A Publication of the British Pain Society

painDecember 2016 Volumenews 14 Issue 4 a publication of the british pain society

To heal or not to heal New perspective on placebo Apps, Bots and Wearables : The future is here at present Educating secondary school students about paediatric chronic pain IssN 2050–4497 Misuse of gabapentinoids

PAN_cover.indd 1 15/11/2016 1:46:12 PM Third Floor Churchill House 35 Red Lion Square London WC1R 4SG United Kingdom Tel: +44 (0)20 7269 7840 Fax: +44 (0)20 7831 0859 Email [email protected] www.britishpainsociety.org

A company registered in England and Wales and limited by guarantee. Registered No. 5021381. Registered Charity No. 1103260. A charity registered in Scotland No. SC039583. contents The opinions expressed in PAIN NEWS do not necessarily reflect those of the British Pain Society Council. PAIN NEWS December 2016

Officers Mr Antony Chuter Chair, Patient Liaison Committee Regulars Dr Andrew Baranowski Ms Felicia Cox President 139 Editorial Editor, British Journal of Pain and 140 From the President Dr William Campbell Representative, RCN Immediate Past President 143 From the Honorary Secretary Prof. Sam Eldabe 144 Spotlight – Thanthullu Vasu Prof. Roger Knaggs Chair, Science & Research Committee Honorary Secretary Dr Barry Miller Dr Heather Cameron Representative: Faculty of Pain Medicine News Honorary Treasurer Dr Arasu Rayen 146 The Patient Reference Group Dr Martin Johnson Editor, Pain News 149 Reflections on the first EFIC topical symposium: acute and chronic joint pain, Vice President Prof. Andrew Rice held in Dubrovnik, Croatia, 21–23 September 2016 Dr Paul Wilkinson Representative, IASP 151 Veterans in pain: new resources Vice President Prof. Kate Seers 152 Report on current state of the specialised pain Clinical Reference Group Chair, Scientific Programme Committee Elected Dr Amanda C de C Williams Prof. Sam Ahmedzai Representative: Science Professional perspectives - Margaret Dunham, Dr Arun Bhaskar Mr Paul Cameron Secretariat Associate Editor Dr Tim Johnson Jenny Nicholas 154 New perspectives on the placebo response: why does giving nothing work so much Chief Executive Officer Dr Austin Leach better than doing nothing? Dr Sarah Love-Jones Dina Almuli 157 To heal or not to heal: the Hamlet effect Dr Zoey Malpus Secretariat Manager 160 brief psychological and hypnotic interventions in the management of pain – giving Dr Ann Taylor Ken Obbard control back to the patient Dr David Glyn Williams Membership & Events Officer 164 Suffering as a guiding call towards transformative change: the movie of pain in the Co-opted Members Martel St Marthe cinema of the mind Mr Neil Betteridge Conference & Communications Officer 171 The misuse of gabapentinoids Representative Chronic Pain Policy Coalition 173 Apps, Bots and Wearables: the future is here at present Dr Elaine Boland Representative, Association of Palliative Informing practice - Christina Liossi, Associate Editor Medicine 177 Experience of managing patients in a joint pain and substance misuse clinic 182 Why should fear lead to suffering for 80% of the world’s population? PAIN NEWS is published quarterly. Circulation The Editor welcomes contributions 1300. For information on advertising including letters, short clinical reports and 184 Educating secondary school students about paediatric chronic pain please contact news of interest to members, including Neil Chesher, SAGE Publications, notice of meetings. 1 Oliver’s Yard, 55 City Road, Next submission deadline : End stuff London EC1Y 1SP, UK. 5th January 2017 187 book Review Tel: +44 (0)20 7324 8601; Email: [email protected] Material should be sent to: 189 Word Search Disclaimer: Dr Arasu Rayen The Publisher, Society and Editors cannot PAIN NEWS Editor be held responsible for errors or any The British Pain Society consequences arising from the use of Third Floor Churchill House information contained in Pain News; the views 35 Red Lion Square and opinions expressed do not necessarily London WC1R 4SG United Kingdom reflect those of the Publisher, Society and Email [email protected] Editors, neither does the publication of advertisements constitute any endorsement ISSN 2050-4497 (Print) by the Publisher, Society and Editors of the ISSN 2050-4500 (Online) products advertised. Printed by Page Bros., Norwich, UK At SAGE we take sustainability seriously. December 2016 Volume 14 Issue 4 We print most of our products in the UK. pain news These are produced using FSC papers and a publication of the british pain society boards. We undertake an annual audit on materials used to ensure that we monitor our sustainability in what we are doing. When we print overseas, we ensure that sustainable papers are used, as measured by the Egmont grading system.

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PAIN NEWS December 2016 vol 14 No 4 137

00_Prelims.indd 137 21/11/2016 5:56:53 PM British Pain Society Calendar of Events

To attend any of the below events, simply book online at: www.britishpainsociety.org/mediacentre/events/

2017

Patient Liaison Committee Webinar Wednesday 18th January 2017 Online

The Patient Liaison Committee will be hosting two 45 minute webinars, these will be free to view and will have the facility to ask questions at the end.

50th Anniversary Annual Scientific Meeting Wednesday 3rd – Friday 5th May 2017 Birmingham

Put the dates in your diary now for this flagship event – the 50th Anniversary Annual Scientific Meeting. We have an exciting and high profile line up of plenary speakers and parallel session topics for the Meeting. The ASM is a great opportunity to:  Network with colleagues  Keep up to date with the latest cutting edge research and developments relevant to pain  Raise questions, partake in debates and discuss outcome  Meet with poster exhibitors and discuss their research To view the list of plenary speakers and for further information please visit: https://www.britishpainsociety.org/2017- asm-birmingham/scientific-programme/

Living Well Right to the End Philosophy & Ethics SIG Annual Meeting Monday 26th – Thursday 29th June 2017 Rydall Hall, Cumbria

How to live well at all can prove elusive and has been much debated for thousands of years. Is it to do with physical health or pleasure or a general sense of wellbeing or happiness or fulfilment or meaning or is it merely the absence of suffering? Can we somehow enable those we care for to achieve a level of wellbeing even as they become ill and perhaps face death? Can we achieve a measure of wellbeing in our own lives? Our meeting this year takes place in the beautiful surroundings of Rydal Hall amongst the lakes and fells of Cumbria where we will be considering all of these issues.

