Pain - The British Pain Society

The Pain Society
The British and Irish Chapter of the International
Association for the Study Of Pain
21 Portland Place
London
W1B 1PY United Kingdom
Telephone (020) 7631 8870
Fax (020) 7323 2015
Email info@painsociety.org
www.painsociety.org
Council Members and Officers 2002-2003
President Dr. Beverly Collett
Immediate Past President
Honorary Secretary
Honorary Treasurer
Honorary Assistant
Secretary
Nursing
Anaesthesia / Pain
Medicine
Nursing
Pain Research
Nursing
Psychology
Pain Medicine
National Occupational
Therapy Pain Association
The views of the IASP
Chair, Patient Liaison
Committee
Association of Palliative
Medicine
Chair, Courses and
Meetings Committee
Editor, The Pain Society
Newsletter
Association of
Anaesthetists of Great
Britain and Ireland
Chair, Local Organising
Committee ASM 2003
The Pain Society Newsletter is
published quarterly.
Circulation 1650.
The editor welcomes
contributions including letters,
short clinical reports and
news of interest to members
including notice of meetings.
Comments on the format of
the Newsletter are welcome.
Dr. Douglas Justins
Dr. Karen Simpson
Dr. George Harrison
Dr. Andrew Vickers
Dr. Eloise Carr
Dr. Kate Grady
Ms. Ruth Day
Dr. Andrew Rice
Dr. Patricia Schofield
Dr. Amanda C de C
Williams
Dr. Cathy Stannard
Mrs. Louise Aylwin
Prof. Sir Michael Bond
Mrs. Jean Gaffin
Dr. Paresh Gajjar
Dr. Paul Watson
Dr. Stephen Ward
Dr. Alastar Chambers
Dr. Chris Spanswick
Material should be sent to:
Dr Stephen P Ward
Editor, The Pain Society
Newsletter
Pain Management Unit
Brighton and Sussex
University Hospitals NHS Trust
Princess Royal Hospital
Haywards Heath
West Sussex RH16 4EX
Tel 01444 892276
Email drspward@yahoo.co.uk
The opinions expressed in the Pain Society Newsletter do not
necessarily reflect those of the Pain Society Council.
Editorial
STEPHEN WARD
For the most part, the
‘new-look’ newsletter has
been well received and I
am grateful for your kind
words and
encouragement. Two
criticisms have been
levelled though and I think both deserve
attention. Firstly, I have been informed that
the cover design is ‘too masculine’. Being
the registered bearer of a Y chromosome, I
can’t see it myself – is it the colour scheme?
Not enough pink? Is the typeface too
Neanderthal?
The second criticism was of greater
importance and relevance. More than one of
you has noted that the Newsletter has
become somewhat downbeat and selfdepreciating
and that the content tends to
favour articles of a ‘moany’ nature. What
would the lay reader think of us as a Society
if he were to flick through our publication?
Almost certainly that we are unloved,
undervalued, underfunded, stressed to
breaking point and that we would much
rather write about our bad experiences in
pain management than our good.
Ok….I agree…it’s a fair cop. Whilst I’m as
much in favour of a good old whinge as the
next man the content of the newsletter
needs to change. I’m not saying that we
pretend all is rosy in Painland as patently it
is not, but let’s pat our own backs a bit
more and try to appear, at least outwardly, a
little less downtrodden. Say it with me…’I
work in Pain Management and I’m proud!’
Allow me to start the ball rolling and
address some of the popular misconceptions
we and others seem to have about pain
management:
We are not undervalued or unloved – in
fact, whenever I spend time looking at our
waiting list figures I feel positively
overvalued! If you believe for a moment
that your patients don’t value the time and
effort you invest in their wellbeing or that
the local GPs and hospital consultants do
not value your opinion and your expertise
then you might as well give up now.
Are we underfunded as a specialty?
Definitely – but name a specialty that isn’t.
Chronic pain has always been considered a
soft target when it comes to resource
allocation and allowing patients to linger on
the waiting list for years has been the norm.
After all, if a patient has had back pain for
25 years, what’s the rush? All fine and
dandy until Big Al Milburn had the barmy
idea of introducing waiting time
targets…… these days if Mrs Jones isn’t
seen within 17 weeks, a manager
somewhere is shot at dawn. On the face of
it this is madness but it can actually work
very much in our favour. A week or two ago
it was suggested to me that I might like
another couple of pain management
sessions to enable me to meet the 17 week
target. Sorely tempted as I was to see my
manager shot that dawn I jumped at this
chance and I am happy to report that I have
finally joined the ever swelling ranks of the
full time pain specialist. A few years ago it
was virtually impossible to increase pain
sessions without selling your soul to
Beelzebub himself – now they’re throwing
them at us?
Are we stressed as a group? If the ASM is
anything to go by I’d say, outwardly at least,
quite the opposite – have you ever come
across a more relaxed, easy going and fun
loving group? If this is the portrait of a
group under pressure then I’m off to join
the Royal Society of Transcendental
Meditants. As individuals, though, we all
suffer stress at some point in our careers
but I suspect this is down to administrative
and managerial foul play and pressure
rather than the nature of the specialty or the
patients we deal with. I find pain
management an immensely rewarding and
fascinating occupation and defy you to find
any specialty more interesting, challenging,
or holistic (Did you hear about the holistic
orthopaedic surgeon? He thought about the
whole bone).
Our specialty leads the field in terms of
scientific expertise and integrity and has
embraced evidence based medicine in its
bosom like no other. We should, quite rightly
feel an immense sense of pride in ourselves
as a group.
By and large the patients we encounter are
pleasant, well informed (apart from the dear
old lady I saw recently who came to clinic
clutching a box of voltarol. ‘What
medication are you taking?’ I asked
‘Voldemort!’ she replied) and grateful for
any help we can give them. Rarely are they
2
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
EDITORIAL

6
14
THE PAIN SOCIETY NEWSLETTER SUMMER 2003
SARAH BARKER &
AMANDA C DE C WILLIAMS
THE PAIN SOCIETY NEWSLETTER
1-3 Months - 54%
1-3 Months - 74%
Acceptable - 46%
SUMMER 2003
20 THE PAIN SOCIETY NEWSLETTER SUMMER 2003
0-4 Weeks - 23%
0-4 Weeks - 17%
Excellent - 17%
Good - 31%
1-3 Months - 54%
Always - 6%
Rarely - 11%
Sometimes - 11%
4-6 weeks - 11%
2-4 weeks - 54%
NEWS FROM PORTLAND PLACE
0-4 Weeks - 23%
Mostly - 51%
0-2 weeks - 14%
FEATURES
FEATURES
the malingering, miserable,
mad-as-a-badger malcontents
that our colleagues seem to
think they are.
So there we are, a few musings
from me. To be involved in any
way in the treatment and
management of pain is a
privilege. To moan about the
shortcomings of our specialty
incessantly simply fuels the
misconceptions of others that
ours is a dreary, thankless world
– and it simply isn’t.
In this issue, you will see that I
have received a handful of
letters. One of these letters is,
admittedly, a bit of a moan
about private practice but I’ve
let this one go on the grounds
that I tend to agree with him.
Another of the letters is from
Professor Richard Dawkins and
requires a brief explanation.
Richard Dawkins is the Charles
Simonyi Professor of the Public
understanding of Science at
Oxford and is, without doubt
one of our most important
evolutionary biologists. Having
recently read his collection of
selected essays entitled ‘A
Devil's Chaplain’ and another of
his books ‘The Selfish Gene’ I
was intrigued by his firmly held
Darwinist belief that genes
survive or fail to survive within
the gene pool of a species by
virtue of their effects upon the
survival of the individual
organism (for example, genes
coding for the various structures
involved in pain pathways are
important to our survival –
acute pain tells us not to move
so that we can heal and not to
do it again!). When we consider
chronic pain however, where is
the evolutionary advantage?
Tissue healing is complete, the
message is useless and the
condition a miserable one. One
would have supposed that this
glitch be ‘ironed’ out over a few
million years but sadly not. Can
it be that genetics plays no part
in chronic pain? Are we more
likely to survive if we are
constantly reminded about an
old injury – even ten years on –
so that we don’t make the
same mistake twice? Are our
pain behaviours passed on like
genes to the next generation so
that they respond in the same
way? Am I just rambling on?
Anyway, he was kind enough to
put his view forward and if any
of you profess any expertise in
this area I’d welcome
comments.
Lastly, thank you all for the
submissions…please keep them
coming.
drspward@yahoo.co.uk
Contents
columns
2 Editorial
4 President’s message
news
6 Glasgow ASM 2003
review
6 Pain Meetings for
Health Professionals
8 Pfizer Prize Awards
10 Obituary
11 New Members
13 Results of Glasgow
ASM : session
evaluations
features
14 Psychological
Assessment and
Interventions
15 A Distress Motivation
Axis
18 Angina Pectoris : A
Historical Perspective
20 Nottingham Pain Clinic
survey
THE PAIN SOCIETY NEWSLETTER
PAIN MEETINGS FOR
HEALTH PROFESSIONALS
CELLULAR AND MOLECULAR MECHANISMS OF PAIN
a satellite symposium to the International Brain
Research Organization (IBRO)
7-9 July Prague, Czech Republic
Email:palecek@biomed.cas.cz / wdwillis@utmb.edu
Web: http://www.biomed.cas.cz/IBRO-PAIN/
BATH PAIN FORUM - CATASTROPHISING ABOUT
CHRONIC PAIN
29 July, Royal National Hospital for Rheumatic Diseases, Bath
Contact: Dr. Chris Eccleston
Director, Pain Management Unit,
University of Bath
Email: pain@bath.ac.uk
PAIN IN EUROPE IV - 4TH CONGRESS OF THE EUROPEAN
FEDERATION OF IASP CHAPTERS (EFIC)
2-6 September, Prague, Czech Republic
Contact: Congress Business Travel
Email: pain2003@cbttravel.cz
Web: www.pain2003.cz
9TH NATIONAL CONFERENCE ON PAIN MANAGEMENT
PROGRAMMES
Organised by the Pain Management Special Interest
Group of the Pain Society
11-12 September, John Innes Centre and University of East Anglia
Contact: Elaine Wellingham
Conference Secretariat, Field End House
Bude Close, Nailsea
Bristol BS48 2FQ
Tel/Fax: 01275 853311
Email: Confsec@blueyonder.co.uk
THE FUTURE OF PAIN THERAPUTICS 2003
15-16 September 2003, London
Email: sara.peerun@visiongain.com
http://www.visiongain.com/futurepaindrugs.html
PROVING OUR WORTH!
Specialist Nurses & Nurse Consultants Conference
25 September, Post Graduate Medical Centre, Worthing Hospital,
West Sussex
THE PAIN RELIEF FOUNDATION 4TH ANNUAL LECTURE
2003
Pain & Central Nervous System Reorganisation”
Friday,17th October at 7:00 pm
The Pain Research Institute, Clinical Sciences Centre, University
Hospital Aintree, Liverpool
Professor Troels Jensen, Danish Pain Research Centre, University of
Åarhus, Denmark
AN UNRECOGNISED PAIN CHALLENGE
a one-day conference on Joint Hypermobility
Syndrome
21 October 2003, 9.30 - 4.40, Postgraduate Centre, Gassiot House,
St Thomas' Hospital
Psychological Asessment
and Interventions
Having a converted cupboard
for an office makes
psychological consultation at
our hospital a cosy affair.
Despite this, a patient’s first
appointment with the clinical
psychologist can seem scary,
associated with psychiatric
labels and ‘all in the mind’
statements, which mark the end
of the pain being taken
seriously by doctors.
Psychological assessment is a
real deterrent for some who
don’t attend the initial meeting.
But there is no avoiding this
meeting for the patient wanting
a spinal cord stimulator or a
peripheral nerve stimulator:
psychological assessment is
mandatory. Many patients
spend the first minutes
emphasising their sanity, the
reality of their pain, and their
entitlement to neuromodulation
to make life worth living again.
The aversive and chronic nature
of patients’ pain makes the
hope of a cure alluring. So what
does the assessment consist of,
and is it really essential?
Nottingham Pain Clinic survey
Although it is widely
acknowledged in pain field that
pain is a psychological
experience as well as a physical
one, the relationship between
pain and psychological factors
remains the subject of
differences and debate. It would
be encouraging to think that
dualistic models are losing their
hold, and that the attribution of
pain in some patients to
psychogenic factors is
understood as an hypothesis
not a finding, but this way of
thinking still leads to
stigmatisation and
discrimination in many areas of
health care. Although
professionals working in the
field of pain hopefully now have
a broader perspective,
misunderstandings can still
occur about the role of
psychology and how it can best
be integrated with medical
treatments.
First: what requests can’t
psychological assessment
satisfy? It can’t establish the
relative contributions of organic
and psychological factors (nor
can any other method, as the
underlying model is erroneous),
What do GPs’ want from the pain
clinic and do we provide it?
The pain department at City Hospital provides a one-day series of
lectures and practical workshops for local GPs.
49 GP’s attended the pain day and 35 returned completed the
questionnaire. The response rate was 71%.
nor can it establish ‘cause and
effect’ relationships between
psychological problems and
pain (Doleys, 2000). The other
purposes for which assessment
is requested is to exclude
patients with gross mental
health problems, which is
reasonable although we do not
know that they would not
benefit from neuromodulatory
methods; and to improve
outcomes in by identifying
predictors of poor outcome (e.g.
North et al, 1996, Nelson et al,
1996). Suggested candidates for
this include ‘somatisation
disorder’, ‘major uncontrolled
depression/anxiety’, ‘severe
sleep disturbances’, ‘serious
drug or alcohol problems’ and
‘lack of social support’; other
factors which the psychologist is
advised to consider include ‘
history of abuse or other
dysfunction’, ‘unusual pain
ratings’, ‘certain personality
disorders’, ‘unresolved
compensation’ and ‘lack of
support from spouse’ (Olsen,
1996). As you can see from this
list, virtually every patient will
present one or more of these
‘warning’ factors.
While the search for predictors
of outcome seems at first a
reasonable scientific pursuit, it
does not stand up to scrutiny.
The only way to discover such
SUMMER 2003
Glasgow ASM 2003 :
Overview
Breakdown of delegates
There were a total number of
1,066 Delegates registered at
the Meeting; an increase of 264
from the 2002 Meeting in
Bournemouth. 50 were
Anaesthetic Research Delegates.
Of the 1066, 70% were
members of the Society.
The specialty of the delegates
continues to mirror the
membership of the Society, with
anaesthetists making up the
largest group of delegates,
followed by nurses,
psychologists, physiotherapists,
occupational therapists and
general practitioners.
Venue
The Glasgow Scottish Exhibition
+ Conference Centre was an
excellent venue for this year’s
ASM and perfectly suited the
Society’s needs in terms of
quality of plenary hall, number
of break-out rooms and size of
exhibition area. The support
staff was excellent and the
additional facilities at the
Centre i.e. café bar, restaurant
and business desk all added to
the success of the meeting.
Scientific Programme
Overall, the view from the
evaluation forms was that the
scientific programme was varied
and very well balanced, with
excellent quality of speakers.
predictors would be to assess
all patients, to treat them all
blind to the assessment process,
and then to compare the
outcome with those
assessments. Instead, lists of
problems such as those above
are used to be very selective
about candidates for
neuromodulation, so that if any
predictors are found
retrospectively, they can only
apply within the limits of those
selection procedures, which of
course vary from clinic to clinic.
These exclusion criteria easily
become proxies for refusing
patients who are already
underserved and disadvantaged.
A close look at the literature on
psychological screening for
neuromodulation shows
generally poor methodologies
and a strong influence from
insurance based health funding
which characteristically focuses
on shortcomings in the
patient/claimant.
Given the unpredictable success
of neuromodulation and the
distress caused by pain and
unsuccessful treatment, what
should psychological screening
aim to achieve? There is
certainly benefit in eliciting
patients’ understanding (or
misunderstanding) both of their
pain problem and of
neuromodulation procedures
Which one of the following statements best describes the
way that you would like the pain clinic to be organised?
(Tick one option)
1- More new patient appointments with a short follow up period
and discharge back to GP care.
2- More new patient appointments with a treatment plan that is
carried out and maintained by the GP. No routine follow up in the
pain clinic.
3- Fewer new patient appointments with long term follow up by the
pain clinic.
regulars
Demographic data
Mean Range
Number of partners 5 1-14
list size 8000 1800-34000
12 training practices and 22 non-training practices were represented.
Organisational issues
A number of participants were from outside Nottingham so gave
responses related to experience with their local provider of pain
services.
How long do
your patients
have to wait
for a routine
pain clinic
appointment?
Option 1 70%
Communication
Do you expect
to receive a
letter after
each
outpatient
episode in the
pain clinic?
How often
does this
happen?
12 Letters to the Editor
16 Special Interest Groups
22 Reflections from the
coalface
What do you
think is an
acceptable
waiting time
for a routine
pain clinic
appointment?
In order to reduce the waiting time for a new patient
routine appointment at the pain clinic it would be
necessary to reduce the number of follow up appointments.
How would
you rate this
change?
How long does it take for a letter to arrive at your practice
after the
patients’ pain
clinic
consultation?
Comments
“A brief letter with a treatment plan is all that is needed.”
“The letters are very important because chronic pain patients are
very demanding and frequent attendees who always want
information from the hospital.”
CONTENTS THE PAIN SOCIETY NEWSLETTER SUMMER 2003 3

