951 he was found in 

possession of heroin and his 

cabaret card was taken, leaving 

him unable to perform in the New 

York clubs. In 1953 he got his card 

back but his reputation meant that 

clubs did not want to employ him. 

In1954 his health was dwindling 

and he attempted suicide twice by 

drinking iodine. 

He died tragically young aged 34 

on March 12th 1955. The official 

cause of death is recorded as lobar 

pneumonia and a bleeding ulcer. 

The coroner mistakenly thought at 

the autopsy that Parker’s body was 

aged 50-60. 

Billie Holiday (1915-1959) 

Billie Holiday, known as “Lady 

Day” was jazz’s first Diva. Billie 

came from a troubled background. 

She was born to a 13 year old 

mother and was constantly 

abandoned to friends and relatives 

as a child. It is reported that 

she was raped at age 11. This 

allegation combined with frequent 

truancy led to Billie being sent 

to a catholic reform school in 

1925. She grew up in the red light 

district of Baltimore. She began 

smoking marijuana in her teens 

and was subsequently introduced 

to heroin by her first husband. 

She did not develop an addiction 

to heroin until she met Joe Guy, 

who latterly became her husband. 

He was a trumpet player, heroin 

dealer and hardened heroin 

user. In 1947 she was arrested for 

52 


the possession of narcotics. She 

pleaded guilty and was sentenced 

to Alderson Federal Prison Camp 

in West Virginia. Her New York City 

Cabaret card was evoked which 

prevented her from working in 

the clubs for the next 12 years. 

Holiday latterly deeply regretted 

her addiction. She is quoted as 

saying, 

“Dope (Heroin) never helped 

anybody sing better or play music 

better or do anything better. 

All dope can do for you is kill 

you- and kill you the long, slow, 

hard way” 

“If you think dope is for kicks and 

thrills you are out of your mind. 

There are more kicks and thrills to 

be had in a good case of paralytic 

polio or by living in an iron lung” 

She was unable to kick the habit. 

Later in her career her voice began 

to deteriorate under the strain 

of smoking, heroin and alcohol 

abuse. On 31st May 1959, she was 

taken to metropolitan hospital. 

Police officers arrested her for 

possession of heroin and searched 

her room. She remained here until 

her death on July 17th 1959, aged 

44, from cirrhosis of the liver. 

Gilbert Millstein of the New York 

Times described her death in the 

1961 sleeve notes, “in the room 

from which a police guard had 

been removed- by court orderonly 

a few hours before her death, 

which, like her life was disorderly 

and pitiful. She had been strikingly 

beautiful, but she was wasted 

physically to a small, grotesque 

caricature of herself. The worms 

of every kind of excess- drugs 

were only one- had eaten her. “ 

Miles Davis (1926-1991) 

Miles Davis was an infamous 

trumpeter, band leader and 

composer. Davis started using 

heroin around 1950. He became 

depressed after his relationship 

to French actress Juliette Greco 

ended. This combined with a lack 

of appreciation from the critics 

and the fact that many of his 

contemporaries were using drugs 

led Davis to start taking heroin. 

At first he snorted it and then 

went on to using it intravenously. 

Davis was from an affluent family 

and did not seem to have social 

problems like Parker and Holiday. 

In 1953 his drug addiction was 

affecting his performances. Heroin 

had also killed two of his close 

friends Navarro and Webster. He 

eventually managed to kick the 

habit after returning to his father’s 

house in St Louis. After this he 

would spend time in towns like 

Detroit where he knew heroin was 

difficult to obtain. Davis’s addiction 

to heroin is unique in that it only 

lasted 4-5yrs. Davis never returned 

to heroin but it is reported that in 

his latter career he was addicted to 

other drugs, mostly cocaine. He 

finally managed to kick his cocaine 

habit in 1979 after he rekindled 

his relationship with actress Cicely 

Tyson. 

Davis died age 65 in 1991 from a 

stroke and pneumonia. 

Conclusion 

Jazz musicians of this time had 

many reasons for turning to 

heroin. Whether they used it 

to escape from troubled social 

circumstances, to cope with a 

disapproving society, to provide 

them with a “high” or in the 

mistaken belief that it would 

increase their creativity, most 

deeply regretted their addiction. 

particularly during the creative 

period from 1940-1960, substance 

abuse did more harm than good, 

and rather than being the road to 

creative genius, it was the pathway 

to premature death.” 

References 

Tolson,G.H. and Cuyjet M.J. (2007) 

jazz and substance abuse: Road 

to creative genius or pathway to 

premature death. International 

Journal of law and Psychiatry, 

30,530-538 

http://www.time.com/time/ 

magazine/article/0,9171,826388,00. 

html 


Drugs+in+Jazz 


Heroin+and+jazz 

www.bps-research-digest.blogspot. 

com/2008/01/would-jazz-greatshave-been-so-great.htm 

Tolson and Cuyjet summarized the 

lives of these addicted artists in 

their 2007 paper,” the untapped 

potential that was languished on 

drugs and alcohol by these artists 

shall never be fully revealed.”” The 

reality is [that] for most jazz artists, 


Charlie_Parker 


Billie_Holiday 

en.wikipedia.org/wiki/Miles_Davis 



Does Vitamin C have a 

role in the prevention of 

Complex Regional Pain 

Syndrome? 

Dr Michael J.E. Neil 

Ninewells Hospital Dundee 

mneil@nhs.net 

Complex regional pain syndrome 

(CRPS) is an important and 

commonly encountered neuropathic 

condition in the pain clinic. CRPS 

has a significant associated morbidity 

and is characterised by spontaneous 

pain, hypersensitivity, sudomotor 

dysfunction and functional loss. It 

can be triggered by potentially any 

stimulus but is most frequently seen 

following fracture, dislocation or 

surgery. 

The pathophysiology of CRPS is 

complex and no one intervention 

has been shown to have consistent 

and reliable efficacy in its 

management. In this regard, there 

has been a lot of work undertaken in 

recent years aimed at preventing the 

syndrome developing. Studies have 

examined many different therapies 

but unfortunately most have 

involved only small patient numbers 

with largely inconclusive results. 

However, there is some good quality 

evidence to suggest that vitamin C 

may have a significant role to play 

in attenuating the development of 

CRPS. 

Vitamin C is a simple water 

soluble sugar-like molecule that is 

an essential dietary component. 

Humans are unable to synthesise 

vitamin C due to a deficiency 

in the enzyme L-gulonolactone 

oxidase required in the last stage 

of its synthesis. The recommended 

adult daily intake of vitamin C is 

75-90mg per day 1 and is relatively 

easily achieved as vitamin C is 

found in plentiful supply in fruit and 

vegetables. Historically however, 

deficiency of vitamin C, popularly 

known as scurvy, carried a significant 

mortality on long sea-faring voyages 

and even during land based 

conflicts as recently as world war 

one. Clinical characteristics include 

fatigue, myalgia and arthralgia 

in minor deficiency progressing 

to neuropathy, haemorrhage 

and convulsions in severe cases. 