Gonnae no dae that! – exploring patient and clinician fears Pain Management Programmes SIG Biennial Conference 14th & 15th September 2017 Glasgow Caledonian University, Scotland

Speakers including: Amanda C-de-C Williams, Tamar Pincus, David Gillanders and Johannes Vlaeyen.

Social events:  Wednesday evening: drinks reception in the iconic Glasgow City Chambers.  Thursday evening: Scottish gin and real ale tasting, plus the chance to play the bagpipes at the National Piping Centre!

Further details for all our meetings can be found on our events listing page: www.britishpainsociety.org/mediacentre/events/

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Editorial

Pain News 2016, Vol 14(4) 139 © The British Pain Society 2016 Dr Arasu Rayen Editor [email protected]

Apps are stores to download apps and explore. Goldingay, researcher and Senior everywhere. Apps are invading health industry thick Lecturer, Department of Drama, University Your and fast. Stephen, Damien and Arun’s of Exeter, in her article, ‘To heal or not to smartphone third article in their series of articles on heal: the Hamlet effect’, compares the is just a brick Technology in health, ‘Apps, Bots and medical practice to theatre performance. if you do not wearbles’ deals with apps and more She compares the health professionals to have any interesting technologies like Bots and the actors with pre-existing script like installed Wearables which are already in use or in ‘history taking’ with white coat and Apps. Apps, the horizon. The future is Apps; the future stethoscope as props. Sarah has also even though is technology. One thing to point out at presented a programme in BBC Radio 4 started in the this stage is about the app that The ‘The Problem of Pain, BBC Radio 4’ mobile world now, have invaded the PC British Pain Society (BPS) will have for (http://www.bbc.co.uk/programmes/ world as well. In 2002, Blackberry was the Annual Scientific Meeting (ASM). b061t68w). Please read the article and introduced, followed by iPhone in 2007 Please read the President’s message to listen to the podcast of the programme in and Android phones in 2008. Because of know more about this. BBC Radio 4 website. its ease of use and multiple functionality, Eric Berne was a prominent We are fast approaching 2017. By the mobile phone adoption among general psychologist from Canada. In his best- time you read this, Christmas is almost public escalated exponentially. Along with selling book, Games People Play, he upon us. We are celebrating our smartphone industry expansion, app introduced a concept ‘transactional 50th ASM Meeting Anniversary next year world grew rapidly. It is estimated that analysis’ – a method for studying with an exceptional meeting in Google Play has around 2.2 million Apps, interaction between people. Berne defined Birmingham. I would encourage you to and Apple’s App Store has around three ego states – parent, adult and child. book your study leave and get ready for 2 million Apps (https://www.statista.com/ He described that every single social great Celebrations. If you have any statistics/276623/number-of-Apps- transaction we make involves any of these nostalgic memories of your yesteryears in available-in-leading-app-stores/ – three ego states in each individual. Similar BPS and ASM, please share it with us. accessed on 10 October 2006). Apple’s to this Performance studies is a discipline You can write to me or if you have any Mac series, Googles’ Chrome books and which takes a whole system analysis to photographs, please send them to me. I Microsoft’s Windows 10, all have App analyse human-to-human interaction. Sara am eager to see them and publish them.

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From the President Dr Andrew Baranowski Pain News 2016, Vol 14(4) 140–142 © The British Pain Society 2016

What is the inception of a national pain Society – app that we have specifically chosen for role of the which started as the Intractable Pain its ease of use, its ability to help President’s Society. This makes us the oldest Pain members organise their meeting day and Report in Pain Society. We are also the only British a functionality that will enable those News? multi-disciplinary Society. attending to be much more involved with I have had a The ASM that we have planned for the speakers by facilitating questions and discussion with a May 2017 will reflect the importance of ratings. We hope to move away from number of people this anniversary and our multidisciplinary more didactic presentations and to about the style of team (MDT). We have started advertising facilitate discussion as our members my President’s the outstanding programme that we have have requested. Report in Pain lined up, both within this newsletter and News. The discussions have been our social media; please prioritise this The ASM party revolving around whether or not this is a meeting as the BPS needs you and The social side of the ASM is important to report by ‘myself’ as President of The hopefully you will see the importance of me (!), and I was pleased to support the British Pain Society (BPS) or from the the Society in supporting the MDT. I am re-introduction of the ASM Party a few years President of the BPS and I happen to be clear that not only are the speakers ago. Choosing the disc jockey (DJ) is the writing it? I am sure that all Presidents highly regarded for their expertise and key, and the play list is essential if we expect will have their own style and in the past delivery, but because the Scientific you to get up and dance. If you have any many may have been more formal in their Programme Committee have organised recommendations for the DJ, please let us reports, but I see Pain News as your the meeting to represent a number of know. Please also consider emailing us five newsletter and not a formal audit report themes, we have maximised the impact songs (band and title) that will drive you or prospectus that needs a Presidential for you. There will be items of relevance crazy on the dance floor and will get even approach … I feel it is important to make throughout the meeting to stimulate all the consultants up there with their team; this exciting newsletter as personal for those attending, whatever your level of please email to asm@britishpainsociety you as possible. As a consequence, I am expertise and discipline. This is one of .org with the subject ‘Let’s get the writing about my thoughts – I will not the changes that we have instigated party started’, and we will see what we always be correct and I aim to listen to following feedback from our members, can do. the responses that come out of my both those that have attended regularly For our 50th anniversary, Team BPS is musing both as a result of this report and in the past and others who are less looking at other ways of making the other contacts. frequently involved. venue a home away from home. We are At the request of our members, we working on moving away from ‘holding have reviewed the branding, design, 2017 is going to be a very slides’ while you are waiting towards presentation and advertising of the exciting year for the BPS more and more interesting approaches – meeting. We have brought in a new Team BPS has been working on I see this as work in development. You company, 22 Design, to modernise our modernising our Society for several years will need to attend to be able to judge ASM documents bringing them in line and whereas there is still a lot to do, you our early efforts and to know more! with our new brand for the BPS (see will see change … below). Hopefully, this will provide a fresher and cleaner experience but more Future ASMs The annual scientific meeting importantly simplify the paperwork so The new app will enable us to collect As I hope you will be aware, the 2017 is that life is easier for those attending. more information about your views of the the 50th anniversary of our Annual As a part of modernising our ASM. It is your opinion that has informed Scientific Meeting (ASM), taking into documentation for the ASM, we will be change to date and will continue to account those meetings from the introducing a conference App. This is an inform change. As we begin to plan for