President’s
message
DR.BEVERLY COLLETT
Welcome to the summer
Newsletter and my opportunity
to share some thoughts with
you.
Glasgow hosted a spectacular
Annual Scientific Meeting. A
marvellous venue and a superb
scientific programme
contributed to this success. We
were educated and challenged
by lecturers from North America
and Europe as well as by
distinguished colleagues from
our own shores. We owe a debt
of thanks to David Rowbotham,
Chairman of the Courses and
Meetings Committee and to his
team for compiling this
excellent programme. David is
now stepping down from this
role and we thank him for his
most valued contribution to the
ongoing improvement of the
standard of our ASM. Paul
Watson has taken on this
important task and plans are
well underway for 31st March-
2nd April 2003 in Manchester.
Please let him know of any
articulate, interesting and
amusing speakers so that we
can continue to present a varied
multidisciplinary high quality
programme.
Congratulations to Kate Grady,
Andrew Rice, Pat Schofield and
Cathy Stannard, our new
Council members. They were
elected from a very strong field
and it is to the Society’s great
benefit that we do have
members who are willing to put
in the extra time needed to
work on your behalf.
Commiserations if you were not
successful on this occasion.
However, I do hope that you
will consider standing again.
Cathy Stannard will be no
stranger to you having recently
passed on the Editor’s role of
the Newsletter to Stephen
Ward. Cathy’s thoughtprovoking
observations on the
state of pain management will
be familiar to you from her
Editorials and we look forward
to much lively debate in our
future Council meetings. Andy
Vickers and Cathy Stannard
have been appointed joint
chairs of a new Committee
tasked with looking at Clinical
Governance issues for the Pain
Society. Pat Schofield and
Andrew Rice are highly
regarded for their academic
credentials and we welcome
their input into Council. Kate
Grady will be involved in the
Courses and Meetings
Committee and will also be
attending the Association of
Palliative Medicine on our
behalf.
George Harrison has taken over
from William Campbell as
Honorary Treasurer. I should like
to thank William for
maintaining robust control of
the Society’s finances,which
continue to be soundly based.
The Pain Society is in the
fortunate position of being the
beneficiary of two recent
legacies. We have been notified
that Mrs Irene Bainbridge of
Stanhope, Co Durham has
bequeathed a third of her
residuary estate to the Pain
Society for its general purposes.
We do not yet know the exact
amount, but it is estimated that
we will receive approximately
£400,000.00. I have contacted
her family to thank them for
this most generous legacy, but
do please let me know if you
knew this lady. We have also
been advised that Elaine
Elizabeth Clulow, who died in
April 2003, has left a legacy to
the Pain Society for basic
research into the causes and
cure of pain. Council will be
discussing how both these
monies should properly be
spent and will let you know
what is agreed.
I should like to convey my
thanks to Dr. Douglas Justins
our Immediate Past-President,
who has skillfully crafted the
Pain Society through the last
two years. Douglas has
considerable knowledge and
perception in matters pertaining
to the Royal College of
Anaesthetists. It is essential that
this important link is maintained
and I am extremely pleased that
he will continue to give us the
benefit of this expertise by
further work on Pain Society
Council as Immediate Past-
President and as the
representative of the Royal
College of Anaesthetists.
Congratulations to Professor
Mike Harmer on his election as
the next President of the
Association of Anaesthetists of
Great Britain and Ireland. We
are delighted that an
anaesthetist with an interest in
pain management is
undertaking this important role.
We look forward to greater
collaboration between our two
organisations in the future.
You should all have received a
copy of the Provisional
Recommendations for the
Appropriate Use of Opioids in
Patients with Chronic Noncancer
Related Pain. Please
feedback comments to Dr Karen
Simpson, Honorary Secretary
and Chair of the
Communications Committee as
soon as possible. The joint
Working Group will be meeting
during the summer to finalise
this document. Council are
pleased to announce that Dr
Simpson will also be convening
a Working Group to develop
guidelines for Neuromodulation
in conjunction with the
Neuromodulation SIG. Draft
proposals should be completed
for the ASM next year. I think
that you will appreciate that
wide consultation and
collaboration amongst various
interested specialities is
essential if Pain Society
recommendations are to have
any credibility.
I thank those of you who
completed the Dr Foster
questionnaire. The full Report is
included with this mailing- so
please do read it. It had been
hoped a Sunday newspaper
would publish it. But, even the
likes of Dr Foster was unable to
excite the interest of the written
media in the current state of
Pain Management Services.
There was some TV and radio
coverage for those of you with
‘early morning wakening’ and
an article in the Independent.
Unfortunately, the media’s
perception of patients with pain
and of NHS services available
for them is that it does not sell
newspapers.
The results mirrored those of
the CSAG Report in that Pain
Management Services continue
to be ‘Cinderella’ services.
Availability is variable, as are
the treatments offered to
patients. Only 58% of services
4
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
PRESIDENT’S MESSAGE