Although it is rare to see frank 

vitamin C deficiency in modern 

practice, some evidence suggests 

that up to 30% of the population in 

North America may have sub-clinical 

deficiency 1 . 

Vitamin C is involved in a number of 

important physiological processes. 

Vitamin C is well known as an antioxidant 

that aids in the elimination 

of reactive oxygen species such 

as hydroxyl ions. This is important 

for the protection of capillary 

endothelium and in decreasing 

vascular permeability. Victims of 

polytrauma and severe sepsis, 

conditions that exert a very high 

oxidative stress on the body, have 

been found to have extremely low 

or absent levels of vitamin C in their 

plasma at an early stage following 

their injury 2 . Vitamin C is also a 

co-factor in at least eight different 

enzyme processes including collagen 

hydroxylation, norepinephrine 

synthesis, tyrosine metabolism and 

amidation of peptide hormones. 

Furthermore, animal studies indicate 

that vitamin C may have an effect on 

the glutaminergic system, of which 

the NMDA receptor plays a key role, 

leading to an anti-nociceptive effect 3 . 

The pathophysiology of CRPS 

involves a number of components 

including a neuroendocrine, 

inflammatory and sympathetic 

response. Increased free radical 

expression has been found to be a 

feature of CRPS and is associated 

with altered micro-angiopathic 

circulation and lipid membrane 

oxidation 4 . With other studies 

demonstrating the utility of vitamin 

C in decreasing membrane 

permeability and scavenging of 

free radicals 5 , there does therefore 

appear to be a rationale for its use in 

this condition. 

Evaluation of therapeutic 

interventions in pain medicine are 

often hampered by a paucity of 

good quality evidence from clinical 

studies. Vitamin C is a rare exception 

to this in that there have been three 

good quality randomised controlled 

trials examining the use of Vitamin 

C in the prevention of CRPS 6,7,8 . 

The first of these was published by 

Zollinger et al in 1999 with a second 

study by the same group in 2007. 

This later study was a double blind 

randomised-controlled, multi-centre 

study looking at the incidence of 

CRPS in patients following wrist 

fracture. Patients were randomised 

to receive a placebo or 200, 500 or 

1500mg of vitamin C starting from 

the day of fracture for 50 days. 427 

patients were enrolled in the study 

with a total of 317 randomised to 

receive vitamin C and 99 to receive 

placebo. 

The results of the trial were clinically 

and statistically significant. Using 

the International Association for 

the study of Pain (IASP) criteria for 

establishing the presence of CRPS, 

they found a total incidence of CRPS 

in the vitamin C group of 2.4% (8 

of 317 patients) and 10.1% (10 of 99 

patients) in the placebo group (p 

value 0.002). Examining differences 

between the vitamin C treatment 

groups revealed a prevalence of 

CRPS of 4.2% in the 200mg group 

and 1.8% and 1.7% in the 500mg 

and 1500mg group respectively. This 

gave a number needed to treat of 12 

for the 500mg dose of Vitamin C. 

The most recent study to examine 

the role of vitamin C in preventing 

CRPS was conducted by Besse et al 

and looked at patients undergoing 

elective foot and ankle surgery. 

This study involved 392 patients 

divided between two groups. The 

first enrolled 177 patients having 

elective foot or ankle surgery over 

a one-year period and were given 

standard treatment. The second 

group were enrolled the following 

year and consisted of 215 patients 

given 1g of vitamin C from the 

first post-operative day for 45 

days. Results were again significant 

revealing that patients in Group 1 

had a prevalence of CRPS of 9.6% 

(18 patients) while those in Group 

2 showed a prevalence of 1.7% (4 

cases) with a p value of 0.0001. 

Although the results of these studies 

are persuasive there are a number 

of potential sources of error. Firstly, 

criticism of the later study could 

be directed at the fact that follow 

up was by case note review and 

not clinical examination. This raises 

questions of sensitivity of screening 

to pick up CRPS and does not 

include information on pain scoring 

and sensory testing that would 

have been helpful. The latter study 

also did not consider peri-operative 

anaesthetic management to identify 

if, for example, a regional technique 

5 4 


was employed as this may have 

had a bearing on outcome. Lastly, 

interpretation in both these studies 

are restricted by the fact that CRPS is 

still, overall, an uncommon condition 

giving wide confidence intervals in 

any statistical analysis. Nonetheless, 

these studies do seem to provide 

compelling evidence to support that 

vitamin C given in the acute setting 

can be efficacious in preventing 

CRPS. 

Despite the results of these studies, 

the use of vitamin C has not made 

its way into common practice. This 

may be due to poor recognition 

of the results of these studies or 

a general scepticism over the use 

of vitamin C in the clinical setting. 

This scepticism may be attributable, 

at least in part, to a hangover 

effect from the negative publicity 

that arose from the promotion of 

‘mega-dose’ vitamin C in the past. 

Regardless of the arguments on 

the scientific basis for this form of 

therapy is that, even when taken in 

extremely high doses, vitamin C is a 

very safe and well tolerated agent. 

In conclusion CRPS remains a 

complicated and debilitating 

condition, that once established, 

requires multi-modal therapy to 

manage. The available evidence 

suggests that supplementary vitamin 

C may offer a very simple, cheap 

and safe therapeutic option for 

helping prevent the onset of this 

condition in certain circumstances. 

Further studies to verify these 

findings and more accurately 

quantify the benefit gained in terms 

of pain reduction and sensory 

disturbance would be helpful. This 

may give a basis for examining if 

vitamin C has any role in established 

CRPS or in the prevention of other 

post-surgical pain syndromes. 

Footnote: 

I would be interested to hear from 

anyone who uses vitamin C as 

part of a routine protocol in their 

peri-operative practice. 

References 

1. Padayatty SJ, Levine M. New 

insights into the physiology and 

pharmacology of vitamin C. 

Canadian Medical Association 

Journal 2001;164(3):353-355 

2. Long CL, Maull KI, Krishnan RS, 

Laws HL, Geiger BS, Borghese 

L, Franks W, Lawson TC, 

Sauberlich HE. Ascorbic acid 

dynamics in the seriously ill 

and injured. Journal of Surgical 

Research 2003; 109:144-148 

3. Rosa KA, Gadotti VM, Roas 

AO, Rodrigues ALS, Calixto JB, 

Santos AKS. Evidence for the 

involvement of glutaminergic 

system in the antinociceptive 

effect of ascorbic acid. 