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Dr Andrew Baranowski

2018 and beyond, we are looking at also have a collection of branded posters with a number of famous artists and smaller venues which hopefully will – these are quite dramatic and societies to launch an arts awards prize provide a warmer more cohesive informative in a punchy way. Finally, we competition, awards ceremony and art atmosphere. That is only one of the have some ideas! show. To date, the discussions have been changes, being discussed; if you have Having been involved in this work for well received, and this may potentially be ideas, then please email to asm@ nearly 5 years, I am amazed as to how an ongoing programme. I’m very excited britishpainsociety.org. much time and effort has been required about the range of possibilities that this to move this forward from our project may enable. In my mind, I feel it Secretariat, Council Members, Execs could potentially put us in closer contact Rebranding and a significant number of volunteers as with those who live with pain, it may help Over the past 6–9 months, we have well as Bill. If we pull this off, it will be due them to express their feelings about the employed a branding consultant. The aim to their altruistic efforts on the behalf of problems they face, it will help us to was to modernise our appearance but the Society and for its members. spread the word and potentially facilitate not lose our heritage. Bill Wallsgrove has us to develop close relationships with done a great job in sharpening our image individuals and agencies that might look but maintaining our traditional logo. It is Exciting ideas aimed at bringing towards supporting the activities of the important that we have a sharp clean in support for the work of the BPS and its members. image that is clearly associated with us Society and easily identifiable. However, To a certain extent, we are now the stage when we just have to do it. Currently, we rebranding was essential as The BPS Proactive working with media brand will be rolled out across all our have the following: In the past, a lot of our BPS work with paperwork, social media and events, media (newspapers, magazines, radio and, as a consequence, had to be Cycle challenge and television amongst others) has been appropriate for those media. Although, Glyn Williams, elected Council member, when we have been contacted for help. ultimately, it is also key for our fundraising. has drawn up a proposal for a cycle However, we have set up a small working fundraising event. Hopefully, there will be group to look at being more proactive. Fundraising more about this in the not too distant The members have been asked to The Society, over the past 5 years or so, future. I have some inkling of what is undertake a number of activities which has made cost savings where possible. involved, and I will need to be sure the include: developing a number of BPS Any further such approaches would ‘granny’ gears work on my bike. As well standard responses so that we can potentially jeopardise the work that we as involving members, we are looking at respond quickly to requests from a well currently undertake. The concept of the variations that may work with those that thought – out position. We are also National Awareness Campaign was, are living with pain, friends and relatives. looking to be more proactive in partly as the title suggests, to increase Glyn and Team Cycle keep up working recognising where opportunities for awareness of the problems of those on the proposal. media working exist (essentially faced with pain and what the BPS does monitoring publications and providing to support such individuals, but also to reports to agencies before they ask for What has become known as the act as a means to enable fundraising so them). We are looking at media training ice bucket challenge? that we can support our members to so that we can develop ‘BPS media A variation of the successful ice bucket support those who live in pain. The gurus’ who sound good on radio or look challenge, where iced water is poured setting-up of the BPS trading arm was good on television! Finally, we will work over someone in the name of charity (!), also to facilitate income generation by up some ideas around engaging media is being devised by Ann Taylor and Sam enabling us to explore new opportunities to include pain in their portfolio of Ahmedzai. This is likely to morph but is that a charity cannot do. activities, documentaries and even as a an example of some of the background After nearly 18 months of research, part of serial story lines. We want to work happening. proposals, business cases, debate and position the BPS as the place to go to for meetings (good for building character advice and information around all issues and for governance, so I am told!), we Art awards related to pain. Thank you Austin Leach, now have an agreed prospectus that can It is early as I write this report. The BPS is Roger Knaggs, Alan Fayaz and Dina be used in our fundraising efforts. We currently working on building up relations Almuli for taking this forward.