offer Pain Management
Programmes despite the
evidence of efficacy. What
happens to patients in the other
42% of services? Do these
patient get offered PMPs
outside of their locality, is this
funded, is it practical or is it not
a treatment option? I think that
Dr. Foster behoves us all to look
critically at how we organise
our services. Given the recent
emphasis on meeting
Government waiting-list targets,
it is not surprising that the
waiting time for most services
was within 21 weeks. Some
services still have extremely
long waiting times (up to 110
weeks) and four services are not
currently accepting GP referrals.
Importantly, we must ask
whether pain services are
suffering as resources are
diverted to those specialities
made national priorities as
defined by a National Service
Framework or to fund additional
anaesthetic sessions to reduce
waiting times for surgery.
Moreover, we must not confuse
quantity with quality. The
average length of a new patient
consultation was 34 minutesalthough
some of us at times
have to see a new patient in 10
minutes, perhaps due to
waiting-list pressures. All of us
have a responsibility to
highlight the deficiencies in
service provision both locally
and where possible nationally.
More positively, on June11th,
the Associate Parliamentary
Health Group held a seminar on
‘ Chronic Pain- A Silent
Epidemic?’ The Pain Society and
the Royal College of General
Practitioners Pain Management
Committee were key players in
this meeting for MPs. Jointly, we
launched ‘5 pledges to help
people living with persistent
pain.’ These five pledges have
been endorsed with an Action
Plan that Parliamentarians, NHS
services commissioners,
healthcare professionals,
patients and educators can
follow. The possibility of a
National Service Framework for
Pain in Wales was raised. Will
our Welsh compatriots steal a
march over the rest of us
again? It is vital that the
initiative gathered at this
meeting is further progressed.
The Chairman, Barry Sheerman
MP, has given an assurance to
raise the profile of chronic pain
with David Hinchcliffe,
Chairman of the Parliamentary
Health Select Committee. We
are meeting again in six months
to ascertain what progress has
been made.
The Patient Liaison Committee
will be holding “An interactive
workshop- Barriers to effective
care” for people living with
chronic pain on 13th October
2003 at the Royal College of
Nursing to mark European
Week against Pain. This will
build on the great success of
last year’s inaugural event.
Again, it will give an
opportunity for health
professionals, patients and
carers to discuss experiences
and challenges within pain
management. This committee
works exceptionally hard for the
Pain Society. It is an example of
how professional and lay
members can work together to
improve patient care in the
broadest sense. I must thank
Jean Gaffin, Chair of this
committee for her expertise and
insight in this pivotal role.
Congratulations to Dr. Clare
Daniel and Dr. Lesley Colvin
who gained the Pfizer
Neuropathic Pain awards. A
large number of high quality
applications were received
despite very tight timelines. It
does show that members are
keen to do research- but that
money is needed. We look
forward to receiving the results
of this research at next years
ASM. Our thanks go to Pfizer
whose financial support made
these awards possible.
Plans continue to progress with
regard to incorporation of the
Pain Society. At the AGM, a
decision was taken for the
Society to be renamed the
British Pain Society after
incorporation. A meeting of
Officers and SIG chairman is
planned for 11th July to discuss
the changes that incorporation
will necessitate and we do hope
to have a good turnout for this
important meeting.
The Royal College of
Anaesthetists and the Pain
Society will soon be publishing
Pain Management Services:
Good Practice. This document
clearly highlights the
importance of the management
of pain and that the
multidisciplinary approach fits
well with the modern day skill
mix and patient-centred
approach of the NHS. It states
very clearly that working
arrangement for the pain
specialist should resemble that
of a consultant physician in
terms of sessional allocation,
accommodation and
administration services. This
document raises many clinical
governance issues for
anaesthetic members of the
Pain Society. Translating this
document into clinical practice
is the next step.
The British Medical Journal
recently devoted a whole issue
to the vexed question of the
relationships between drug
companies and doctors.
Pharmaceutical companies
impact upon us both
individually and as a whole. The
NHS, as a large organisation, is
almost unique in not financing
education and ongoing
professional development and
expecting its employees to
mostly fund these themselves.
As a multidisciplinary society,
this impacts significantly on
many of our members and does
expose potential vulnerabilities
and leads to inequalities. The
challenge is to facilitate the
best of the relationships with
pharmaceutical companies
without letting the resulting
flows of goodwill, money and
influence distort the caring,
healing and teaching
dimensions of medicine. Council
and society members must be
appropriate and open in
dealings with the
pharmaceutical industry. In
September, Council will be
debating this issue, which will
undoubtedly continue as a topic
of debate in practice.
Dr Peter Nathan, Neurologist at
the National Hospital for
Neurology and Neurosurgery
died peacefully at his home in
London at the age of 88years.
Peter was a founding member
both of IASP and of the Pain
Society. A very moving obituary
has already been written in Pain
to note his very great
achievements, including those in
the field of clinical pain
research. I would concur with
Geoff Schott that ‘it has been a
privilege for so many of us, now
and in the past, to have known
and learnt from this most
distinguished, cultured, and
loveable man.’
John Reid is now the new
Minister for Health. Alan
Milburn is off to spend more
time with his family- so should
you. Have a good summer
break!
PRESIDENT’S MESSAGE THE PAIN SOCIETY NEWSLETTER SUMMER 2003 5

PAIN MEETINGS FOR
HEALTH PROFESSIONALS
CELLULAR AND MOLECULAR MECHANISMS OF PAIN
a satellite symposium to the International Brain
Research Organization (IBRO)
7-9 July Prague, Czech Republic
Email:palecek@biomed.cas.cz / wdwillis@utmb.edu
Web: http://www.biomed.cas.cz/IBRO-PAIN/
BATH PAIN FORUM - CATASTROPHISING ABOUT
CHRONIC PAIN
29 July, Royal National Hospital for Rheumatic Diseases, Bath
Contact: Dr. Chris Eccleston
Director, Pain Management Unit,
University of Bath
Email: pain@bath.ac.uk
PAIN IN EUROPE IV - 4TH CONGRESS OF THE EUROPEAN
FEDERATION OF IASP CHAPTERS (EFIC)
2-6 September, Prague, Czech Republic
Contact: Congress Business Travel
Email: pain2003@cbttravel.cz
Web: www.pain2003.cz
9TH NATIONAL CONFERENCE ON PAIN MANAGEMENT
PROGRAMMES
Organised by the Pain Management Special Interest
Group of the Pain Society
11-12 September, John Innes Centre and University of East Anglia
Contact: Elaine Wellingham
Conference Secretariat, Field End House
Bude Close, Nailsea
Bristol BS48 2FQ
Tel/Fax: 01275 853311
Email: Confsec@blueyonder.co.uk
THE FUTURE OF PAIN THERAPUTICS 2003
15-16 September 2003, London
Email: sara.peerun@visiongain.com
http://www.visiongain.com/futurepaindrugs.html
Glasgow ASM 2003 :
Overview
Breakdown of delegates
There were a total number of
1,066 Delegates registered at
the Meeting; an increase of 264
from the 2002 Meeting in
Bournemouth. 50 were
Anaesthetic Research Delegates.
Of the 1066, 70% were
members of the Society.
The specialty of the delegates
continues to mirror the
membership of the Society, with
anaesthetists making up the
largest group of delegates,
followed by nurses,
psychologists, physiotherapists,
occupational therapists and
general practitioners.
Venue
The Glasgow Scottish Exhibition
+ Conference Centre was an
excellent venue for this year’s
ASM and perfectly suited the
Society’s needs in terms of
quality of plenary hall, number
of break-out rooms and size of
exhibition area. The support
staff was excellent and the
additional facilities at the
Centre i.e. café bar, restaurant
and business desk all added to
the success of the meeting.
Scientific Programme
Overall, the view from the
evaluation forms was that the
scientific programme was varied
and very well balanced, with
excellent quality of speakers.
PROVING OUR WORTH!
Specialist Nurses & Nurse Consultants Conference
25 September
Post Graduate Medical Centre, Worthing Hospital, West Sussex
THE PAIN RELIEF FOUNDATION 4TH ANNUAL LECTURE
2003
Pain & Central Nervous System Reorganisation”
Friday,17th October at 7:00 pm
The Pain Research Institute, Clinical Sciences Centre, University
Hospital Aintree, Liverpool
Professor Troels Jensen
Danish Pain Research Centre, University of Åarhus, Denmark
AN UNRECOGNISED PAIN CHALLENGE
a one-day conference on Joint Hypermobility
Syndrome
21 October 2003, 9.30 - 4.40
Postgraduate Centre, Gassiot House, St Thomas' Hospital
6
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
NEWS FROM PORTLAND PLACE

The plenary lectures received
particularly high praise, both
with regards to the range of
topics and choice of speakers.
Both Prof Herta Flor’s and Prof.
Howard Field’s plenary lectures
received particularly high marks
out of the 9 lectures. Once
again, a number of delegates
asked for there to be ‘questions
and answers’ during the plenary
sessions.
A number of delegates felt
there were too many workshop
choices running at the same
time and it was also felt that
there was too much repetition
in the workshop sessions, which
involved the plenary speakers.
Workshop sessions, which
received a particularly excellent
feedback were How to Get Your
Pain Management Programme
Funded and the Psychology SIG:
Changing Self-identity in
Chronic Pain. Feedback
received from the
Clerical/Managerial Staff was
very positive indeed, and found
the session on Principles of Pain
Management extremely
interesting and useful and
asked for it to be repeated next
year.
The list of workshop topic
suggestions for the 2004 ASM,
has been forwarded to the
Courses & Meetings Committee.
Prize Paper Presentation
and Poster Exhibition
The Prize Paper Presentation
session, once again, proved to
be a great success and
following feedback from the
2002 ASM, was allocated a
main session in the plenary hall.
The winners of the Prize Paper
Presentations were as follows:
1st Prize - Poster No. 94:
“Future Possible Selves”
conditionality and adjustment to
chronic pain.
Prof. Stephen Morley
2nd Prize - Poster No. 100 :
Efficacy of two cannabis based
medicinal extracts for relief of
central neuropathic pain from
brachial plexus avulsion: results
of a randomized controlled trial.
Dr Jonathan Berman
3rd Prize - Poster No. 68: The
WEST Study - a cost
effectiveness study of epidural
steroids in the management of
sciatica: 12 month effectiveness
data.
Dr Cathy Price
160 posters made up this year’s
Exhibition and proved to be a
very valuable and interesting
part of the meeting, but a
number of authors felt that
allotted times should be given
during the course of the
meeting, when they are to
stand by their poster to discuss
their work; this will be reviewed
for the 2004 meeting.
Technical Exhibition
The Technical Exhibition was
perfectly situated giving the
exhibitors maximum exposure -
feedback received from the
exhibitors was very positive
indeed. 60 stands were sold,
with a total of 64 stands in the
Exhibition (Pain Society/IASP
stand, Charity Literature stand,
PACS stand and DIPEX stand
making up the additional 4
stands).
Catering
Although the majority of
delegates felt that the lunchbox
was a very good idea, as it
avoided queuing, the poor
quality of the food was perhaps
the one thing people
complained most about.
Satellite Meetings
There were three satellite
meetings in total this year,
Merck Sharp & Dohme, Pfizer
Ltd and Janssen-Cilag. The
attendance figures and the
results from the evaluation
forms showed that delegates
are very interested in this aspect
of the meeting, which proves to
be more and more successful
each year.
MANAGING CANCER PAIN
A half-day course for members of all Healthcare
Professions with Professor Frank Keefe, in Bristol on
the afternoon of Tuesday 21st October 2003.
Application form from: Anne Hartley, administrator, Pain
Management Centre, Frenchay Hospital, Frenchay Park Road, Bristol
BS16 1LE.
Tel: 0117 975 3890
E-Mail: anne.hartley@north-bristol.swest.nhs.uk
Cheques for the sum of £40 made payable to “The North Bristol
NHS Trust” to be sent with application form by 22nd September
2003.
MANAGING PAIN IN RHEUMATOLOGICAL DISEASE
A half day course for members of all Healthcare
Professions with Professor Frank Keefe in Bristol on
Tuesday 21st October 2003
Please register an early interest in attending with Heather Muncey
on: Tel: 0117 975 3890
Email: Heather.Muncey@north-bristol.swest.nhs.uk
BATH PAIN FORUM - PHANTOM PAIN
4 November, Royal National Hospital for Rheumatic Diseases, Bath
Contact: Dr. Chris Eccleston
Director, Pain Management Unit,University of Bath
Email: pain@bath.ac.uk
2004
PAIN RELIEF FOUNDATION -
20th ANNUAL CLINICAL MANAGEMENT OF CHRONIC
PAIN COURSE
10-14 November
PAIN SOCIETY 37TH ANNUAL SCIENTIFIC MEETING
30 March – 2 April, Manchester, UK
Abstract Deadline: Friday 30 January 2004
7th INTERNATIONAL CONFERENCE ON THE
MECHANISMS AND TREATMENT OF NEUROPATHIC PAIN
13-16 May 2004, Madrid, Spain
Social Programme
This year’s Drinks Reception was
a huge success. The Science
Park was of obvious interest to
the majority of the delegates
and added greatly to the
success of the evening. The
venue for the Annual Dinner
was most impressive, so too
was the food, but the evening
was let down a little by poor
acoustics.
Conclusion
Overall, the Meeting was a
great success in terms of the
well-balanced scientific content,
the high quality of speakers, the
excellent organisation and the
suitability of the venue. In
addition, the Technical
Exhibition, the satellite
meetings and the social
programme made the Meeting
an all round positive,
informative and enjoyable
event.
The Courses & Meetings
Committee would like to thank
the 141 delegates who
completed and returned their
Evaluation Forms and is pleased
to announce that Dr D R
Hughes from Addenbrookes
Hospital in Cambridge has won
£100 worth of Waterstones
book vouchers!
NEWS FROM PORTLAND PLACE THE PAIN SOCIETY NEWSLETTER SUMMER 2003 7