Neuroscience Letters 2005; 381: 

185-188 

4. Van der Laan L, Ter Laak HJ, 

Gabreels-Festen A, Gabreels 

F, Goris RJ. Complex regional 

pain syndrome type I (RSD): 

pathology of skeletal muscle 

and peripheral nerve. Neurology 

1998;51(1):20-5 

5. Reuben SS. Prventing the 

development of complex 

regional pain syndrome after 

surgery. Anesthesiology 2004; 

101:1215-1224 

6. Besse J-L, Gadeyne S, Galand- 

Desme S, Levat J-L, Moyen 

B. Effect of Vitamin C on 

prevention of CRPS Type 1 in 

foot and ankle surgery. Foot and 

ankle surgery 2009;15: 179-182 

7. Zollinger PE, Tuinebreijer WE, 

Breederveld RS, Kreis RW. Can 

vitamin C prevent complex 

regional pain syndrome in 

patients with wrist fracture? 

Journal of bone and joint 

surgery of America 2007; 

89:1424-1431. 

8. Zollinger PE, Tuinebreijer WE, 

Breederveld RS, Kreis RW. Effect 

of vitamin C on frequency of 

reflex sympathetic dystrophy in 

wrist fractures: a randomised 

trial. Lancet 1999; 354:2025- 

2028 

New Members 

Ratified on 16 April 2010 by The British Pain 

Society Council 

Name Position Institution 

Mrs Sarah Louisa Weaving Acute Pain Team Southampton General Hospital 

Dr John O'Hanlon Consultant in Anaesthesia and Pain Mater Hospital, Belfast 

Dr Mohammed Akram Ali St5 Anaesthetics Royal Gwent Hospital 

Miss Felicity Conrad Staff nurse ITU Glenfield Hospital, Leicester 

Mr Anand Metha 

Pst Grad Research Student - Health Norwich University 

Science 

Mr Helen Mary Wood Acute Pain Sister Southampton General Hospital 

Mrs Wendy Hill Specialist OT in Pain Management Queen Elizabeth Hospital, Kings 

Lynn 

Ms Jill Fryer Clinical Nurse Specialist Sittingbourne Memorial Hospital, 

Kent 

Dr Orla Magee Anaesthesia trainee NHS Northern Ireland 

Mr Phillip Daniel Austin Osteopath/ Student Work, Stockholm, Sweden / 

University of Edinburgh 

Mr Andrew Oliver Clinical Specialist Physiotherapist New Cross Hospital, 

Wolverhampton 

Mrs Judith Rafferty Lead Nurse - Pain Services Ninewells Hospital, Dundee 

Dr Quazi Al Mahud Siddiqui SR in Anaesthetics & Pain Fellow Kent and Sussex Hospital, 

Tunbridge Wells 

Ms Deborah McDaid Specialist Nurse Pain Management Great Western Hospital, 

Swindon 

Dr Sivanesan Saravanan Locum Consultant Victoria Hospital, Blackpool 

Dr Karim Shoukrey SPR in Anaesthetics Peterborough Hospital 

Dr Theresa Knock F2 Anaesthetics Nottingham City Hospital 

Dr Devjit Srivastava Pain Fellow The Walton Centre 

Miss Claire Martin Clinical Nurse Specialist James Paget Hospital 

Dr Norman Kufakwaro SPR Anaesthetics Kent and Cantebury Hospital 

Dr Shoma Khan 

Grade 7 Pain Management UCL Pain Management Centre 

Psychologist 

Dr Sangeeta Das Anaesthetic Registrar Leeds Teaching Hospital 

Dr Gautham Srinivasan Advanced Pain trainee Medway Maritime Hospital, 

Gillingham 

Mr Christopher Halsey Staff Nurse Jersey General Hospital 

Dr Muralidhar Thondebhavi Anaesthetic trainee 

Ipswich Hospital NHS Trust 

Subbaramaiah 

Miss Faustina Aikins-Snyper Chronic Pain Nurse Specialist Royal National Orthopeadic 

Hospital 

Mrs Sarah Peat 

Senior Pain Management 

Formerly at Swindon Pain Clinic 

Physiotherapist 

Dr Caroline Davies 

Consultant in Paediatric Anaesthetics 

and Acute Pain 

Guy's and St Thomas' NHS 

Trust - Evelina Childrens 

Hospital 

Dr Seshu Tatikola SPR in Anaesthetics York District Hospital 

Mrs Shiji Thomas Staff Nurse, Chronic Pain unit Wythenshawe Hospital 

Dr David Beard Advanced Pain trainee Western General Hospital, 

Edinburgh 

Dr Andrew Lloyd Consultant Anaesthetist James Cook University Hospital 

Dr Vishal Aggarwal NIHR Clinician Scientist University of Manchester 

Dr Balajj Velayudam Anaesthetics Wirral University Teaching 

Hospital 

Dr Vijay Bandikatla Anaesthetics Queen Elizabeth Hospital, Kings 

Lynn 

Dr John Francis 

Consultant in Anaesthetics and Pain University Hospital of North Tees 

Management 

Dr Maliha Shaika Clinical Research Fellow Addenbrooke's Hospital 

Asst Prof Aatit Payngmali Lecturer in Physiotherapy Chaing Mai University 

Dr Patrick Schweder Fellow - neurosurgery John Radcliffe Hospital 

Miss Brenda Kosamu Nurse Kamuchanga District Hospital 

Dr Juliane Goeke-Glatzel Anaesthetics Pennine Acute Hospitals Trust 

Dr Anish Bahra Consultant Neurologist National Hospital for Neurology, 

University College NHS Fdn 

Dr Arumachalam 

Consultant 

Pennine Acute Hospitals Trust 

Swayamprakasam 

Mrs Joanne Jones Pain Clinic Staff Nurse Wirral Hospital NHS Trust 

Dr Ben Huntley Anaesthetics Gloucestershire Hospitals NHS 

Trust 

Dr Michelle Siobhan Conn Clinical Psychologist Frimley Park Hospital 

Dr Andrea Magides Consultant Anaesthetist South Devon Healthcare Trrust 

PAI N N E W S S P R I N G 2010 

55


A Personal Reflection 

on the British Pain 

Management Programme 

Society (SIG) Conference 

2009 

Dr Paul Wilkinson 

Consultant in Pain Management, 

Newcastle upon Tyne 

The Pain Management Programme 

held its 12th National SIG 

conference at Northumbria 

University in Newcastle upon Tyne. 

The title "Clearing the Fog on the 

Tyne” reflected not only the aims 

of the conference but also some 

nostalgia for the famous folk song 

from Lindisfarne, the band which, 

for many years, held Christmas 

concerts in Newcastle. 

As the Chair of the organising 

committee, I offer here a personal 

reflection of the conference. 

Although this meeting was many 

months ago the issues discussed 

continue to be both pertinent and 

topical. The aim is to provide a 

summary for the benefit of those 

who were unable to attend and 

serve as a reminder for some of 

those who did. Please note these 

are personal reflections and may 

reflect my own bias and memory! 