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Dr Andrew Baranowski

Enhanced member engagement Recognising member Membership fees and what you through improved contributions through awards as members benefit communication William Campbell in his capacity as Martin Johnson is involved in multiple As you’ll see, I am really keen that the Immediate Past President is leading a discussions and meetings looking at the members have the opportunity to interact working group looking at our current way we structure membership fees and with Council and Execs as much as awards system. There are a number of the benefits of being a member. Despite possible. There is no doubt this has to be proposals, and, in due course, these will a huge amount of work to date, there is in a controlled manner as I already receive be presented to the members. However, still a lot to be done. We are listening to around 100 emails a day. For that reason, I there is one area that I am keen to push members as the team review am suggesting that we set up specific forward: recognition of BPS members by membership. email addresses for certain issues (as their colleagues and patients. The details above). We have also made the minutes are to be ironed out; however, at this In conclusion - there is a lot to from Council available under the members stage, my thoughts are that members of do... section of the website, and we are working the Society who are recognised (such as So, 2017 is a significant year. We will be on developing discussion forums within our by a thank you letter) from their instigating numerous changes to improve website. This work is ongoing but should, colleagues or patients will have their your experience, and we will continue to over the next year or so, significantly open name, institution and a key paragraph or evolve as is right for a 50th Anniversary. the Society for its members. so published in a quarterly (possibly As I have said before, we need you. monthly) push email from the President Please approach us if you have the time to all our members. The details would Enhanced website to work on BPS projects and are happy also be published on our website. Every As you are aware, John Goddard and to be a work engine to bring about time we publish a new list, we would his team revamped the website. Ann change that will improve what the Tweet it. We are always happy to Taylor and Sam Ahmedzai, as Society can do to support its members complain, we need to be more positive Webmasters, have provided Council to help those living with pain and to work about promoting our members who have with further recommendations as to how towards the Society meeting its values: been acknowledged. I hope that you will to open up the website so that it is more all see the benefit of a system where your user-friendly and how we can improve ENABLING BEST PATIENT CARE: colleagues’ achievements are recognised its functionality. Those developments will So people in pain live their lives to the by the BPS and our members. be undertaken in the context of the fullest. rebranding exercise. Zoey Malpus is currently leading a working group that is Regional meetings SUPPORTING EFFECTIVE collaborating very closely with Ann Members have for many years requested PARTNERSHIPS: Taylor to look at how we integrate many that meetings are less London-centric. So health and social care professionals features from the Pain Community Paul Cameron and the Education work together to provide comprehensive Centre website into our website. For Committee are currently looking at ways support. Ann Taylor, to have facilitated this in which this could occur. Joint meetings merger is a huge gift for our members. between local departments, societies MAKING PAIN VISIBLE: The merger of the two websites will and agencies with the BPS are one such So pain and its consequences are on the significantly increase the amount of model. The benefit for the local team national health agenda. information that we have for patients would hopefully come from the and members as well as providing collaboration with the BPS and the INFORMING PROFESSIONAL continued medical education facilities. badging of the meeting by our Society EXCELLENCE: We will have to strike a balance providing evidence that the meeting So professional standards are elevated between what is free for members, what meets certain standards. I envisage that through research, audit and education. members are charged at a nominal fee this would only be available where the and what non-members are charged. organising committee has a significant INVESTING FOR THE FUTURE: The fact that this is your website will be number of BPS members, that it is a So we have sustainable financial growth central to any decisions around that. benefit for members. to invest in our mission.

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From the Honorary Secretary Professor Roger Knaggs Pain News 2016, Vol 14(4) 143 © The British Pain Society 2016

Special encourage you to think about how you In response to the APPG group report, Interest contribute more actively to the SIGs elected Council members issued the Groups: the that you are a member of or consider statement below: lifeblood of joining a new SIG, or if you feel an area the Society of pain medicine is not represented by The British Pain Society welcomes the During the the current SIGs think about creating a interest of the APPG for Drug Policy ongoing review of new one. Reform in expanding access to membership and medicinal cannabis. recruitment, I have Access to medicinal cannabis: been reminded on meeting patient needs The expert report commissioned by numerous No doubt you will have seen media the APPG identifies that there have occasions that reports from an influential parliamentary been several studies that have The British Pain Society primarily is an group, the All-Party Parliamentary Group investigate the effectiveness of organisation for its members. One of the (APPG) on Drug Policy Reform. After cannabinoids for different types of many ways that the Society serves its taking evidence from patients, medical persistent (chronic) pain although members is by providing a range of professions and examining how medical there have been other studies that Special Interest Groups (SIGs). The SIGs cannabis is regulated in other countries, have showed negative results too. In allow members who have a specific they proposed the legalisation of neuropathic pain specifically, cannabis interest to discuss and debate their cannabis for medicinal purposes. A and cannabinoids are not effective. interest in more depth and the Society report commissioned by APPG that encourages the work of the SIGs as it reviewed the evidence for use of Like all medicines, cannabinoids demonstrates the multidisciplinary nature cannabis for a range of conditions and have side effects and potential of the Society. the final report from the APPG are worth harms for users. There are significant There are currently 14 SIGs which reading. concerns from the epidemiological cover specific types of pain or specific In an online survey of medicinal literature that cannabis use has populations (e.g. acute pain, headache cannabis use in the United Kingdom, the significant mental health risks in and neuropathic pains, pain in children most common indications were chronic susceptible individuals and the and older people), treatments for pain and severe pain (24% of respondents), degree of this risk for ‘therapeutic’ (e.g. interventional pain medicine and arthritis (12%), insomnia (21%), users is unknown. pain management programmes) to fibromyalgia (9%), post-traumatic stress other aspects of clinical practice disorder (PTSD) (7%), depression (30%) The British Pain Society welcomes the (e.g. medicolegal and pain education). and anxiety (26%). There is also a APPG for highlighting the issue but SIGs only work with dedication and summary from a survey of pain clinicians recommends there is insufficient commitment of a relatively small that was organised by the Chronic Pain evidence to support its use in pain number of members. I would Policy Coalition. management at present.

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Regulars Spotlight – Thanthullu Vasu Pain News 2016, Vol 14(4) 144–145 © The British Pain Society 2016

The width and breadth of BPS membership is testimony to the diversity within the organisation and in the pain world. The Editorial Board would like to acknowledge this richness by shining a spotlight on some of our members. In this edition, we speak to Dr Thanthullu Vasu, Consultant and Head of Pain Management Services, Leicester.

1. What first unique opportunity to work with of satisfaction from our patients. brought you different Presidents of BPS including Furthermore, our paediatric chronic in contact Dr Hester, Prof. Bond, Prof. Langford pain service achieves 100% satisfaction with the and Dr Campbell; I have realised that rate in the Friends and Family test. BPS? the role of the President is very challenging with huge responsibility! If 7. Where can we find you in your As an this dream comes true, I will heavily spare time? What is your favourite enthusiastic subsidise the next ASM fees to make way to spend a weekend or a trainee, I sure that many hundreds of members Sunday afternoon? attended the attend the 50th ASM meeting in British Pain Birmingham. You will find me walking with my Society (BPS) friends along a scenic canal-side or in Dr Thanthullu Vasu Annual Scientific 4. What are you known for a rural farm side in Leicestershire Consultant and Head Meeting (ASM) professionally? during my spare time; I lead a walking of Pain Management regularly. This club in Oadby, Leicester. I organise Services, Leicester paved the path I am known for my skills in helping cultural events and take active part in for networking young children with persistent pain; this dancing and debates in these events. among numerous friends in the pain is made possible by our multidisciplinary My two children keep me very busy specialty. team in Leicester. I also lead the pain and happy during the weekend. service at the University Hospitals of 2. What was your role in the BPS? Leicester NHS Trust. 8. Any other volunteer activities apart What excited you about this role? from the BPS that you’re 5. What are you most passionate passionate about? I was honoured to be elected as a about professionally? BPS Council Member (2009–2012). I have linked with patient charity The most exciting role was that of the I am very passionate about our groups in and around Leicester and Honorary Editor of the Pain News. paediatric pain clinic and the have used these links to start new Being the Editor helped me to achievements that we have made in services for patients with persistent establish productive professional the last 2 years (including winning the pain. I am proud that these activities relationships with a wide variety of National Grunenthal Award for an are publicised with appreciation in multidisciplinary healthcare innovative project for young children the local media. professionals. living with pain). 9. Any favourite non-profit organisations 3. If you were President of the BPS 6. What do you have a knack for? that you support and why? for a day, what would you do? My biggest strength is in setting the I support Leicester Hospitals Charity It is said, ‘You have to dream before patient expectations to the right level and they reciprocate by supporting our your dream can come true!’ I had the that could be delivered! I have high rate innovations. Recently, I have established