The Society wishes to congratulate both Claire Daniel (£25,000) and Leslie Colvin (£5,000) for their successful Pain Society/Pfizer grant award applications.
We only have space to print the abstracts!
A survey to define the
characteristics of post
thoracotomy pain
DR LESLEY COLVIN
Consultant/ Senior Lecturer
Dept of Anaesthesia, Critical Care & Pain Medicine
Western General Hospital
Persistent pain after surgery is a
significant problem, that is
often not recognised or
managed correctly. It is unclear
whether this pain is
predominantly neuropathic in
nature, although peripheral
nerve injury seems to be an
important factor, with a high
incidence being found after
surgery involving nerve injury
such as amputation (75%),
thoracotomy (67%) and
mastectomy (30%). In order to
institute early and appropriate
management, it is important to
define the problem accurately.
The primary aim of this study
is to define and characterise
post surgical pain in a patient
group with a high incidence of
this problem – patients
undergoing thoracotomy. We
aim to carry out a prospective
survey of consecutive patients
undergoing thoracotomy, in
order to characterise the
prevalence, severity and type of
pain found in this population. In
the clinical setting, in addition
to sensory changes, many other
emotional and cognitive factors
may contribute to the
experience of pain. Thus a
detailed assessment of sensory
changes using Quantitative
Sensory Testing (QST) will be
used in combination with use of
structured validated
questionnaires to examine
psychological factors.
Assessments will commence
immediately pre-operatively to 3
months post-operatively to
determine changes that may
indicate progression from acute
to chronic.
The main objective is to develop
an evidence-based description
of post thoracotomy pain. This
can then serve as a tool to
improve pain management in a
clinical setting as well as
providing valuable information
for future research into
mechanisms of neuropathic pain
in a clinical setting.
‘The Impact of
Neuropathic Pain on
the Psychological and
Physical Quality of
Life’
DR H. CLARE DANIEL
Clinical Psychologist & Research Associate
Department of Anaesthesia & Intensive Care
Imperial College London
Chelsea and Westminster Campus
It is widely acknowledged that
differences exist between the
models of neuropathic and
musculoskeletal pain and also
the quality of pain experienced
(Melzack & Katz, 1999).
However, differences in the
impact of neuropathic and
musculoskeletal pain have not
been specifically addressed.
Although the impact of
musculoskeletal pain on quality
of life is well documented
(Eccleston, 2001; Vlaeyen et al.,
2002), there is a paucity of data
for the same in neuropathic
pain.
The studies that report
psychological distress in the
neuropathic pain population do
so in the context of pain relief
outcomes (Meyer-Rosenberg et
al., 2001) rather than
elucidating the specific impact
of neuropathic pain
(Haythornthwaite & Benrud-
Larson, 2001; Schmader, 2002).
It is suspected that this
situation is a contributing factor
to the minimal focus that that
has been placed on cognitive
behavioural interventions and
neuropathic pain.
Therefore, the small percentage
of people with neuropathic pain
who do receive cognitive
behavioural pain management
generally receive an intervention
that is validated by research on
musculoskeletal pain (Evans &
Fishman, 1997).
Although these interventions
are effective in musculoskeletal
pain (Morley, Eccleston &
Williams, 1999), ‘there are no
noteworthy, evidence based
studies specifically evaluating
these techniques in neuropathic
pain’ (Harden & Cohen, 2003).
This two-cohort postal
questionnaire survey will aim:
1. To identify the impact of
neuropathic pain on
psychological and physical
quality of life and on
everyday functioning
2. To identify key beliefs about
causation and mechanisms
of neuropathic pain held by
people with postherpetic
neuralgia
3. To identify key problems in
the psychological and
physical functioning of
patients with postherpetic
neuralgia
4. To identify similarities and
differences in 1-3 above
between a postherpetic
neuralgia population and
those with musculoskeletal
pain
8
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
NEWS FROM PORTLAND PLACE

Obituary
MARK SWERDLOW
Mark Swerdlow created the
specialty of pain medicine in Great
Britain. Although others may claim
to have started pain clinics before
Mark, it was he who called
together those who had an
interest in the relief of pain, and
he who held the meeting that led
to the formation of the Intractable
Pain Society (IPS) in 1967. The IPS
later merged with the British and
Irish Chapter of the International
Association for the Study of Pain,
to form the large and active body
that it is today. Mark was the first
Chairman of the IPS, but it is
typical of the man that he
arranged for another to hold the
post of President while he got on
with organising the running and
development of the new society.
Mark Swerdlow was born in 1920
and graduated MB ChB from
Manchester and held both M.Sc
and MD degrees from that
university. He served with
distinction in the Royal Army
Medical Corps from 1943 to 1948
and saw service in France,
Belgium, Holland and Germany.
On his return he specialised in
anaesthesia and held the Diploma
in Anaesthesia and was a Fellow
of the Faculty of Anaesthetists of
the Royal College of Surgeons of
England. He spent time as an
Exchange Fellow at the University
of Pittsburgh in 1954 before
being appointed as Consultant
Anaesthetist to the Salford
Hospital Group, University of
Manchester School of Medicine.
In 1955 he founded the pain clinic
which became the North West
Regional Pain Relief Centre
twenty four years later and which
remains to this day one of the
finest pain management centres
in the world. Throughout his
career Mark was incredibly
productive as an administrator,
but it is his role as an educator
that made a permanent and
beneficial impact upon the
management of pain. Mark wrote
or co-wrote seven textbooks and
numerous book chapters and
articles about the clinical
treatment of pain. Over a thirty
year period his academic
production was consistent, prolific
and wide-ranging.
He was in great demand as a
lecturer and had a fund of
practical knowledge that was
simply unsurpassable. He had an
ability to recognise when
techniques of pain relief were
becoming outmoded and he never
dwelt in the past, but encouraged
all he came into contact with to
change and improve their practice
where possible. His worldwide
contributions were recognised by
over a dozen visiting
professorships, membership of
editorial boards and honorary
memberships of national and
international societies. He was
Adviser to the World Health
Organization Cancer Pain Relief
Programme from 1981 to 1987.
The formal recognition and
honours tell nothing of the
gentleman who was Mark
Swerdlow; a man who had perfect
manners and who always listened
to and considered the views of
others. Mark was generous with
his wisdom and practical
knowledge and rarely critical
without good reason. Retirement
permitted him to enjoy his wide
range of interests and his music
and painting were a source of
pleasure. He read a paper at the
Welcome Institute only two
months before his sudden death
from complications of a brain
tumour. He was 84 years of age.
He is survived by his wife
Elizabeth and three children: a
son, currently Professor of
Epidemiology at the Royal
Marsden Hospital, and two
daughters. Our sympathy is
extended to them all.
Mark Swerdlow, pioneer pain
clinician, died 26 February, 2003.
J. E. CHARLTON.T.P.NASH
June 2003
10
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
NEWS FROM PORTLAND PLACE

New Membership Applicants
Mrs J Barrett
Mr Stephen Bliss
Miss Jane Bott
Dr Eric Brodie
Mrs Pauline Chinn
Miss Ursula Collignon
Mrs Jill Compton
Dr Jon Cort
Dr Christina Cox
Dr Natasha Curran
Dr Mark Dale
Dr H Clare Daniel
Dr Chris Davies
Dr Paul Dawson
Dr Lorraine de Gray
Dr Johannes Van der
Merwe
Mr Graeme Dickson
Mr B Drysdale
Miss Ruth Edgecumbe
Miss Louise Evans
Dr Ronald Feathers
Dr Jo Fitz-Henry
Mrs Marion Francis
Dr Aidan Gill
Mrs Sara Goulder
Miss Gillian Gourlay
Dr Gary Gutteridge
Dr Sarah Halliday
Mr Alan Hassard
Mrs Jacqui Hawkins
Dr Melanie Hearn
Mrs Suzanne Henderson
Miss Stella Howden
Dr Martin Johnson
Mrs Hilary Jones
Ms Judith Kappesser
Mrs Jane Knight
Ms Kate Mackie
Dr Ivan Marples
Mrs Lesley Marshall
Dr Dennis Marshall-
Hasdell
Miss Sophia
Mavrommatis
Nurse Specialist
Senior Physiotherapist
Physiotherapist
Reader in Psychology
Acute Pain Nurse
Acute Pain Pharmacist
Pain Clinic Sister
Consultant Anaesthetist
Consultant Anaesthetist
SpR Anaesthesia
SpR Anaesthesia
Clinical Psychologist
Clinical Psychologist
Consultant Anaesthetist
SpR Anaesthesia
Consultant Clinical
Psychologist
Charge Nurse
Clinical Psychologist
Acute Pain Management
Sister
Assistant Scientist
Clinical Assistant
Consultant Anaesthetist
Staff Nurse
Medical Director
Staff Nurse
Assistant Scientist
Consultant Anaesthetist
Clinical Psychologist
Clinical Psychologist
Clinical Specialist
Physiotherapist
Consultant Anaesthetist
Acute Pain Sister
Post Graduate Researcher
General Practitioner
Staff Nurse
PhD Student
Occupational Therapist
Pain Directorate Pharmacist
Consultant in Pain
Medicine
Senior Physiotherapist
Manager
Senior Physiotherapist
Dorset County Hopsital
Kings Mill Hospital
Royal National Hospital
Glasgow Caledonian
University
Peterborough Hospitals
NHS Trust
Guys & St Thomas’s NHS
trust
Addenbrookes Hospital
Chesterfield Royal Hopsital
Salisbury District Hospital
North Middlesex Hospital
Leicester University
Hospital
Chelsea & Westminster
Hospital
Wansbeck General Hospital
Southampton General
Hopsital
Addenbrookes Hospital
St Thomas’s Hospital
St James University
Hospital
Psychology Dept North
Place
Birmingham Heartlands
NHS Trust
Organon Laboratories
Kent & Canterbury
Hospital
Nottingham City Hospital
BUPA Hospital, Leeds
Scirex Ltd
Addenbrookes Hospital
Organon Laboratories
Bristol Royal Infirmary
University Hospital
Birmingham
Derriford Hospital
Worthing Hospital
Torbay Hospital
University Hospital of
Hartlepool
Queen Margaret University
College
Ashville Medical Centre
St Marys Hospital
St Thomas’s Hospital
Royal Bolton Hospital
Middlesex Hospital
Western General Hospital
Astley Ainslie Hospital
Vocational Pain Service
Royal National
Orthopaedic Hospital
Ms Jean McCallum
Mrs Lorraine McMain
Miss Katie Mullins
Dr Susan Nimmo
Mrs Suzanne Nimmo
Dr Jonathan Norman
Mrs Moira O’Gorman
Mrs Lynne Owen
Ms E Phipps
Ms Cliona Purecell
Mrs Elizabeth Quinn
Dr Joanne Regan
Mrs Mary Ricketts
Dr Mark Rockett
Mrs Claire Ross
Dr Satinder Sanghera
Dr Ram Seereekissoon
Mrs Brenda Slater
Dr James Smart
Mrs Karen Smith
Dr Shona Smith
Dr Ian Stevens
Dr Ajit Sukumaran
Dr Jonathan Tring
Mrs Jacqueline Vasey
Mrs Eva von Mantripp
Dr Heather Wells
Ms Felicity White
Mrs Marcella Williams
Pain Management Sister
Nurse Specialist
Pain Management Sister
Consultant Anaesthetist
Senior Clinical Nurse
SpR Anaesthesia
Acute Pain Sister
Psychotherapist
Sister – Pain Management
Clinical Specialist
Physiotherapist
Clinical Nurse Specialist
Clinical Psychologist
Clinical Nurse Specialist
Clinical Research Fellow
Staff Nurse
Part Time OP Principal
Acute Pain Nurse
Chronic Pain Sister
Clinical Research Fellow
RGN Bank Nurse
SpR Anaesthetics
Consultant Anaesthetist
SpR Anaesthesia
Consultant Anaesthetist
Staff Nurse
CNS Acute Pain
Clinical Psychologist
Clinical Nurse Specialist
Senior Nurse
Gartnavel General Hopsital
Charing Cross Hospital
Leeds General Infirmary
Western General Hospital
Stirling Royal Infirmary
Royal Preston Hospital
Glenfield General Hospital
Montagu Hospital
Princess Royal Hospital
Springburn Health Centre
Kent & Canterbury Hospital
Royal Preston Hospital
Bath Pain Management
Unit
Royal Infirmary of
Edinburgh
Addenbrookes Hospital
Stanhope Health Centre
West Middlesex University
Hospital
University Hospital of
Hartlepool
Middlesex Hospital
Nuffield Hospital
Edinburgh Royal Infirmary
Ipswich Hospital
Blackpool Victoria Hospital
Leicester Royal Infirmary
Pinderfields General
Hospital
Singleton Hospital
The Hillingdon Hopsital
Hammersmith Hospital
The Horder
NEWS FROM PORTLAND PLACE THE PAIN SOCIETY NEWSLETTER SUMMER 2003 11