As well as focusing on core issues 

of pain management programmes, 

the conference attempted to 

consider issues allied to pain 

management programmes. In 

order to facilitate this, specialists in 

other fields were amongst those 

who were invited to help our 

understanding. 

Early Interventions in the 

Management for Chronic 

Pain 

The conference began with 

Professor Chris Main of Keele 

University talking about designing 

and implementing early 

psychosocial interventions. What 

was made clear during his talk is 

that there is now a high level of 

consensus about those factors 

which predict chronicity. High 

risk groups such as depression, 

anxiety, high levels of early 

disability, catastrophisation, 

fear avoidance and other pain 

morbidity predicted prognosis 

and can be screened for early. It 

is clear that properly tailoring and 

targeting early interventions within 

clinical trials is not trivial, especially 

ensuring that interventions have 

appropriately been carried out. 

Despite these problems there 

is now clear evidence for the 

benefit of early psychosocial 

interventions. There is a large, 

flourishing contemporary field of 

implementation science. This was 

probably news to many including 

myself. 

NICE Guidelines for Early 

Management of Persistent 

Low Back Pain 

We asked Professor Martin 

Underwood, Professor for 

Research at Warwick University 

to help us understand better 

the procedural elements of 

undertaking NICE guidelines. 

He was Chair of guidance 

published in 2009. Clearly these 

guidelines have been highly 

controversial. The guidelines are 

very procedurally driven and 

have to rigorously adhere to 

these procedures. Those involved 

expose themselves to considerable 

media and professional interest. 

Professor Underwood defined 

the scope of the guidelines which 

had initially been between 6 

weeks to 6 months and not to 1 

year. He outlined that referring to 

spinal surgeons but not referral 

to pain clinics was considered as 

part of the scope. He discussed 

the procedures and how the 

workings of the reference group 

operated. In order to illustrate 

the link between the conclusions 

and the evidence, he focused 

on the most controversial areas 

namely acupuncture and injection 

of therapeutic substances into 

the back. As we now know these 

issues are still the subject of 

much controversy and discussion 

at both NICE and the BPS ( see 

the joint letter published by 

NICE and the BPS in this issue). 

For interventional procedures 

this had only led to one low 

powered admissible study and in 

contrast, according to Professor 

Underwood, there were several 

recognised controlled studies 

for acupuncture. Another area 

which is the subject of much 

debate. Further discussions were 

undertaken about the nature and 

the validity of all the evidence 

presented in the document. 

Complex arguments about the 

nature of any evidence will no 

doubt continue. All at the meeting 

(including many from the BPS) 

will be proactive in ensuring 

the best care for all patients. Dr. 

David Walsh, Associate Professor 

in Rheumatology at Nottingham 

and Chair of the SIG highlighted 

that the NICE guidelines had 

recognised the benefits of 

physical and psychological 

treatment in people who display 

high disability or significant 

psychological distress early. This 

was obviously of great interest to 

all PMP SIG members. The CPP 

programme (combined physical 

and psychological programme) 

is recommended before the 

pain becomes permanent and 

before all treatment options have 

been exhausted. Successful CPP 

programmes require specialist 

multi-disciplinary input helped 

by CBT within group settings. 

Healthcare providers have an 

obligation to put NICE guidelines 

into practice but there was anxiety 

as to whether money for these 

interventions would come from 

existing funding or otherwise. 

Update on catastrophisation 

Professor Michael O'Sullivan 

from McGill University in Canada 

updated us on catastrophisation. 

A tour de force again! One 

particularly interesting fact out of 

many is that catastrophisation can 

carry a considerable amount of 

the variance in treatment during 

a trial. It has been shown in some 

trials that if the castastrophisers 

are included in the trials then 

the treatment appears not to 

work but if they are taken out 

the treatment does! Treatment 

resistance of catastrophisers 

needs to be considered 

carefully in the planning of care 

and specific interventions to 

minimise the consequences of 

5 6 


the catastrophisation. Another 

interesting element is the 

consequences of physicians 

who are catastrophisers on the 

assessment of pain. 

On the second day of the 

conference we focused on areas 

allied to pain management 

programmes titled "Never 

on a Pain Management 

Programme"… 

Sexual problems and 

impotence 

This was commenced by 

consideration of psychosocial 

aspects of pain by Dr. Ian Eardley 

discussing male impotence 

and erectile dysfunction while 

Professor Kevan Wylie considered 

sexual dysfunction more broadly. 

Dr. Eardley discussed 

communication issues and the 

confusion which occurred in clients 

differentiating orgasm, desire, 

erection and ejaculation. Problems 

with ejaculation can be treated 

medically with high levels of success. 

Intra-penile devices and prosthesis 

are much more rarely required. Men 

who have psychological contributory 

factors to erectile function may have 

suggestive features. These may 

include situational erection failure, 

the retention of early morning or 

masturbatory erections. Of relevance 

to us, selective serotonin reuptake 

inhibitors, tricyclic antidepressants 

and some anticonvulsants may lead 

to impotence as well as alcohol 

abuse and opioid abuse. Impotence 

is more common in obesity and 

it is also relevant that exercise 

is a protector. For me, the main 

messages were to be more proactive 

The British Pain Society’s 

Pain Management Programme Special Interest Group 

Clearing the fog… 

on the Tyne 

12 th National Conference 

on Pain Management Programme 

10 th & 11 th September 2009 

Northumbria University - Newcastle upon Tyne 

in screening for impotence and to 

realise that appropriate treatments 

are often very effective. 

Professor Wylie focused on female 

psychosexual issues and pain. He 

discussed the organic, psychogenic, 

relational and social factors which 

may impact on sexual function. We 

realise that psycho-sexual problems 

are common in patients attending 

pain management programmes. 

We should all be mindful of the 

problem, ask more frequently about 

sex and facilitate patients to talk 

and deal with the boundaries. Pain 

management programme teams 

will have to decide how far along 

the ladder of care they wish to go. 

This care pathway may involve basic 

counselling, specific psycho-sexual 

work (body work including pelvic 

floor training and body awareness 

training), as well as behaviour and 

couple therapy. Because of the 

nature of some of these treatments, 

liaison with local psycho-sexual 

services will be important. 

At the end of these sessions I was 

left with a lingering memory that 

satisfaction with sex is highest in 

Nigeria and lowest in Japan (and 

perhaps surprisingly) France! Why? 

Unexplained pain, Chronic 

Fatigue syndrome, Irritable 

Bowel syndrome, Dorsal 

column stimulation 

Prevailing themes in Chronic 

Fatigue were explained by Mrs 

Sue Pemberton highlighting the 

considerable overlap and similarity 

between these conditions and 

chronic pain. In fact, the word 

pain could have replaced the 

word fatigue on some slides, since 

many aspects of assessment and 

management appeared similar. 