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Spotlight – Thanthullu Vasu

link with another patient charity ‘A way I want to be remembered as a Faculty of Pain Medicine published with Pain’ and have written patient compassionate and caring friend this as very innovative project in information details for their website who will not hesitate to challenge their website (https://www.rcoa. (http://www.awaywithpain.co.uk/ when necessary but support at all ac.uk/faculty-of-pain-medicine/ acupuncture-children). times. useful-links).

10. What would be impossible for 12. Any life achievements you are 13. Anything else you’d like to tell you to give up? particularly proud of? people about yourself?

Reading – I have to read at least I changed the style and format of BPS has given me a new 30 minutes every evening before Pain News when I was the Editor; dimension to my professional life bedtime. My favourite authors this was appreciated by the and instilled the importance of include Dan Brown, Paulo Coelho Executive committee, Council and team working. It is famously said, and Jeffrey Archer; I am addicted the wider membership. ‘If you want to walk fast, walk to the Tamil authors Balakumaran, alone; but if you want to walk far, Sujatha and Kalki. I am proud to win the National walk together’. Let us all walk Grunenthal Pain Award for our together to raise the profile of our 11. How do you want to be innovative paediatric pain Specialty. See you all at next ASM remembered? workshop; I was elated when the in Birmingham!

The British Pain Society is nothing without you, its members, and we appreciate your continuing involvement and support. We recognise that, for many members, in recent years, the decision to pay the membership fee for a non-compulsory professional society has been more challenging so we will continue to look closely at our fees and we will take care to limit any increases. We hope that you will continue to encourage your colleagues to joins us. May we also remind you that The British Pain Society is a registered charity and we welcome funds received from legacies and through sponsorship. As we know from the numbers who have joined fun runs at previous ASMs, many of our members are actively engaged in sporting activities. So, if you are signing up for any marathons, half-marathons, triathlons, swims or tiddlywinks contests, please consider nominating The Society as your chosen charity.

Follow the Society on twitter Thank you for supporting the BPS!

Follow the Society on twitter Please follow the Society on twitter@BritishPainSoc We will be sharing relevant information and updates from the Society.

Please follow the Society on twitter @BritishPainSoc December 2016 Vol 14 No 4 l Pain News 145

We will be sharing relevant information and updates from the Society.

04_PAN677463.indd 145 21/11/2016 5:58:03 PM Six years on, the Grünenthal Pain Awards go from strength to strength

Following the recent announcement of the 2016 winners of the Grünenthal Pain Awards, here we review their aims, the Overall Winners of the last six years and the impact this Award has had on the teams. We also invite entries for the 2017 Awards. What are the Grünenthal Pain Awards? The Grünenthal Pain Awards began in 2011; they are designed to recognise and reward excellence in the field of pain management and significant improvements in patient care. Being a finalist or winner of the Grünenthal Pain Awards can have a significant impact on your pain management service. Antony Chuter, Patient judge commented “These awards improve patient care. Teams that win awards are valued and recognised by their patients and their Trust.” The Grünenthal Pain Awards Judging Panel is an independent group who have agreed to oversee the evaluation, assessment and awarding of the Grünenthal Pain Awards. Awards will only be made available to institutions for the benefit of patients and the NHS and not to the individual healthcare professionals. These awards and the event ceremony including hospitality have been organised by Grünenthal Ltd. All costs, including catering and judging honoraria have been paid by Grünenthal Ltd.

Overall Award Winner 2011 Rachel Goodwin and team, University Hospitals Bristol NHS Foundations Trust “Using performance is a powerful way of enabling patients to see how they respond to situations and make choices as to how they live their lives.” Rachel Goodwin, Specialist Pain Management Physiotherapist Summary of entry Using drama in pain management and chronic conditions management settings To use drama to help participants reach acknowledgement and acceptance so that they can move on with making life choices in line with their own personal values, and to roll this out to a wider audience. What impact has this Award had? “Our DVD that has rolled out from the Award enables others to use this valuable tool to help manage their pain.” Rachel Goodwin

Overall Award Winner 2012 Vathana Sackett and team, University College London Hospitals NHS Foundation Trust “Pain, timings and geography make it difficult for patients attending clinics, so our project outlined an internet-based service. This new way of working challenged how we maintained governance and confidentiality.” Vathana Sackett, Clinical Specialist Physiotherapist, Adolescent Rheumatology Summary of entry Live web self-management intervention for adolescents with chronic pain Delivering live group sessions facilitated by a therapist on the web, promoted patients sharing experiences and problem-solving. The benefits of a more accessible and cost effective intervention will mean adolescents receive more support and feel better prepared for discharge and transition. What impact has this Award had? “The Award was an amazing opportunity to raise the profile of the service and to engage stakeholders.” Vathana Sackett