Letters to
the Editor
drspward@yahoo.co.uk
This is the question I put to
Professor Dawkins
Given that chronic pain is generally
pain persisting despite tissue healing
and no on-going stimulation,and
therefore offers very little advantage
in terms of survival, what would be
the explanation for the continuation
of such a phenomenon in humans ?
Dear Dr Ward
I think it is an interesting
question you raise. I don't have
an authoritative answer. The
nearest I can approach one is as
follows, and I admit that it
sounds a bit lame.
1. As you say, we can
understand the evolution of
pain when it is a guide to
survival (putting your hand in
the fire is bad for survival, and
the pain of doing it once, warns
directly against doing it again).
2. Given 1, we have to ask why
natural selection should 'bother'
to make a distinction between
pain that we can do something
about (like refrain from picking
up hot coals in the future) and
pain that we can do nothing
about (the chronic pain you are
dealing with).
As far as natural selection is
concerned, the rule of thumb is:
"Build a nervous system which
feels pain whenever the tissues
are damaged." Now, if natural
selection were of a benevolent
disposition, it might amend the
rule to: "Build a nervous system
which feels pain whenever the
tissues are damaged, EXCEPT
when there is nothing the
unfortunate subject can do
about it." But natural selection
is, of course, not benevolent. It
is indifferent to everything
except reproductive success. The
trick to understanding this, in
my view, is to switch the
question from "Why should
natural selection make cancer
painful?" to "Why should
natural selection make an
exception of cancer, given that
the general rule -- tissue
damage = pain -- works very
well?"
Having said all that, I can think
of reasons, other than
benevolence, why natural
selection might have reduced
the painfulness of things like
cancer.
We can imagine circumstances
in which reducing chronic pain
might increase reproductive
success. A person who is still
young enough to reproduce but
is suffering from cancer, might
be distracted from doing so by
the pain.
Natural selection might
therefore modify the nervous
system to reduce the pain,
because this would increase the
chance of a child being born
who bears the genetic tendency
to feel less of this kind of pain.
Well, I did say my attempts to
answer your question might
sound a bit lame!
All best wishes
Richard Dawkins
Dear Editor
I am rather surprised by the
total lack of response from the
Pain Society with regards to the
attempt by BUPA Insurance to
influence the practice of pain
management by means of
financial pressure. The
document they have recently
issued with regards to
management of back pain is
described by them as being
‘evidence based’ and if so
would be highly laudable.
However, of their three main
advisors, one is Professor
Gordon Wadell, Professor of
Orthopaedic Surgery, whose
antipathy towards any form of
intervention with regards to
back pain is well known and
another is Professor Chris Main,
Professor of Clinical Psychology
who is one of the main
proponents in this country of
behavioural pain management
programmes. If there were
contributions from actively
practising spinal orthopaedic
surgeons and the Pain
Intervention Group of our own
Society then I would have felt
that their document was more
balanced.
I am now retiring from pain
practice and therefore have no
personal axe to grind but feel
that this document is financially
rather than scientifically based
and their main ‘experts’ have
produced the sort of result that
is in the financial interests of
the insurance societies. The
effects of their new policy are
already being felt. I have
patients whom I am able to
keep mobile and at work with
the occasional epidural, facet
block or nerve root injection
and who have already been told
that cover will not be given for
any further injections. Another
patient was referred to me by
an orthopaedic spinal surgeon
with extremely severe pain
which seeded to be discogenic
in origin and in whom I was
asked to give temporary respite
with an indwelling epidural
catheter for several days whilst
a decision was made with
regards to surgery. Cover was
refused for this procedure on
the grounds that ‘there was no
evidence to show that it was an
effective procedure’ as I was
told by a non-medical member
of the back pain team at BUPA.
This same patient, after two
spinal surgeons had agreed that
spinal fusion was indicated ,
was then contacted by a
nursing member of the back
pain team and asked whether
she would consider a spinal
rehabilitation programme rather
than surgery. She declined this
and subsequently underwent a
totally successful spinal fusion.
I am all in favour of the
rationalisation of medical
treatment but this must be
through a proper peer review
process and not by an insurance
company with a vested interest
producing a document with
their main experts being people
with their own particular vested
interest.
Yours sincerely
Dr S M Berger MBBS FFARACS
FANZA FRCA
Manchester
Dear Editor
The London RCN and Pain
Network Forum is comprised of
Pain Management Clinical
Nurse Specialists, Pain Research
Nurses and Senior Nurses
practicing in Pain Management
within the London area. We
would like to register our views
regarding the Pain Society's
recent publication,
"Recommendations for Nursing
Practice in Pain Management"
As a Forum we read with
interest the recommendations.
This document is very
comprehensive and the authors
should be commended for this
publication which will
undoubtedly contribute to the
debate on higher level practice.
We would however like to share
some concerns.
From reading the document we
feel that the working party has
extended some of the standards
originally intended by the NMC.
Our main concern is that if
12
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003

employers interpret this
document literally and assess
nurses against the standards
laid out in the document this
could make it very difficult for
nurses working in pain
management to attain specialist
posts or higher level practice
posts.
This is highlighted by the two
following examples.
With respect to Standard 4:
Leading and Developing
practice 4:2, the working party
interprets this standard as;
"educates own and other
professionals on a local,
national and/or possible
international basis.... arranges
local, national and possibly
international study days and
short courses". We would
question how realistic it is for a
Clinical Nurse Specialist to set
up and run international study
days and advise professionals
on an international basis? We
note from the results of the
survey that 42% of acute pain
teams and 31% of chronic pain
teams have only one nurse. For
nurses working alone it would
be impossible to expect them to
organise international study
days and short courses. Whilst
we would endorse the fact that
CNS' should be involved in
work at a local and even a
national level, the inclusion of
"International" implies nurses
should also be meeting this
objective in order to fulfil the
Results of Glasgow ASM :
sessions evaluation
Average Mark
Content Present’n Overall
Repeat?
PLENARY SESSION I: 5 4 4 128/141 (90%)
Prof Herta Flor
Pain, Learning & Plasticity: Results from Imaging
PLENARY SESSION II: 4 4 4 121/141 (85%)
Dr Lars Arendt-Nielsen
Models of Muscle Pain: Experimental & Clinical…
PLENARY SESSION III: 3 4 4 125/141 (88%)
Dr Maureen Simmonds
Assessment of Function
PLENARY SESSION IV: 4 4 4 110/141 (78%)
Kate Seers
Implementing Evidence: Possibilities & Pitfalls….
PLENARY SESSION V: 4 4 4 109/141 (77%)
Dr Kenneth Craig
The Faces of Pain: An Interpersonal Core
PLENARY SESSION VI: 4 4 4 122/141 (86%)
Dr Bill Macrae
Postoperative Pain. Why Can It Become Chronic?
PLENARY SESSION VII: 4 3 4 118/141 (60%)
Prof. Mansel Aylward
Social Policy and the Welfare System: The Challenge.
PLENARY SESSION VIII: 3 3 3 85/141 (60%)
Prof. Peter Reeh
Inflammatory Pain Mechanisms
PLENARY SESSION IX: 5 4 4 86/141 (60%)
Prof. Howard L Fields
Setting the Stage for Pain
requirement for higher level
registration. Would such
international ventures be
expected of our medical
colleagues who are practicing at
Consultant level?
Similarly with respect to
Standard 3: Evaluation and
Research 3:2, which states that,
"higher level practitioners
should critically appraise and
synthesise the outcomes of
relevant research, evaluations
and audits and apply them to
improve practice". The working
party state that at a higher level
of practice nurses working in
pain management should
be"....able to undertake metaanalysis
and systematic reviews
if warranted".
Those of us who have been
involved in undertaking
research whilst trying to fulfill a
CNS role are only too aware of
the difficulties involved in this.
To carry out meta-analyses or a
systematic review would require
considerable academic expertise
and can often only be achieved
if working as a full time
researcher.
We would very much appreciate
any feedback from the working
party, nursing and medical
colleagues to find out whether
the concerns we have noted
here are shared by others.
Members of the London RCN
and Pain Network Forum
14/11/02
Content Present’n Overall Repeat?
Session A – Wednesday 2 April, 14:00-15.30
1. Muscle Physiology in Pain & Rehabilitation 4 4 4 10/16 (62%)
2. Acute Pain Services – Can We Deliver? 4 4 4 17/24 (70%)
3. Pain, War and Victims of Torture 4 4 4 12/15 (80%)
4. Patient Involvement: from Leaflets to… 4 4 4 12/15 (80%)
5. Chronic Abdominal Pain: Causes & Cures 4 4 4 19/25 (76%)
6. Medico-legal Workshop 3 3 3 3/4 (75%)
7. Psychology SIG: Changing Self-identity in… 5 5 5 10/13 (76%)
8. Pain Intervention Interest SIG: Back Pain… 3 3 3 7/17 (41%)
8a. Pain in Children SIG Workshop… 2 2 2 0/2 (0%)
Session B – Wednesday 2 April, 16.10 – 17.40
9. Neurophysiology of Phantom Limb Pain 4 5 4 16/22 (72.%)
10. Patient-centred Assessment in Chronic Pain 4 4 4 10/12 (83%)
11. Mechanisms of Pain 3 3 3 6/11 (54%)
12. Dealing with Anger in Patients and Self… 4 5 4 6/7 (85%)
13. Debate: This House Believes that Acute Pain.. 4 4 4 12/18 (66%)
14. Pain and Palliative Care 4 4 4 14/20 (70%)
15. Pain Management Programme SIG: Has the.. 4 4 4 14/24 (58%)
16. Neuromodulation SIG: Evidence Base and… 4 4 4 2/6 (33%)
Session C – Thursday 3 April 14.00 – 15.30
17. The Expert Patients Programme
18. Placebo in Pain 4 4 4 9/15 (60%)
19. Pain in Burns 4 4 4 14/21 (66%)
20. Governance in Pain Management 4 4 4 6/8 (75%)
21. Pain in Children SIG Workshop: moved to 8a 4 3 3 9/16 (56%)
22. Opioids for Non-cancer Pain: The New… 4 4 4 39/52 (75%)
23. Clinical Information SIG: The Problems and… 3 3 3 8/13 (61%)
24. DIPEx Chronic Pain – A Web-based Database. 5 5 5 2/3 (66%)
25. Principles of Pain Management 5 5 5 3/3 (100%)
Session D – Thursday 3 April 16.10 – 17.40
26. A Revolution in Back Pain 4 4 4 22/33 (66%)
27. Communicating Pain 3 3 3 7/11 63%)
28. Integrating the Medical and Psychological… 4 4 4 10/12 (83%)
29. How to Get Your Pain Management… 5 5 5 4/6 (66%)
30. Debate: This House Believes that there is no.. 4 4 4 9/14 (64%)
31. The Problem with Chronic Pain in Scotland… 4 4 4 3/3 (100%)
32. Nursing Competencies in Pain Management.. 4 4 4 18/26 (69%)
33. Angina SIG: Modern Management of… 4 4 4 6/7 (85%)
THE PAIN SOCIETY NEWSLETTER SUMMER 2003 13