Vincent Dreary highlighted that 

patients with unexplained symptoms 

and pain are frequently labelled with 

prejudicial terms. A variety of other 

longstanding and allied psychological 

issues may coexist. Patients must 

be helped to make sense of the 

symptoms and assess their impact. 

CBT approaches were discussed 

including acceptance, commitment 

therapy and mindfulness. 

An excellent talk by Professor 

Peter Whorwell on irritable 

bowel syndrome (IBS) helped us 

understand this condition. Again 

there were many themes which 

made us feel we could be talking 

about patients with chronic pain. 

Most of the treatments used for IBS 

are focused on bowel management 

but one stood out, namely the 

evidence base for hypnosis in 

difficult cases. 

Peter Murphy talked about dorsal 

column stimulation and emphasised 

that the variability in outcome may 

result from various psychological 

factors. Historically patients waiting 

for major intervention such as dorsal 

column stimulation did not get onto 

a pain management programme. 

Patients can now attend pain 

management programmes either 

before dorsal column stimulation 

insertion or afterwards. Defining 

the priority of treatments cannot be 

grounded in strong evidence based 

medicine, but multi-disciplinary 

assessment and management plans 

remain pivotal. 

Medico legal cases 

An intriguing talk by Dr. Ian 

Yellowlees on medico-legal cases 

highlighted the current caution 

about placing patients on pain 

management programmes that 

had coexisting medico-legal cases. 

The central concern appeared to 

be that of financial disincentives to 

improve from a pain management 

programme. This view is currently 

not grounded on evidence. Wider 

studies in other interventions in 

patients with chronic pain provide 

mixed evidence that interventions 

are less effective with a medico-legal 

case ongoing. In charismatic style, 

Dr. Yellowlees made this a brief 

part of the talk because, though 

much was affirmed, little which was 

grounded in evidence. Dr. Yellowlees 

then switched to put the audience 

through the complexities of the legal 

process presenting a powerful view 

that rather than focusing on the 

issue of financial disincentives for 

improvement, the personal toll of 

legal cases on the individual should 

be the main consideration (e.g. pain 

behaviour, body vigilance and self 

worth to mention a few). He also 

made a few interesting observations 

about those businesses involved 

in the processing of medico legal 

complaints. 

Pain and addiction 

Dr. Freedman led a session on 

addiction and pain medication. 

Reducing and managing pain 

medicines are frequently a theme 

of pain management programmes 

and the time beyond. People with 

addiction problems have more pain 

problems statistically. In addition, 

many with pain can misuse 

medication and alcohol. Red flags 

for addiction such as prescription 

forgery, using non-prescribed 

medicines and even obtaining 

medicines from non medical sources 

represent extreme cases. While 

dependency can be defined as 

craving, continued and compulsive 

use (3c's), people can experience 

subtle problems with medicines 

and substances. Dr. Freedman 

recommended thinking very 

carefully about what the function of 

individual drugs were for patients. 

In summary, I hope some of these 

brief, highly selected, personal 

reflections are helpful to those that 

did not attend the conference or 

whose specialist interest lie in other 

areas and give an accurate flavour 

of the conference to those that 

did. Others may have taken away 

completely different key points of 

course! 

I would like to thank the University 

for hosting the conference, the 

members of the organisation 

committee and all the work which 

was done in the secretariat especially 

Ken Obbard. 

Finally, a lingering memory, 

for many was the Gateshead 

Millennium Bridge, the “winking eye 

bridge” which opened almost by a 

twist fate as we stood in front of it 

drinking wine at the Baltic Museum 

balcony. For those who like to plan 

well in advance, the next conference 

is in Bath in 2011. 

PAI PAI N N NNE E WS S S US PM RMI NE G R 2010 

57


Monitoring and 

intravenous access for 

epidural injections in 

chronic pain management: 

survey of practice 

Table 1. Caudal approach 

Caudal During procedure After Procedure 

NO ECG 19 / 47 (40%) 6 / 47 (13%) 

NO NIBP 26 / 47 (55%) 6 / 47 (13%) 

NO SpO2 12 / 47 (25%) 8 / 47 (17%) 


Table 2. Lumbar approach 

Lumbar During procedure After procedure 

NO ECG 18 / 45 (40%) 9 /45 (20%) 

NO NIBP 23 / 45 (51%) 7 / 45 (15%) 

NO SpO2 12 / 45 (27%) 10 / 45 (22%) 


Dr Iordan Mihaylov 

Dr Shyam Balasubramanian 

University Hospitals Coventry and 

Warwickshire 

Epidural injections are performed 

for pain secondary to nerve root 

irritation. The three common 

approaches for the epidural 

injections are lumbar, caudal and 

transforaminal routes. Although 

pain clinicians perform these 

procedures frequently, there 

is paucity of robust guidelines. 

We require evidence based 

information on the medications 

used, need for intravenous access 

and the minimum monitoring 

standards during and after the 

procedure. The Royal College 

of Anaesthetists and British 

Pain Society have published 

recommendations in 2002 

regarding the minimum standards 

of monitoring required for the 

performance of epidurals via 

the lumbar and caudal routes if 

local anaesthetics are injected. 

This includes blood pressure and 

pulse oximetry during and blood 

pressure and heart rate after the 

procedure (1). 

We conducted a prospective 

survey of practice of members 

attending the Interventional 

Pain Medicine Special Interest 

Group meeting in Manchester, 

9th October 2009. Fifty two out 

of fifty eight clinicians completed 

the survey questionnaire, making 

it a 90% response rate; 46 were 

consultants, one was an associate 

specialist and five were trainees. 

Results 

There was a wide variation 

with the amount and volume 

of medication injected. In the 

caudal and lumbar approach, 

the local anaesthetic injected 

ranged between three and twenty 

mls of 0.25% bupivacaine (or 

levobupivacaine). The volume was 

between one and four mls in the 

transforaminal approach. Two of 

the participants preferred lidocaine 

0.5% over bupivacaine for the 

lumbar and caudal approach. 

The status of intravenous access 

for these procedures and the 

monitoring used are presented in 

the tables 1-3. 

The results highlight that about 

one third of the epidural injections 

are done without intravenous 

access. It is debatable whether 

intravenous access is necessary if a 

small amount of local anaesthetic 

is injected into the epidural 

space (although the potential risk 

of intrathecal spread is always 

present). We noticed that many 

of the clinicians inject significant 

Table 3. Transforaminal approach 

Transforaminal During procedure After procedure 

NO ECG 14 / 37 (38%) 6 / 37 (16%) 

NO NIBP 22 / 37 (59%) 5 / 37 (13%) 

NO SpO2 9 / 37 (24%) 6 / 37 (16%) 


amount of bupivacaine 0.25% (5 – 

20 ml) without intravenous access. 