Overall Award Winner 2013 Dr Scot Richardson and team, St. Andrews Group Practice, Hull “Some MS patients have very complex pain, and ATS can be beneficial. It stimulates the body’s own action potentials. We want to use the services available in the area, and assess the appropriateness of therapy, including the potential use of APS therapy, to improve patients’ lives.” Dr Scot Richardson, GP Registrar ST3 Summary of entry Action Potential Simulation (APS) therapy: a novel approach for management of MS-related pain To develop a holistic community primary care-based service for patients in Hull with multiple sclerosis (MS)-related pain, including the use of APS therapy, a micro-current electric therapy, to enhance existing services and improving access for patients with MS living in Hull. What impact has this Award had? “Since winning the Award, our project has gone from strength to strength in our delivery of services to people with MS. The recognition we got from the CCG, secondary care and community services opened doors for further collaboration in the Hull region which has been very positive for our patients, us as a team and the Trust.” Dr Scot Richardson

Thinking of entering the Grünenthal Pain Awards for 2017? If you are thinking of entering the 2017 Awards, remember that entries are considered from all healthcare professionals working in pain management. “It is not only specialists in pain management that now enter these awards; there are a diverse range of applications from a range of healthcare professionals managing pain every day. If you are part of a project that you think offers a good service, apply for this Award as it can offer you a multitude of benefits,” advises Dr Scot Richardson, 2014–2016 judge and 2013 Overall Award Winner. Dr Hannah Twiddy, 2015 Overall Award Winner, adds “If you are thinking of entering this award, do it! It is not hard to complete the application forms, and you gain recognition of your work. Bringing your work to life in a video was a great experience for the entire team, and allows you to show off your department, your team and its services.”

05_PAN676982.indd 146 21/11/2016 5:58:43 PM Six years on, the Grünenthal Pain Awards go from strength to strength Overall Award Winner 2014 Professor Tara Renton and team, King’s College Hospital NHS Foundation Trust “This service will help to streamline pain management and services for patients with orofacial pain, as well as allow the collection of valuable research data.” Professor Tara Renton, Professor of Oral Surgery Summary of entry Facilitating artificial intelligence diagnostics for chronic orofacial pain via a dedicated website The development of a specialist website for orofacial pain (OFP) for patients and clinicians providing information and advice with appropriate links to existing patient specialist groups and data collection, with the ultimate aim of improving patient care. What impact has this Award had? “The benefits of winning this Award have been significant. We have been developing the multimedia aspects and content for the website (orofacialpain.org.uk that has already had 16,000 visits). We have recruited 500 patients for a research project that has resulted in several publications, and will soon be filming patient stories and education videos. Also, we have submitted our focus group paper for publication in the European Journal of Pain and have facilitated another 4 groups. Our website project is slow but progressing (mainly due to slow pace of NHS IT departments!). It is also important to note that winning the Grünenthal Pain Awards enables you to be eligible to develop a portfolio study, so you not only receive the funding from the Award and recognition for your team, but you can get additional funding for patient recruitment which is a fantastic bonus. We cannot more highly recommend this unique national recognition of patient centered pain initiatives, which provides only modest funding, however provides opportunities even we did not foresee!” Professor Tara Renton

Overall Award Winner 2015 Dr Hannah Twiddy and team, The Walton Centre NHS Foundation Trust Liverpool “Young adults need to be able to link the information we’re giving them to manage their pain within their values, so we use materials that are accessible to this population.” Dr Hannah Twiddy, Clinical Psychologist Summary of entry Supporting young adults with chronic pain: a multimedia based specialised pain management programme The Walton Centre Pain Management Programme improves care provision for young adults (aged 18-30 years) with chronic pain by providing focused and specialised services and interventions through accessible and engaging multimedia modalities. What impact has this Award had? “One of the main positive impacts of winning the award is the Trust then decided to invest in two brand new virtual reality exercise bikes for use by the young adult groups. It has raised the profile of the young adult intervention group we run and meant that we have started to receive enquiries and referrals from additional sources, neighbouring and less specialised pain clinics. It has been so important to have the work we have done for our young adults recognised and expanded.” Dr Hannah Twiddy

Overall Award Winner 2016 Dr Bianca Kuehler, Susan Childs and team, Chelsea and Westminster Hospital NHS Foundation Trust Hospital “Patients who have been exposed to human cruelty and torture need a specially planned service. The unique feature of this service is its multi-disciplinary input, with doctor, nursing, psychology and physiotherapy support to bring patients towards their identified values and goals.” Dr Bianca Kuehler, Specialty Doctor Pain Anaesthetics Summary of entry A one stop multidisciplinary pain clinic for survivors of torture This clinic offers a single appointment medical, psychological and medication assessment in a safe environment for this vulnerable and poorly understood pain patient population. What impact has this Award had? “This award will allow the commencement of measures that investigate post-traumatic stress disorder (PTSD), alongside the development of a specialised compassion-focussed pain management programme for survivors of torture and the provision of a swift access psychiatry clinic. Our main experience so far is that it raised our profile. We are already seeing an increase of referrals to the specialist service including direct referrals from GP’s. This is achieving exactly what we want as we hope to help health care providers to understand this complex patient group better and give them the opportunity to refer patients to us.”

This advertorial has been written by Grünenthal Ltd. Its placement in this journal has also been funded by Grünenthal Ltd. Calling for submissions for 2017 Grünenthal is delighted to announce that it is supporting the Grünenthal Pain Awards for the seventh year in 2017. There will be three award categories, with a top award for 2017 of £10,000 for the Overall Award Winner. Grünenthal would like to thank all applicants and judges over the last six years, and welcomes submissions for 2017. For further information about the Awards, or to request a 2017 entry pack, please contact the organisers, Jango Communications Ltd., by emailing [email protected] or calling 01344 860612. Awards will only be made available to institutions for the benefit of patients and the NHS and not to the individual healthcare professionals. These awards and the event ceremony including hospitality have been organised by Grünenthal Ltd. All costs,

including catering and judging honoraria have been paid by Grünenthal Ltd. October 2016 UK/G16 0039c Date of preparation:

05_PAN676982.indd 147 21/11/2016 5:58:44 PM PAN0010.1177/2050449716676982The Patient Reference GroupThe Patient Reference Group 676982news2016

News The Patient Reference Group Pain News Living with or in pain? Caring for someone who lives with or2016, is in pain? Vol 14(4) 148

If so the Patient Reference Group (PRG)© could The be justBritish for you. WePain are lookingSociety for people 2016 Antony Chuter from all areas of the UK, both people living with pain and their carer and the group seeks Chair of the Patient Liaison Committee to be representative of the wide range of patients living with pain and carers.

