Summer 2010 - The British Pain Society

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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
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
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Registered charity in Scotland No. SC039583
The opinions expressed in PAIN NEWS do not necessarily reflect those of the British Pain Society Council.
contents
PAI N N E W S S U M M E R 2010
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
15 Citation for award of Honorary
Membership British Pain Society:
Professor Troels Staehelin Jensen
15 Poster Prize presentations, 2010 ASM
16 Citation for award of Honorary
Membership British Pain Society:
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
http://everything2.com/title/
Heroin+and+jazz
www.bps-research-digest.blogspot.
com/2008/01/would-jazz-greatshave-been-so-great.htm
en.wikipedia.org/wiki/
Charlie_Parker
en.wikipedia.org/wiki/
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%)
No intravenous access 12 / 45 (27%)
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%)
No intravenous access 11 / 37 (30%)
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