The results also suggest that the 

level of monitoring was often 

better after the procedure rather 

than during the procedure. Whilst 

the post-procedure monitoring 

is more important to rule out 

any haemodynamic changes, 

monitoring during the procedure 

may equally be necessary 

to identify episodes such as 

vasovagal syncope. The purpose of 

the audit is to survey the practice 

rather than analyse the outcome 

of these procedures. 

Conclusion 

The practice guidelines from 

International Spine Intervention 

Society (2) recommends 

physiologic monitoring and 

intravenous access for all 

procedures in which needles are 

placed near the dural sac. 

Although epidural techniques for 

pain management have been in 

existence for several decades, 

practitioners learn the techniques 

and the practice in different 

ways. The performance is based 

on personal experience rather 

than on robust evidence. One 

of the widely raised concerns 

and the discussion following the 

publication of the recent NICE 

low back pain guidelines was the 

heterogeneity of the interventional 

pain practice. Many of us agree 

that interventional treatment 

procedures form an important 

facet in pain management. Whilst 

there are several hurdles in 

bringing uniformity to the practice 

due to the multiple variables in 

the nature of the patients we deal 

with and the available resources, 

still efforts must be taken to 

standardise our practice as much 

as we can. To survive in a world 

of evidence based medicine, 

focus should be on establishing a 

guideline development group to 

bring consistency to our practice. 

Reference 

1. http://www.britishpainsociety. 

org/epi_inj.pdf 

2. Spinal Diagnostic & Treatment 

Procedures 2004, International 

Spine Intervention Society 

(ISBN 0-9744402-0-5) 

5 8 


BOOK REVIEW 

Oral feeding difficulties 

and dilemmas 

Dr Fiona Ring, Dr Emily Collis 

Imperial College Healthcare NHS Trust 

Joint publication between RCP and the 

British Society of Gastroenterologists 

Jan 2010 ISBN: 9781860163715 

At first look this publication may 

seem a daunting eighty page read. 

With a little perseverance though, 

you begin to appreciate what the 

authors are trying to achieve and 

realise it is well worth the time 

and effort. 

Divided into five chapters, the 

book does not provide a definitive 

management plan for patients 

with oral feeding difficulties. It 

does however equip you with 

the knowledge, and thus the 

confidence, to approach this 

increasingly common and always 

difficult issue pragmatically. 

The book starts off with the 

basics, looking at the mechanism 

of swallowing, how different 

diseases impact on this and how 

swallowing is assessed, before 

LETTERS 

considering the principles of 

managing it when it is impaired. 

Pertinent paragraphs discuss 

the metabolic consequences of 

withholding nutrition and what 

happens at the end of life. You 

then move on to a concise, 

evidence-based review of the 

techniques of artificial nutrition, 

including their indications, 

complications and consideration 

of the alternatives. This is followed 

by particularly useful chapters 

which outline the ethical principles 

applied to oral feeding difficulties 

and the relevant law. The final 

chapter serves to draw everything 

together and apply it to clinical 

practice. Disappointingly, the case 

studies do not cover the most 

taxing of clinical situations that 

may be encountered, but they are 

a good place to start. 

The report is undoubtedly a 

useful resource and having read 

it, can instantly be translated into 

practice. It gives a structure 

within which to consider a patient 

with oral feeding difficulties and 

highlights the key questions 

that should be addressed. It is a 

reassuring reference in times of 

uncertainty and is an invaluable 

source of relevant information and 

evidence, facilitating discussion 

with patients and their relatives. 

All of these points can only serve 

to help us to arrive at the best 

decision and outcome. It is an 

insightful book you’ll be glad to 

have on the shelf! 

Letters to the Editor 

Dear Editor 

I read with interest article written 

by Dr. Thanthullu Vasu on pain 

research- ethics committee. 

The article is well constructed 

answering most of the doubts 

trainees have regarding ethics 

committee. It clearly explains the 

steps taken by the committee. 

I look forward for more such 

informative articles. 

Dr.Ravi Srinivasagopalan 

St.Georges School of anaesthesia 

London 

INTRODUCTION TO MINDFULNESS 

AS A HEALTH CARE INTERVENTION 

2-Day Events for Health Professionals 

Training events at venues including Manchester, Leeds, Ely in 2010 

and Scotland, Manchester, London in 2011. 

Workshops introduce mindfulness theory and practice, research outcomes, 

and ways that mindfulness can be introduced into work with patients. 

Attendance on a 2-day introductory event also constitutes the first module 

in our progressive training leading to accreditation as a Mindfulness Trainer. 

Breathworks CIC is a not-for-profit social enterprise offering courses, training 

and resources in Mindfulness-Based approaches to Pain and Illness (MBPI). 

Our founder trainer Vidyamala Burch has used mindfulness to manage severe 

chronic spinal pain for 25 years, and is a member of the BPS. 

Details at: 

www.breathworks-mindfulness.co.uk/training 

To find out more about advertising, or 

placing an insert in Pain News 

contact Rikke Susgaard-Vigon on 

020 7269 7840 or email 


PAI N N E W S S U M M E R 2010 5 9

Papers appraised by Dr Aileen Clyde Pain Fellow Glasgow 

PAIN SHORTCUTS 

Incidence and Root Cause 

Analysis of Wrong-site Pain 

Management Procedures 

Anesthesiology 2010;112:711-8 

The objectives of this study were 

to estimate the incidence of wrong 

site pain management procedures, 

to perform an analysis to identify 

the cause of these mistakes and to 

publicise the issue of wrong site 

surgery and its causes to prevent 

further occurrences. 

Quality improvement records 

were reviewed from pain clinics 

at 10 institutions in the USA ( 

4 academic teaching hospitals, 

2 military teaching hospitals, 1 

non-academic treatment facility 

and 3 private practices) during 

a 2 year period from 2007-2009 

to identify wrong site procedure 

events. All physicians involved in 

pain management at each facility 

were questioned to identify wrong 

site procedures that may not have 

been reported. Billing records from 

the non-military institutions were 

examined and procedure codes 

and scheduling records from the 

military institutions examine to 

identify the total number of pain 

procedures carried out in this 2 

year period. When multiple distinct 

procedures were performed 

during a single visit, these were 

counted separately. For related 

or multilevel procedures that did 

not constitute an additional risk of 

wrong site surgery, then only the 

primary procedure was tabulated. 

Individual procedure reports 

were examined during a 6 month 

period to determine the number 

of unilateral procedures or spinal 

procedures in which correctly 

identifying the pathological level 

was deemed to be critically 

important. These procedures 

were called ‘at risk’ procedures. 

Causation was determined by 

referring to quality improvement 

records and by ‘debriefings’ with 

personnel involved in the event. 

The review found that 48,941 

unrelated procedures were 

completed at the 10 institutions 

during the 2 year time frame. The 

review of 500 billing records along 

with daily schedules and electronic 

record review indicated 6 duplicate 

procedures or procedures that 

were not reflected in the billing 

records. This gives an estimated 

error rate of 1.2%. 