Members of the group will be asked to comment on materials such as patient guidance documentation, take part in surveys and questionnaires which in turn help the Society to understand how patients and carers feel.

This is an online email group, so you need access to email.

We will keep your details securely and we won't share them with any organisation outside of the British Pain Society.

To join please go to: http://eepurl.com/ZaIkv

The Patient Reference Group (PRG) was 355 people identified as a person living established by the British Pain Society’s with pain and 45 people identified as a Patient Liaison Committee (PLC) just person living with pain who is also a over a year ago. Within a very short time carer. In total, 400 people identified as and with little publicity, it grew to over White British or a similar phrasing; 21 400 members. The Society and the PLC people identified as Black and minority wanted to reach out to people who live ethnic (BME) or similar phrasing. with or in pain and to their carers. The We would now like to expand the

PRG has been sent a number of group and grow the online community

newsletters and is also being used as a that the Society connects with. I need

For more information about the British Pain Society and what we do, please visit our website at: survey base. The PRG is very diverse in your help to do this. I would be delighted www.britishpainsociety.orgMembers. You of can thealso find moregroup information will specifically be about asked the Patient Liaison to Committee at https://www.britishpainsociety.org/people-with-pain/patient-liaison-committee/

age, location and other demographics. if you would please download and print comment on materials such as patient We have had an average open rate of off the poster we have designed to guidance documentation, take part in 54.2% for emails, which is far higher than advertise the group to patients and their surveys and questionnaires which in turn the industry average open rate of around carers. You can find it here: https:// help the Society to understand how 20%. We have also had a slightly above www.britishpainsociety.org/people- patients and carers feel. industry click rate of 16.9% when the with-pain/patient-liaison- This is an online email group, so you industry average is 16.5%. This needs to committee/#patient-reference-group. need access to email. be taken in context that not every email We will keep your details securely and we sent had a survey and some had links we won’t share them with any organisation back to the British Pain Society. For the Living with or in pain? outside of the British Pain Society. surveys we had click rates of about 20%. Caring for someone who lives with To join, please go to http://eepurl. The group has a significantly higher or is in pain? com/IoFwv proportion of women with 371 being If so the PRG could be just for you. We For more information about the British women and 40 being men. are looking for people from all areas of Pain Society and what we do, please visit The youngest member is 19 years old the United Kingdom, both people living our website at www.britishpainsociety. and the oldest is 88 years, with the group with pain and their carer and the group org. You can also find more information mean age of 45.6 years. The group has seeks to be representative of the wide specifically about the PLC at https:// 17 people who identify as caring for range of patients living with pain and www.britishpainsociety.org/people- someone who lives with pain. A total of carers. with-pain/patient-liaison-committee/

148 Pain News l December 2016 Vol 14 No 4

05_PAN676982.indd 148 21/11/2016 5:58:45 PM PAN0010.1177/2050449716676983Reflections on the first EFIC topical symposium: acute and chronic joint pain, held in Dubrovnik, Croatia, 21–23 September 2016Reflections on the first EFIC topical symposium: acute and chronic joint pain, held in Dubrovnik, Croatia, 21–23 September 2016 676983news2016

News Reflections on the first EFIC topical Pain News 2016, Vol 14(4) 149–150 symposium: acute and chronic joint © The British Pain Society 2016 pain, held in Dubrovnik, Croatia, 21–23 September 2016

Neil Betteridge [email protected]

Apart from being the first topical world due to his substantial contributions There are other potential policy symposium held by The European towards the understanding of surgical implications here, as there is clearly an Federation of IASP® Chapters (EFIC), the pathophysiology. In the United Kingdom evidence-based need to develop an European Pain Federation, the event also and many other countries, he is approach to surgery which proactively marked the first formal collaboration recognised as the founder of the tackles post-surgical pain before the between EFIC and The European League Enhanced Recovery pathway, which has surgery has taken place, the way this is against Rheumatism (EULAR). I provided ‘win-wins’ to patients and done being variable according to the participated in my capacity as healthcare systems in many countries nature of the specific intervention in each International Liaison Officer for EULAR, now by accelerating the pace of the case. presenting on Patient Empowerment, patient pathway, reducing admission Prof. Meisner, from the Jena University and Prof. Maurizio Cutolo, EULAR Past periods (and therefore costs) while Hospital, Germany, is well known for the President, gave the opening lecture. delivering patient experience and Pain Out initiative (see www.paineurope. Prof. Cutolo’s presentation stimulated outcome measures which are as good or com). Here, he illustrated how to great interest, dealing with Circadian pain better than traditional surgical pathways. optimise the organisation of perioperative management in chronic rheumatic He continues to perform pain management. inflammatory disease. The evidence groundbreaking work and, at this My own presentation had the presented illustrated how the human meeting, presented new, procedure- objectives of challenging some common body performs a ‘reboot’ during the specific evidence for optimal analgesia in perceptions of ‘Patient Empowerment’. night, the immune system sending its joint surgery. This included the This is a term sometimes more used in ‘police officers and firefighters’ to attack PROSPECT studies and the use of the breach than the observance, I find, unhealthy cells in well people and healthy prospective patient databases. He as commitments to Shared Decision cells in people with rheumatic disease. looked specifically at hip and knee Making rub shoulders with more This was clearly of great interest to an replacement, and his summary of the traditional approaches to care, based on audience comprising predominantly pain evidence concluded that there was little clinician led direction. So my aim was to doctors, together with some orthopaedic or no evidence for the routine use of better define our terms: for example, is surgeons and representatives of other opioids in these interventions, especially ‘patient’ really the right word for disciplines. without clear evidence of side effects. someone with a long-term condition Other highlights included workshops In the United Kingdom, we at the such as chronic pain, who manages that on surgical pain, led by two of the most Chronic Pain Policy Coalition are condition 24/7 but is only in a clinic a tiny renowned leaders in the field, Henrik addressing the need for chronic pain amount of their life? Kehlet and Winfried Meissner. patients to have an annual review of their But more than that I wanted to offer Dr Kehlet has been working in management regime, including use of concrete examples of what patient Copenhagen for many years and is opioids, and in policy terms this is part of empowerment means in practice. To this perhaps the most well-known surgeon a wider movement to greater opioid end, I drew on examples from my work among anaesthesiologists around the sparing’ where appropriate. with National Health Service (NHS)