Psychological Assessment
and Interventions
SARAH BARKER &
AMANDA C DE C WILLIAMS
Having a converted cupboard
for an office makes
psychological consultation at
our hospital a cosy affair.
Despite this, a patient’s first
appointment with the clinical
psychologist can seem scary,
associated with psychiatric
labels and ‘all in the mind’
statements, which mark the end
of the pain being taken
seriously by doctors.
Psychological assessment is a
real deterrent for some who
don’t attend the initial meeting.
But there is no avoiding this
meeting for the patient wanting
a spinal cord stimulator or a
peripheral nerve stimulator:
psychological assessment is
mandatory. Many patients
spend the first minutes
emphasising their sanity, the
reality of their pain, and their
entitlement to neuromodulation
to make life worth living again.
The aversive and chronic nature
of patients’ pain makes the
hope of a cure alluring. So what
does the assessment consist of,
and is it really essential?
Although it is widely
acknowledged in the pain field
that pain is a psychological
experience as well as a physical
one, the relationship between
pain and psychological factors
remains the subject of
differences and debate. It would
be encouraging to think that
dualistic models are losing their
hold, and that the attribution of
pain in some patients to
psychogenic factors is
understood as a hypothesis not
a finding, but this way of
thinking still leads to
stigmatisation and
discrimination in many areas of
health care. Although
professionals working in the
field of pain hopefully now have
a broader perspective,
misunderstandings can still
occur about the role of
psychology and how it can best
be integrated with medical
treatments.
First: what requests can’t
psychological assessment
satisfy? It can’t establish the
relative contributions of organic
and psychological factors (nor
can any other method, as the
underlying model is erroneous),
nor can it establish ‘cause and
effect’ relationships between
psychological problems and
pain (Doleys, 2000). The other
purposes for which assessment
is requested is to exclude
patients with gross mental
health problems, which is
reasonable although we do not
know that they would not
benefit from neuromodulatory
methods; and to improve
outcomes in by identifying
predictors of poor outcome (e.g.
North et al, 1996, Nelson et al,
1996). Suggested candidates for
this include ‘somatisation
disorder’, ‘major uncontrolled
depression/anxiety’, ‘severe
sleep disturbances’, ‘serious
drug or alcohol problems’ and
‘lack of social support’; other
factors which the psychologist is
advised to consider include
‘history of abuse or other
dysfunction’, ‘unusual pain
ratings’, ‘certain personality
disorders’, ‘unresolved
compensation’ and ‘lack of
support from spouse’ (Olsen,
1996). As you can see from this
list, virtually every patient will
present one or more of these
‘warning’ factors.
While the search for predictors
of outcome seems at first a
reasonable scientific pursuit, it
does not stand up to scrutiny.
The only way to discover such
predictors would be to assess
all patients, to treat them all
blind to the assessment process,
and then to compare the
outcome with those
assessments. Instead, lists of
problems such as those above
are used to be very selective
about candidates for
neuromodulation, so that if any
predictors are found
retrospectively, they can only
apply within the limits of those
selection procedures, which of
course vary from clinic to clinic.
These exclusion criteria easily
become proxies for refusing
patients who are already
underserved and disadvantaged.
A close look at the literature on
psychological screening for
neuromodulation shows
generally poor methodologies
and a strong influence from
insurance based health funding
which characteristically focuses
on shortcomings in the
patient/claimant.
Given the unpredictable success
of neuromodulation and the
distress caused by pain and
unsuccessful treatment, what
should psychological screening
aim to achieve? There is
certainly benefit in eliciting
patients’ understanding (or
misunderstanding) both of their
pain problem and of
neuromodulation procedures
14
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
FEATURES

and effects, and various
members of the team contribute
to rectifying such
misunderstandings. But
arguably we could be following
through the multidimensional
model of pain with strategies in
various dimensions, not only
neuromodulation. The
psychological interview can be a
chance to introduce the patient
to pain management principles
and practices which are
compatible with invasive
treatments. At present,
organisation of services and
referral patterns often
instantiates the separation
between physical and
psychological which many pain
clinicians try so hard to
integrate.
In areas such as psychiatric
rehabilitation and cystic fibrosis,
a multicomponent care plan is
used to plan treatment over a
particular time span. The
patient and those close to him
or her take a major part in
discussion and decisions while
the various health professionals
involved meet briefly with them
to consider their various health
needs, from physical treatments
to social support. This produces
a treatment plan with actions
assigned to particular
professionals, and a copy held
by the patient. It then forms the
basis of reviews and outcome
assessment. Applied to
persistent pain, this would
enable physiotherapy,
occupational therapy and
psychology to be strategically
planned alongside
pharmacological and invasive
treatments. For a psychologist it
would offer the chance to work
on a patient’s depression, fears
about procedures, and problem
solving in the context of other
treatments, and for the patient
is of far more value than a stack
of questionnaires and possible
refusal of neuromodulation on
obscure psychological grounds.
References
Banks, SM and Kerns, RD (1996).
Explaining high rates of depression in
chronic pain: a diathesis-stress framework.
Psychol. Bull. 199, 95-110.
Doleys, D.M. (2000). Psychological
assessment for implantable therapies.
Pain Digest, 10, 16-23.
Melzak, R. and Wall, P. (1988). The
Challenge of Pain. London: Penguin.
Nelson, DV et al (1996).
Psychological selection criteria for
implantable spinal cord stimulations.
Pain Forum 5(2), 93-103.
North, RB; et al (1996). Prognostic
value of psychological testing in
patients undergoing spinal cord stimulation:
a prospective study.
Neurosurg 39 (2), 309-11
Olsen (1996). The value of multiple
sources of data in decision making.
Pain Forum 5(2), 104-6.
A Distress Motivation Axis
A simple axis diagram was developed for the new patient
assessment form in the pain clinic. The clinician ticks the quadrant
they perceive best matches the patients mental state. Its aim is to
serve as a reminder for the clinician at a subsequent consultation as
to whether they elicited, or the patient expressed, distress relating to
their pain and personal situation and how ready the patient
appeared to be to adopt selfmanagement principles. It appears to be
useful but is limited by the fact that the patients may have changed
their attitudes and beliefs after the first consultation. It is also only a
record of a clinical impression and is not patient centred. The
concepts behind the axis are not original; both 'psychological
distress' (1) and 'readiness to change'(2) can be elicited by using
patient self rating instruments in addition to patient interview.
(1) Main C J, Wood P L R, Hollis S, Spanswick C C, Waddell G. The
distress and risk assessment method. A simple classification to
identify distress and evaluate the risk of poor outcome. Spine, 1992;
17(l):4252
(2) Kems R D, Roseriher. R et al. Readiness to adopt a
selfmanagement approach to chronic pain : the Pain Stages of
Change Questionnaire. Pain, 1997 ; 72: 234 237
Douglas Natusch - Consultant Anaesthetist
Pain Management Offices, Torbay Hospital, Lawes Bridge, Torquay.
TQ27AA
FEATURES THE PAIN SOCIETY NEWSLETTER SUMMER 2003 15

SIGS
Special Interest Groups
Any group of 30 or more full members of the Pain
Society may form a Special Interest Group of the Society.
Such a group must apply in writing to the Council for
recognition.
Such an application must provide:
1. The name of the special interest group (SIG).
2. A description of the proposed activities and scientific
focus.
3. The names, signatures and Pain Society membership
numbers of the founding members.
To be approved by the Society it is expected
that:
1. All members will be members of the Pain Society.
2. The group will be multidisciplinary.
3. The interest will be within one subject area.
4. The membership will be open to all members of the
Pain Society.
The SIG will be expected to:
1. Submit an annual report to the Society describing
meetings held, financial affairs, list of members and
other matters as deemed appropriate.
2. May submit proposals to Council for subjects and
speakers for Society meetings.
3. May adopt bylaws and operating procedures for
regulation of their affairs providing they do not conflict
with the ordinances and constitution of the Pain
Society.
4. May elect their own officers using the principle of one
vote per member and may charge dues to their
members.
5. May hold scientific or professional meetings provided
that these are organised and financed by the SIG. Such
meetings must be open to all members of the Pain
Society on a space available basis and must not
conflict with the three day Annual Meeting of the
Society. However, it will be permissible to hold such a
meeting immediately preceding or post the annual
meeting.
6. Details of the SIGs and their officers will be listed in
the biannual handbook of the Society.
7. SIGs will be permitted to use the Society mailing lists
and facilities to publicise forthcoming meetings or
events.
SIGs meet annually with the Officers of the Pain Society.
Special Interest Group:
Pain in Children
The Special Interest Group: Pain
in Children would like to extend
sincere thanks to Dr. Martin
Ward Platt and Ms. Zoe Sully, as
outgoing Chair and Secretary of
the group for all their time and
enthusiasm expended over the
last few years in leading the
group.
It is now accepted that pain
should be anticipated, and
safely and effectively controlled,
in all children, whatever their
age, maturity or severity of
illness (Fisher & Morton 1998).
The Audit Commission (1993)
identifies pain prevention as
one of ten indicators of quality
of care in its report on children’s
care in hospital.
The SIG has the following aims:
• To improve the
identification, prevention
and management of pain in
children.
• To promote multidisciplinary
collaboration in paediatric
pain management.
• To encourage education and
research in paediatric pain.
• To provide a focus within
the Pain Society for matters
relating to pain in children.
The management of acute,
chronic and palliative paediatric
pain remains complex. Within
the diverse paediatric
population the goal to deliver
optimal pain management can
often encompass all three
components, whether in the
postoperative period, the
chronic trajectory or at the end
stages of a child’s life.
Acute pain management for the
majority of children is now
widely recognised and delivered
effectively and safely.
Early identification and
management of chronic
paediatric pain has been less
successful and there are only a
16
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
SIGS