13 wrong site procedures were 

identified (0.027%; CI 0.01- 

0.05%). 12 were from quality 

improvement records and 1 from 

staff questioning. 

The proportion of ‘at risk’ 

procedures from each institution 

ranged from 39-65%, the 

weighted average was 52.4%. 

Therefore, the incidence of 

wrong site procedures was 

estimated to be 2.7 per 10,000 

pain management procedures 

and 5.1 per 10,000 high risk pain 

management procedures. 

Of the 13 wrong site procedures, 

5 were wrong side transforaminal 

epidural steroid injections. 

There was 1 wrong side facet 

radiofrequency denervation, 1 

wrong side intercostal nerve radio 

frequency ablation, 1 wrong side 

intercostal nerve block, 2 wrong 

level spinal procedures, 1 wrong 

side lumbar sympathectomy, 1 

wrong side suprascapular nerve 

block and 1 wrong side lumbar 

facet injection. 

In 5 cases either the side or level 

was not noted on the consent 

form. In four of the 8 cases where 

the consent form was correct, it 

was signed by a different person 

to that carrying out the procedure. 

In one patient the consent form 

was not sent with the patient to 

the procedure area. A ‘time out’ 

was performed in only 6 of the 13 

cases and the side was marked in 

only 2 cases. 

The authors identified some 

causative factors which appear 

to increase the chances of wrong 

site surgery. There appeared to 

be an increased risk of wrong site 

procedures when the responsibility 

for safe performance is shifted 

between providers, steps in the 

‘universal protocol’ are missed, 

the site is not marked, bilateral 

pathology is present or if a 

different practitioner from the 

one carrying out the procedure 

is involved in obtaining consent. 

Strangely in 8 of the 13 cases the 

patients knew that the wrong side 

Anesthesiology 111(2), August 2009 

pp416-431 

Intravenous analgesic infusion tests 

have been used for some time to 

facilitate the management of patients 

with chronic pain. The rational 

behind their use is that they can 

quickly predict who will respond 

to a subsequent course of oral 

medication, eliminating the time and 

expense of an oral medication trial 

and reducing the risks of adverse 

effects associated with ineffective 

drug treatment. 

This is the first attempt to review 

systematically the literature on 

intravenous analgesic infusion tests. 

The aim of the systematic review 

was to discern the value of these 

analgesic drug infusions tests as 

prognostic tools in guiding future 

drug therapy. 

was being targeted. 6 of the 13 

patients received sedation for the 

procedure. 

No legal, professional or 

procedural consequence resulted 

from the errors although 2 

practices determined that the 

mistake might lead to future litigation. 

No studies like this have been 

conducted to determine the 

incidence of wrong site pain 

procedures in the UK. The WHO 

surgical safety checklist, which has 

recently been implemented in many 

UK hospitals may help to reduce the 

problem of wrong site procedures. 

It is interesting to note that in many 

of the wrong site pain procedures 

mentioned in this study, there was 

a breach of universal protocol (U.S. 

version of surgical safety checklist) 


Intravenous Infusions for 

Chronic Pain- a systematic 

review 

The authors performed a MEDLINE, 

EMBASE and OVID search using 

appropriate key words. The search 

identified 111 published articles on 

the subject. Of these 22 articles were 

suitable for analysis. 

10 studies looked at the predictive 

value of lignocaine infusion tests for 

treatment with oral sodium channel 

blocker mexiletine. Although these 

studies are small the data suggests 

that a brief lignocaine infusion test is 

predictive of subsequent response 

to oral mexiletine for patients with 

neuropathic pain. There is only 

weak evidence that the response to 

intravenous lignocaine can predict 

response to mexiletine in nociceptive 

pain. The authors point out that the 

long term effectiveness of mexiletine 

therapy remains in question as a 

result of its significant side effect 

profile, mainly nausea and sedation. 

6 0 


3 studies ( n=25,34,56) looked at 

the use of intravenous ketamine 

infusion to predict the response to 

the oral NMDA receptor antagonist 

dextromethorphan. One study 

(n=8) evaluated the efficacy of oral 

ketamine in subjects who responded 

positively to an infusion of ketamine. 

The authors emphasise the flaws 

associated with these studies namely 

short follow up period, use of single 

dose ketamine (0.1mg/kg) and the 

absence of any control treatment 

group. The review concludes that 

the studies included provide weak 

evidence supporting the use of a 

ketamine infusion test to predict 

short term treatment response to 

oral NMDA receptor antagonist 

therapy for both neuropathic and 

nociceptive pain. 

There were 4 studies (n=48,12,16,26) 

that looked at the use of opioid 

infusions to predict response to 

either oral or transdermal opioid. 

These yielded mixed results. 2 

studies showed very poor correlation 

between the predictive results of an 

opioid infusion test and response 

to oral opioids while two studies 

showed that there was a correlation 

between the responses but only 

a small percentage of patients 

reported sustained benefit from oral 

opioids lasting at least 6 months. 

There were 3 studies (n=104,6,41) 

and one case report looking at the 

predictive effects of IV phentolamine. 

There are a number of significant 

flaws with these studies. The 

authors of the systematic review 

concluded that there was no 

credible evidence that the use 

of intravenous phentolamine 

infusion reliably predicts response 

to pharmacological sympathetic 

blockade (transdermal or oral 

clonidine used in these studies), and 

only weak evidence supporting the 

use of intravenous phentolamine 

before intravenous regional 

guanethidine. 

Despite having very liberal inclusion 

criteria in this review, there is little 

data on the predictive value of 

intravenous analgesic infusion tests. 

It is surprising that there is a paucity 

of literature available to support 

a commonly used test in pain 

management. Further, randomised, 

double blind studies are obviously 

required to determine the predictive 

nature of these tests. 


Group cognitive behavioural 

treatment for low back pain 

in primary care 

cognitive behavioural intervention. 

Subjects in the Control, advice only, 

group received a copy of the ‘back 

book’ and a 15 minute session on 

active management advice delivered 

by a nurse or physiotherapist. The 

intervention group subjects attended 

the Back skills training programme, 

which comprises an individual 

assessment and 6 sessions of group 

cognitive behavioural therapy. 

This cognitive behavioural therapy 

targets behaviours and beliefs about 

physical activity and avoidance of 

activity. Subjects were deemed to 

be compliant with the cognitive 

behavioural intervention if they 

attended the initial assessment and 

at least 3 of the subsequent sessions. 

Outcomes were assessed at 3, 6 and 

12 months after randomisation by 

postal questionnaire. Subjects were 

asked to fill in the Roland Morris 

disability questionnaire and the 

modified Von Korff scale, mental 

and physical health related quality 

of life survey, fear avoidance beliefs 

questionnaire, pain self-efficacy scale 

and a questionnaire relating to selfrated 

benefit from and satisfaction 

with treatment. The authors 

estimated the costs of delivering 

both interventions and health care 

costs associated with lower back 

pain over 12 months by use of a 

within trial analysis. Quality Adjusted 

Life Years (QALY) were used to 

estimate cost utility. 