handful of centres resourced to
manage it. There is a distinct
lack of guidelines. There can be
difficulty in recognising nonopioid
responsive pain and
adolescent society appears to
particularly suffer from problems
in accessing appropriate and
individually titrated treatments.
The importance of palliative
pain management in children
also requires emphasis,
paediatric pain specialists can
often be based in acute Trusts
and children at end stage of life
may frequently be cared for in
the community. All community
staff should have the
opportunity to easily access
support, advice and education
regarding the most effective
methods of analgesia for these
patients at what can potentially
be an extremely distressing time
for family and staff.
The SIG would like to invite Pain
Society members to consider
methods of raising the profile of
all components of paediatric
pain management. Perhaps your
centre would like to propose a
member as a named contact for
children’s pain management?
Requests have also been sent to
all SIG members for suggestions
to the group on taking this area
forward. Current suggestions
that have been submitted are:
the development of a national
guideline on paediatric pain
management using SIGN or the
Cochrane Methodology; the
development and collation of
educational material for the
child and family regarding all
aspects of pain assessment and
management and the proposal
of a model of service and
standards of care for children
with complex persistent pain –
with an observation by the
group member that the Clinical
Standards Advisory Group
Report on Pain Services (1998)
only briefly mentioned children
with chronic pain.
Any suggestions would be
warmly welcomed. Thank you in
anticipation.
Mrs.Susan Aitkenhead
Chair, SIG: Pain in Children.
References:
Audit Commission (1993)
Children First: A Study of
Hospital Services. London:
HMSO.
Clinical Standards Advisory Group
(1998) Services for Patients with
Pain. London: Stationary Office
Books.
Fisher S & Morton NS (1998) Pain
Prevention and Management in
Children. In: Morton NS (Ed)
Acute Paediatric Pain
Management: A Practical Guide.
WB Saunders.
Contact:
Mrs. Susan Aitkenhead
Consultant Nurse in Paediatric
Pain Management
The Pain Management Service
The Royal Hospital for Sick
Children
Glasgow G3 8SJ
Tel: 0141 201 0186
E-mail:
susan.aitkenhead@yorkhill.scot.nh
s.uk
SIGs and their Chairmen :
Acute Pain Special Interest Group
(APSIG)
Dr D Counsell
Tel: 01978 291 100
Angina Special Interest Group
Dr M Chester
Tel: 0151 228 1616
SIGS
Special Interest Groups
Clinical Information Special Interest
Group (CISIG)
Dr C Price
Tel: 02380 796135
Pain Intervention Interest Group (PIIG)
Dr A Lawson
Tel: 020 8746 8026
Pain Management Programmes Group
Dr G Cavill
Tel: 01670 529 540
Psychology and Pain Special Interest
Group
Dr C Eccleston
Tel: 01225 826439
Pain in Children Special Interest Group
Mrs S Aitkenhead
Tel: 0141 201 0186
Neuromodulation Special Interest Group
Dr D Dickson
Tel: 0113 392 4682
Neuropathic Special Interest Group
Dr D Bowsher
Tel: 0151 523 1486
The University of Sydney Pain Management Research Institute offers a Graduate Certificate,Graduate Diploma and Masters in Science or Medicine (Pain Management) for students seeking to further their knowledge and
skills in pain medicine.Students may also elect to study single non-award subjects.The Program is multidisciplinary and available to medical,dental and allied health professionals with an interest in pain management.The
curriculum includes modules on pain concepts,pain neurobiology,pharmacology and clinical aspects such as pain in children,pain in older people,musculoskeletal pain,cancer pain and psychological approaches to pain
management.The Program has now been running for 7 years and over 150 students have enrolled,including 28 international students from 14 different countries.The Program has two student intakes,one commencing in
March and one in July.All components of the Program including study guides,materials and discussion groups are accessed on-line and are therefore available worldwide.The Program has a two week face to face component
but this is optional and the requirements for the degrees can all be completed by distance.
For further details of the Program including curriculum,admission requirements,course fees and scholarships,please visit the Program website at:www.painmgmt.usyd.edu.au/html/domdip6.html.
Information can also be obtained from the administrative assistant Ros Wyllie,Tel:+61 2 9926 7386;Fax:+ 61 2 9926 6780,or email:rwyllie@med.usyd.edu.au.
SIGS THE PAIN SOCIETY NEWSLETTER SUMMER 2003 17

Angina
Pectoris :
A Historical
Perspective
AUSTIN LEACH
Since the beginning of recorded
history mankind has
differentiated between visceral
and superficial (somatic) pain.
From examination of
archaeological relics and
modern day primitive cultures, it
seems clear that pain was
regarded as being due to
external forces. For superficial
pain, these external forces were
usually obvious, such as an
accidental injury, but deep or
internal, pains, which had no
readily identifiable source, were
attributed to metaphysical
causes such as evil spirits or
curses.
The traditional medicine
practiced by the Chinese for
4500 years describes how the
balance of vital energy or ch'i is
maintained by its flow through
a network of conduits or
meridians which are connected
to visceral structures or organ
function. If there develops an
imbalance between the two
opposing forces of Yin and
Yang, disease and pain result.
This is due to an obstruction
(deficiency) or outpouring
(excess) in the circulation of
ch'i. Thus the Chinese were able
to link pathology in visceral
structures with pathology in
somatic structures, and also link
abnormal sensation in one site
with abnormal sensation in
another.
Western thinking is linked
strongly to the ancient Greek
philosophies. Plato felt that
sensation in humans was
processed by the heart and the
liver, which communicated with
the rest of the body by the
movement of atoms through
communicating veins. (Not that
different, if slightly less
sophisticated, from the Chinese
notions). In De Anima Aristotle
wrote that the centre of
perception was in the heart.
Pain was felt in the heart as a
"quale", a passion of the soul,
and a sensation or experience
opposite to pleasure, the
epitome of unpleasantness. This,
in essence, is how we describe
the affective quality of pain
today. Aristotle also described
pain as being an excess in any
of the five sensations. All five
senses, vision, taste, smell,
hearing and touch arose in the
end organs of the flesh and
were conveyed by blood to the
heart. Pain was thus regarded
as an intensityrelated
phenomenon.
Nearly 2000 years passed
before this concept was
seriously challenged. In 1628
William Harvey examined the
exposed heart of the young
Viscount Montgomery, who had
earlier suffered a chest injury
following a riding accident and
had a well healed defect
opening into his pericardium.
Harvey touched, pinched and
pricked the surface of the heart,
after which he concluded that
the heart was insensate. In
1664 Descartes published his
book L'homme, in which he
suggested that sensation was
transmitted centrally along
nerves, which caused an
opening of pores in the brain
resulting in sensation. This
concept is an early suggestion
of specificity theory.
A century later Heberden is
credited with adopting the term
angina pectoris ("strangling of
the chest") in an address to the
Royal College of Physicians in
1768, although his descriptions
of angina, angor animi (anguish
and mortal fear associated with
angina) and its relation to
physical exertion were not
published until 1772.
Between 1890 and 1925
intense interest surged around
the functionings of the nervous
system, the perception of pain
and the differences between
visceral and somatic pain. It
seems that the experiences of
the workers a century ago were
little different to the frustrations
encountered today:"...I had
become so deeply interested in
the line of research I had
pursued for years that I fancied
I had been making a
considerable advance. But ..
doubts began to arise in my
mind as to the sufficiencies of
the researches that had been
made ... by myself and others ...
It became evident that,
notwithstanding the new
phenomena that were being
brought to light .. no progress
was being made towards
attaining the great object of all
our undertakings."
Sir James Mackenzie "Diseases
of the Heart" 1925 Preface to
4th edn.
Two schools of thought
prevailed during this period, and
intense debate sprang up
between the protagonists of
each body of opinion. The link
between coronary vessel
atheroma and cardiac pain had
been well established by this
time, but the mechanisms
linking ischaemia and pain
generation were more tenuous.
Most interest centred on the
observations of exercise induced
intermittent claudication and,
having established that muscle
could be a primary source of
pain, attempted to extrapolate
these findings to events in the
ischaemic myocardium.
The observation that viscera are
insensate led to an alternative
hypothesis, namely that cardiac
pain was generated primarily by
an abnormal excitability in the
nervous system. This was
supported by the appearance of
cutaneous and subcutaneous
hyperalgesia in association with
angina pectoris. This led to the
adoption of the term 'cardiac
neurasthenia', a vague term
encapsulating the concept of
the CNS becoming
hypersensitive so that a
previously trivial sensory input
from the organ in question,
which would hitherto be below
a perceptual threshold,
somehow gets translated into a
painful stimulus. Extremely
elaborate charts of the nervous
connections of the heart were
produced following meticulous
anatomical dissections in an
attempt to define macroscopic
links between the various parts
of the sympathetic chain and
spinal cord. The reporting of
cutaneous hyperalgesia and
subcutaneous tenderness is a
commonly recurring theme. In
the days before sophisticated
monitoring detailed
examination formed the basis
for much medical theory and it
is difficult to believe that so
many distinguished clinicians
were making a truly spurious
observation. It seems more
likely that this potentially
important clinical finding has
been forgotten.
Against the neurasthenia
hypothesis were ranged such
worthy opinions as Colbeck's,
who stated in the Lancet in
1903: "the rarity of its
occurrence among women are
features opposed to the purely
nervous theory of its mode of
production. "
The inability to match pathology
with symptoms, which persists
to this day, led to Mackenzie
postulating "...two forms of
cardiac pain ... produced in
different ways which have a
significance of a widely different
kind. One form is associated
with actual disease of the heart.
This should be called 'primary
angina pectoris'. In the other
18
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
FEATURES

form there is no disease of the
heart, the symptoms being
referable to a hypersensitive
central nervous system. This
form I call 'secondary angina
pectoris'."
It seems that in certain aspects
of medicine nothing changes.
One of the most widely
discussed themes in the old
textbooks is whether or not
angina pectoris is a disease
entity in its own right, or a
symptom; in other words a
manifestation common to
several distinctly separate
disease processes. If modern
medical writing is often accused
of being dry, I would refer
interested parties to the
relevant chapter in Albutt's
book Diseases of the Arteries
including Angina Pectoris
published in 1915. These nine
turgid pages (pp211-220),
densely printed in eight point,
debate the differences between
the definitions of symptoms,
syndromes and diseases and
conclude: "... if the title of
angina pectoris be used to
include a variety of symptom
groups which, although they
may present a superficial clinical
resemblance, yet in their
aetiological and pathological
relations differ widely and
fundamentally, all definite use
of names comes to an end "
Relying on case reports and
clinical observational
associations clearly had its
drawbacks, and contributed to
the frustrations and inaccuracies
of the day. Albutt continues
(describing his trawl through
the literature): "...surely it is
levity to confuse the squalls of
unstable neurotics, mostly
women, with the assault of one
of the fiercest and most
searching afflictions which can
fall upon steadfast and resolute
men ... Could professorial
pedantry be more extravagant!
unless, indeed, it be surpassed
by a comparison of the pain of
angina with that of colic, of
hysteralgia or of heartburn! But
the most egregious example of
this eccentricity which I have
noted is the description, by a
well known modern physician,
of a case of angina pectoris
originating in the clitoris.
"However, some workers had
useful insight: "Sir James Barr
thinks that in angina the heart
has too much (sic) calcium
ions... " which could be taken
to predict the value of calcium
channel blocking drugs in
angina.
In the late 1920's the debate
regarding angina's aetiology
appears to come to an abrupt
halt, and, for no clear reason,
comes down on the side of the
"primary angina" side of the
fence. Since then, it has become
enshrined as a piece of medical
dogma that the pain of angina
pectoris is a warning that
myocardium threatening
ischaemia looms. This has been
the understanding for several
generations of doctors, and
therefore patients, but the
evidence to support this
hypothesis remains as patchy as
it was seventy five years ago.
The available treatments of that
time are still part of the
therapeutic framework of today.
Atropine, amyl nitrite,
nitroglycerine and morphine
were popular and widely used
drugs; one Dr Dieulafoy
recommended aspirin, in a dose
of 500 mg every two hours.
Remedies used less often today
are such preparations as sodium
and potassium iodide, strontium
bromide, peppermint ("Once
break the wind, they say, and
the attack is relieved'), arsenic
(syphilitic aortitis was a
common cause of coronary
disease) and high frequency
electrical current, delivered via a
sulphur bath. In terms of
prevention the importance of
diet and rest was stressed.
Vigorous exercise was regarded
as dangerous.
Surgical treatments at this time
were confined to extracardiac
procedures carried out by a
minority of enthusiasts. In 1880
Langer noted that numerous
minute vascular connections
existed between coronary
vessels and surrounding
structures such as diaphragm,
bronchi and pericardium. This
paved the way for attempts at
indirect revascularisation.
Procedures such as pericardial
poudrage (direct surgical
irritation by abrasion and
instillation of talc into the
pericardium) achieved some
popularity. In anticipation of the
increasingly discredited modern
day transmyocardial laser
"revascularisation" (TMLR)
there are descriptions of
myocardial perforation with
acupuncture needles in an
attempt to stimulate
neovascularisation. However,
until the 1930's, most surgical
procedures centred on the
cardiac nerve supply. The first
human cardiac sympathectomy
was carried out by Jonnesco in
1916. This was reasonably
effective in relieving the
sensation of angina, but was
also believed to produce
coronary vasodilation.
Sympathectomy was achieved
by surgical extirpation or
injection of neurotoxic
substances such as ethanol.
Success for this procedure was
reasonably good, though there
was a significant complication
rate. Neuropathic pain or even
paralysis could occur, although
the mortality rate of 510%
probably reflects the belief that
removing “Nature's warning”
was dangerous, and palliative
surgical sympathectomy was
reserved for the most extreme
of circumstances. Only patients
with apparent end stage
coronary disease and impending
heart failure would be offered
this treatment and techniques
of anaesthesia and
understanding of cardiovascular
physiology were less well
developed than nowadays.
Enthusiasts continued
denervation until the 1960's but
the development of
extracorporeal oxygenation and
direct revascularisation of the
myocardium led to
sympathectomy's fall from
grace.
Since then, all efforts have
concentrated on developing
more sophisticated (for which
read expensive!) and less
dangerous methods of
increasing the calibre of the first
ten inches or so of the
epicardial arteries. This appears
to have resulted in a serious
neglect of the other part of the
equation: namely, how cardiac
signalling is translated into the
perception of pain, and how
those signals are handled by
the central nervous system once
they arrive. It is well known that
there is no correlation between
stimulus intensity (degree of
ischaemia) and stimulus
perception (what the sufferer
feels). Approximately one third
of myocardial infarctions are
silent, i.e. painless. The
speculations and debates of the
early twentieth century
regarding the nature of angina,
and other visceral pain
syndromes, deserve to be
resurrected. With new expertise
available to us using
sophisticated imaging
techniques, improved
understanding of such matters
as genetic expression and
neural biochemistry, we may yet
get much closer to truly
understanding one of Nature's
remaining conundrums.
Austin Leach
National Refractory Angina
Centre, Liverpool UK
May 2003
FEATURES
THE PAIN SOCIETY NEWSLETTER SUMMER 2003 19

Nottingham Pain Clinic survey
What do GPs’ want from the pain
clinic and do we provide it?
The pain department at City Hospital provides a one-day series of
lectures and practical workshops for local GPs.
49 GP’s attended the pain day and 35 returned completed the
questionnaire. The response rate was 71%.
Demographic data
Mean Range
Number of partners 5 1-14
List size 8000 1800-34000
Which one of the following statements best describes the
way that you would like the pain clinic to be organised?
(Tick one option)
1- More new patient appointments with a short follow up period
and discharge back to GP care.
2- More new patient appointments with a treatment plan that is
carried out and maintained by the GP. No routine follow up in the
pain clinic.
3- Fewer new patient appointments with long term follow up by the
pain clinic.
Option 1 70%
Communication
12 training practices and 22 non-training practices were represented.
Organisational issues
A number of participants were from outside Nottingham so gave
responses related to experience with their local provider of pain
services.
How long do
your patients
have to wait
for a routine
pain clinic
appointment?
0-4 Weeks - 23%
Do you expect
to receive a
letter after
each
outpatient
episode in the
pain clinic?
How often
does this
happen?
No - 20%
Always - 6%
Yes - 80%
Mostly - 51%
1-3 Months - 54%
Rarely - 11%
0-4 Weeks - 17%
What do you
think is an
acceptable
waiting time
for a routine
pain clinic
appointment?
1-3 Months - 74%
Sometimes - 11%
How long does it take for a letter to arrive at your practice
after the
4-6 weeks - 11%
patients’ pain
0-2 weeks - 14%
clinic
consultation?
In order to reduce the waiting time for a new patient
routine appointment at the pain clinic it would be
necessary to reduce the number of follow up appointments.
How would
Acceptable - 46%
you rate this
Excellent - 17%
change?
2-4 weeks - 54%
Comments
“A brief letter with a treatment plan is all that is needed.”
“The letters are very important because chronic pain patients are
very demanding and frequent attendees who always want
information from the hospital.”
Good - 31%
20
THE PAIN SOCIETY NEWSLETTER
SUMMER 2003
FEATURES

Have you ever
tried to phone
a pain
Consultant for
telephone
advice?
No - 71%
Yes - 26%
A 30-year-old
male with a 12-
week history of
acute back pain
following a
lifting injury who
has had 2 weeks
off work.
The 50 year old - 63%
Both - 23%
Why did you
not phone?
You did not want to be kept on hold
for ages by switchboard - 24%
You did not need
advice - 28%
A 50-year-old
male with a 20-
The 30 year old - 9% Neither - 6%
year history of progressively increasing back pain that has caused
him to take early retirement.
Comments
“It would be helpful to have a direct line number and a time period
when GP’s could telephone a Consultant for advice about a patient,
especially to prevent a referral.”
How satisfied
are you with
the advice that
you receive
from the
Consultants at
the pain clinic?
You didn’t think that advice would be forthcoming
because the Consultant was busy or unobtainable - 32%
Fair - 34%
Poor - 6%
The role of
the pain clinic
Rank the following in order of importance for a pain
service: (where 1 is the most important and 8 is the least
important)
1st Multidisciplinary approach by a large margin
2nd Psychological assessment
3rd Pain management program
4th Nerve blocks
5th TENS service
6th Acupuncture service
7th Highly specialised techniques
8th Massage and relaxation therapy
The 2nd and 3rd choices were almost equally popular and then there
was a gap before 4th, 5th and 6th choices, which were almost
equally popular. The 7th and 8th choices were a lot less popular
compared with other options.
Comments
“TENS and Acupuncture direct GP access”
“TENS and Acupuncture provided by the PCT”
Very good - 6%
Good - 46%
Which of these patients would be appropriate to refer to a
chronic pain clinic?
A 40-year-old,
otherwise fit
gentleman, is
started on
MST to relieve
back pain. He
is discharged
from clinic
because he
has exhausted
all other
Yes
for a short time
- 37%
Yes
indefinitely
- 60%
No - 3%
treatment modalities. Would you be happy to continue his
care whilst on MST for non-malignant pain?
Conclusions
Over 75% of patients referred to clinic were seen within 3 months
and this was deemed acceptable by 75% of GPs’ who responded.
Many GPs would accept fewer follow-up appointments if this
resulted in more new appointments with a shorter waiting time.
It was a surprise that 20% of GPs did not consider a letter to be
desirable after an outpatient appointment. Those who did want a
letter wanted it to include a treatment plan and be brief.
The telephone advice line did not appear to be a popular option
although more than 50% of GPs considered advice from the pain
clinic to be of good quality.
The multidisciplinary approach was considered to be the most
important feature of the pain clinic although access to a pain
management program was highly sought after.
A number of GPs would like direct access to TENS and acupuncture
clinics and would like their PCTs to provide these services
independently of the acute trusts.
A good proportion of GPs seemed happy to prescribe opioids for
non-malignant pain although this question requires further
examination.
Reference:
Clarke Leo. What does a GP want from a pain clinic? The Exeter Audit.
The Pain Society newsletter. Winter 199/2000; Volume 1: 8-9.
Authors : Dr. Richard J Faleiro - Pain Fellow and SpR
Anaesthetics City Hospital Nottingham. Dr Andrew Ravenscroft
Consultant Pain Anaesthetist City Hospital Nottingham.
FEATURES THE PAIN SOCIETY NEWSLETTER SUMMER 2003 21

Reflections
from the
coalface
DR AL O’DYNIA
Department of Pain
and Snake Oil Medicine
One of our anaesthetic trainees,
who is about to start her pain
module, announced that she
wasn’t sure in which camp she
was going to find herself; that is
whether to be a pain
interventionalist or not. It is a
curious perception of somebody
coming new into the field that
there should be such polarised
positions. How did this
situation come about? In the
past decade we have seen the
rise of evidence-based medicine.
We have of course had some of
the most vocal proponents of
this approach within the field of
pain medicine and perhaps we
are closer to it than some
specialties. What does
evidence-based medicine
actually tell us that is useful in
the field of pain management?
In the field of pain
pharmacology with a number of
good quality studies we are
presented with data in the
forms of numbers-needed-totreat;
this gives a comparison of
effectiveness between drugs,
but may not give us a huge
amount of help when it comes
to treating individual patients.
Patients’ response to analgesics
is often unpredictable and for
reasons that are not at all
apparent some drugs seem to
be highly effective in some
patients and not in others. The
use of analgesic drugs is often
limited by side-effects, especially
in the elderly, and we often use
drugs in combination as well.
Numbers-needed-to-treat seem
to offer us little help in
choosing a drug therapy beyond
telling us that these drugs have
analgesic properties.
When we move on to chronic
pain interventional therapies the
information provided by
evidence-based medicine
becomes even more difficult to
interpret. To look at the
technique of intravenous
regional sympathetic block, for
example, as evaluated by Drs
McQuay and Moore, there have
been 8 randomised controlled
trials on a total of only 96
patients, each trial used a
different combination of drugs.
It was concluded from this that
intravenous regional
sympathetic blocks were not
supported by the systematic
review. This had led to many
people now not using this
technique; however many Pain
Clinics around the country
continue to use the technique,
and in combination with a good
hand therapist, find that the
technique gives excellent service
year after year to many
thousands of patients. The
fundamental problem here is
that what the evidence-based
experts should say to us is that
while there is not enough
evidence to support the use of
intravenous regional blocks,
there is not enough evidence
not to support it either. The
trials are simply too small and
too disparate to tell us very
much at all. If the authors were
intellectually honest they would
say that there is simply not
enough evidence to comment
on this technique and they
should keep their own counsel
until such time that there is
enough information for them to
provide a useful comment either
way.
However evidence-based
medicine has a strong whiff of
political correctness about it,
which is somewhat inherent in
the title. If you call a form of
medicine evidence-based and
make somewhat dogmatic
statements about what can and
can’t be supported, then
anyone who is practicing
outside that dogma must by
definition be practicing non
evidence-based medicine, akin
to the use of snake oil or similar
preparations. Evidence-based
medicine runs the risk of
becoming mantric and dogmatic
and I detect from speaking to
many colleagues around the
country a definite swing against
the positions and stances
adopted by the proponents of
evidence-based medicine.
In reality in the Pain Clinic we
are presented with patients
with difficult clinical problems;
we often have to mix and
match and there is often not a
very clear way or right way
forward in treating patients.
Sometimes we end up using
treatments that we may
normally be uncomfortable
with, such as referring
occasional back pain patients to
spinal surgeons for spinal fusion
(another non-evidence based
pain relieving treatment). The
correct treatment of course is
the one that works in the
individual patient; from that
point of view, perhaps in the
Pain Clinic more than in other
area of medicine, n-of-one trial
is the correct way to treat the
patient and that simply means
in effect trying different
treatments until you find the
one or ones that works. This is
all very well, but what about
the risk? Procedures done in
the Pain Clinic are generally of
very low risk, especially when
compared to what many of our
surgical colleagues do. For
example after intravenous
regional sympathetic blocks
some of the patients may suffer
feelings of light-headedness or
perhaps even low blood
pressure, which are transient
and no threat to the patient.
This compares with hip
replacement surgery (another
non-evidence based pain
relieving therapy), where there
is one to two percent mortality
in the pre-operative period and
up to twenty percent serious
morbidity. It is fair to say that
‘no permanent damage’ is a
reliable motto within the Pain
Clinic. In the past ten years a
series of systematic reviews that
have not supported, or largely
ignored (University of York
review of back pain)
interventional pain relieving
treatments, have led to a period
of intense navel-gazing,
particularly in the pain world,
which has perhaps not served
us well and I suspect has not
served the patients very well
either. I am unaware of my
orthopaedic colleagues being
filled with self doubt about the
value of their procedures,
although their evidence base is
likely to be even thinner than
ours. Evidence-based medicine
in its true form is of course to
be applauded; it may however
be best viewed as an ideal to
which we should aspire, as
when we look at the evidence
base available now it looks very
much like a case of the
Emperor’s new clothes.
I shall say to our new trainee
that there isn’t a right way or a
wrong way to treat patients
with chronic pain, but we
should use all our efforts and as
many techniques, be they
interventional, pharmacological
or psychological, as we have
available to attempt to alleviate
patients’ pain and suffering. It is
the patients after all that we
are here to serve, and not
academic purists in ivory
towers, who have the luxury of
not having to treat patients on
a day-to-day basis.
REFLECTIONS FROM THE COALFACE THE PAIN SOCIETY NEWSLETTER SUMMER 2003 23