701 subjects were randomised. 

There was 233 in the control group 

and 468 in the CBT group (1:2 ratio 

control:test). Followup was 85% 

in both groups at 12 months. The 

Roland Morris questionnaire score 

changed by 1.1 points (95% CI 0.39- 

1.72) from baseline to 12 months in 

the control group and by 2.4 points 

(1.89-2.84) in the CBT group(1.3 

points difference between gps, 0.56- 

2.06; p=0.0008). The modified Von 

Korff pain score changed by 6.4% 

in the control group and by 13.4% 

in the CBT group (7% diff between 

groups,3.12-10.81; p

PAIN SHORTCUTS (CONTINUED) 

for more than 28 days before entry 

into the study and remained on 

the same medications and doses 

throughout the study. Subjects had 

not had ketamine before. 

Appropriate exclusion criteria 

were applied and the subjects 

randomised to either the ketamine 

or the placebo group. 

The subjects received a full 

neurological examination and 

pain evaluation at the start of the 

study. The subjects were asked 

to complete a short form McGill 

questionnaire, quality of life 

questionnaire and a seven question 

pain questionnaire weekly until the 

start of the infusions. 

The subjects all wore an activity 

watch for at least 2 weeks prior to 

treatment and 2 weeks following 

treatment. The subjects underwent 

sensory and motor tests 2 weeks 

prior to treatment and at 1 and 3 

months post treatment. 

On all 10 infusion days the subjects 

were monitored for cardiac 

rhythm, blood pressure, pulse 

and oxygen saturation. Subjects 

were given Clonidine 0.1mg orally 

and midazolam 2mg IV prior to 

the infusion and 2mg IV following 

the 4 hour infusion. All subjects 

were infused with 100ml normal 

saline with or without ketamine 

for 4 hours daily for 10 days ( 5 

days on, 2 days off, 5 days on)The 

maximum ketamine infusion rate 

was 0.35mg/kg/h, not to exceed 

25mg/hr. On the first day the IV 

ketamine infusion was set to 50% 

of the max rate, 75% max rate on 

the second day and maximum rate 

on the third day and maintained 

at maximum rate for the duration 

on the study. Following the 

last infusion the subjects were 

reviewed at 2 weeks and then 

monthly for 3 months. They were 

asked to wear the activity watch 

from the last infusion until the 2 

week post infusion visit and were 

asked to complete the short form 

McGill, quality of life and pain 

questionnaires weekly until the end 

of the study 3 months after the last 

infusion. 

The study was stopped at the 

halfway point because an interim 

analysis was conducted which 

showed there was little placebo 

effect .This meant that statistical 

significance could be reached in 

many of the study parameters with 

a smaller number of study subjects 

than was originally anticipated. Also 

further experience with outpatient 

ketamine infusions showed that 

50mg/hr provided much greater 

pain relief for a greater period of 

time. 

10 subjects were in the placebo 

group and 9 subjects in the 

ketamine group. The study 

showed a significant reduction 

in pain (p

R E S E A R C H & D E V E L O P M E N T 

COST EFFECTIVE 

MINIMALLY INVASIVE 

PERIPHERAL NERVE STIMULATION 

THE FIRST GENERATION OF OFFICE BASED 

NEUROSTIMULATION THERAPIES 

PENS THERAPY 

Frequency dependant electrical current 

delivered directly to a peripheral nerve, or to 

the most peripheral branches of a peripheral 

nerve, to inhibit pain signals. 

PENS is used to identify patients who are 

likely to benefit from a permanently implanted 

peripheral neurostimulator, thereby reducing 

the incidence of late failure. PENS also offers 

patients the potential for intermediate relief 

and management of chronic peripheral 

neuropathic pain. 

For more information on PENS therapy: 

Tel: +44 (0)1293 763 070 or visit www.algotec.com

For the treatment of neuropathic pain associated with post-herpetic neuralgia 

Works where it hurts 

Versatis is a novel analgesic plaster which 

delivers 5% lidocaine topically. 1 

Versatis has demonstrated sustained efficacy 2 

and has a reassuring safety and tolerability profile 1,3 

Adverse events should be reported. Reporting forms 

and information can be found at: www.yellowcard.gov.uk. 

Adverse events should also be reported to Grünenthal Ltd 

(tel: 0870 351 8960) 

V0833. Date of preparation: January 2010. 

Versatis 5% medicated plaster. Refer to the Summary of Product Characteristics (SPC) for 

full details on side effects, warnings and contra-indications before prescribing. Presentation: 

Versatis is a medicated plaster (10cm x 14cm) containing 700 mg (5% w/w) of lidocaine in 

an aqueous adhesive base. Indication: Symptomatic relief of neuropathic pain associated with 

previous herpes zoster infection (post-herpetic neuralgia, PHN). Dosage and method 

of administration: Adults and elderly patients: Use up to three plasters for up to 12 hours, 

followed by at least a 12 hour plaster-free interval. Cover painful area once daily. Apply 

the plaster to intact, dry, non-irritated skin (after healing of the shingles). Remove hairs in 

affected area with scissors (do not shave). Remove the plaster from sachet and its surface liner 

before applying immediately to the skin. Plasters may be cut to size. Re-evaluate treatment after 

2 to 4 weeks. Patients under 18 years: Not recommended. Contra-indications: Hypersensitivity to 

active substance, any excipients, or local anaesthetics of amide type (e.g. bupivacaine, etidocaine, 

mepivacaine and prilocaine). Do not apply to inflamed or injured skin (e.g. active herpes zoster 

lesions, atopic dermatitis or wounds). Warnings and precautions: Should not apply to mucous 

membranes or the eyes. Plasters contain propylene glycol which may cause skin irritation, methyl 

parahydroxybenzoate and propyl parahydroxybenzoate which may cause allergic reactions. 

Use with caution in patients with severe cardiac impairment, severe renal impairment or severe 

hepatic impairment. In animals, metabolites of lidocaine have been shown to be genotoxic, 

carcinogenic and mutagenic, with unknown clinical significance. Interactions: No clinically 

relevant interactions have been observed in clinical studies. Absorption of lidocaine from the 

skin is low. Use with caution in patients receiving Class I antiarrhythmic drugs (e.g. tocainide, 

mexiletine) or other local anaesthetics. Pregnancy and lactation: Do not use during pregnancy 

or breast-feeding. Undesirable effects: Very common (≥10%): administration site reactions 

(e.g. erythema, rash, pruritus, burning). Uncommon (>0.1%-≤1%): skin injury, skin lesion. 

Very rare (

Summer 2010 - The British Pain Society

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