December 2016 Vol 14 No 4 l Pain News 149

06_PAN676983.indd 149 21/11/2016 5:59:02 PM News

Reflections on the first EFIC topical symposium: acute and chronic joint pain, held in Dubrovnik, Croatia, 21–23 September 2016

England, developing a patient booklet on public policy for both patients and •• Fast developing interest in seeking to Enhanced Recovery in close consultation healthcare professionals. change practice, doing more pre- with patients and carers; from EULAR’s I would be very happy to share my operatively to optimise/minimise work in building a strong patient network slides and/or hear from anyone post-operative pain. via PARE (Patients with Arthritis and interested in discussing this matter •• Ongoing interest in use of opioids: Rheumatism Europe), to collaborate with further. better targeting of their use, to avoid clinicians and health professionals and to As EULAR PARE reminds people who over-prescribing (a major policy issue) provide an authoritative patient voice in its are discussing issues that affect the lives and the personal consequences own right; and from public affairs/political of patients, ‘Nothing about us without us!’ which can follow. work carried out by the Chronic Pain It’s a demand, but a very reasonable •• Growing recognition that a Policy Coalition in the United Kingdom, one. multidisciplinary approach (MDT) and EULAR at European Union (EU) level. approach is the only way to I hope these initiatives and Personal conclusions handle the surgical pathway achievements generated by these •• High attendance and mixed audience effectively. projects and organisations demonstrate reflects strong interest in Joint Pain, •• The patient is the most important that when patient empowerment is done with many expressing interest in a member of the MDT and needs to be well, it delivers better patient experience, meeting on this topic to be held appropriately empowered to play an better patient outcomes and better regularly. active part in that pathway. 50th Anniversary Annual Scientific Meeting of the British Pain Society 3rd - 5th May 2017 The ICC, Birmingham

For further information please visit www.britishpainsociety.org/2017-asm-birmingham/ follow us on twitter: #BPSASM50th

150 Pain News l December 2016 Vol 14 No 4

06_PAN676983.indd 150 21/11/2016 5:59:03 PM PAN0010.1177/2050449716676984Veterans in pain: new resourcesVeterans in pain: new resources 676984news2016

News Veterans in pain: new resources Pain News 2016, Vol 14(4) 151 © The British Pain Society 2016

Pain concern Recognising the scale of the problem of our website: painconcern.org.uk/ Thousands of British ex-servicemen and of chronic pain among veterans and veterans. women live with chronic pain. Dr Alan the difficulties many face in accessing Topics discussed in the programmes Barrett, the Clinical Lead at the Pennine pain management services, Pain include the transition from military to Care Military Veteran Service for Greater Concern have produced resources civilian healthcare, rehabilitation after limb Manchester and Lancashire, says that designed to support veterans and their amputation and the interaction between chronic pain is the most common health families, as well as, we hope, proving post-combat psychological distress and complaint among his service users. Long- invaluable for healthcare professionals chronic pain. Our evaluation from the term musculoskeletal problems, which are faced with the often complex needs of programmes found that as well as being typically accompanied by pain, are the most this patient group. With the support of helpful for veterans, they were valued by common reason for discharge from the the Forces in Mind and MacRobert healthcare professionals with all those we British armed forces. Studies in the United trusts, we have produced a miniseries spoke to saying they would recommend States, meanwhile, found that between of three Airing Pain podcasts focusing the resources to colleagues. 40% and 50% of US veterans who saw on veterans’ experiences and the Listen to all three programmes and active service in Iraq and Afghanistan support available. These are still find more information about the services have developed chronic pain compared available to listen to and download and available to veterans on our website: to 29% of the general population. are hosted on a newly developed page painconcern.org.uk/veterans.

Have your say and contribute to Pain News today Pain News is the Members newsletter and as such we encourage and welcome member contributions to share your news with the wider membership and beyond. Do you have a news item to share? Perhaps a professional perspective, or informing practice piece? Maybe you would you like to feature as our ‘Spotlight’ member? We’d love to hear from you so drop the Editor an email today at: [email protected] Upcoming submission deadlines: Issue Copy deadline March 2017 2nd January 2017 June 2017 31st March 2017 September 2017 30th June 2017 December 2017 29th September 2017

December 2016 Vol 14 No 4 l Pain News 151

07_PAN676984.indd 151 21/11/2016 5:59:16 PM 0010.1177/2050449716677467Report on current state of the specialised pain CRG (9 October 2016)Report on current state of the specialised pain CRG (9 October 2016) news2016

News Report on current state of the Pain News 2016, Vol 14(4) 152–153 specialised pain Clinical Reference © The British Pain Society 2016 Group

Sarah Love-Jones Specialised Services Representative BPS, Consultant in Pain Medicine and Anaesthesia, North Bristol NHS Trust

National Health Service (NHS) England The process is that the CRG agrees the ways that specialised services should has announced the appointment of affiliates and then approaches the be provided. chairs for 40 Clinical Reference Groups society – I have just this week completed CRGs lead on the development of (CRGs), in addition to the establishment the application form to apply for the BPS. clinical commissioning policies, service of four cross-CRG working parties, to be The role of the CRGs is to provide specifications and quality dashboards. focused on research, data and resource, specialty-specific clinical advice and They also provide advice on innovation, and guidance and value. leadership for Specialised conduct horizon scanning, advice on Although some CRG chairs are new Commissioning. CRGs lead the service reviews, identify areas of appointments, others are returning development of clinical commissioning unexplained clinical variation and guide following the implementation of revisions policy, service specifications and quality work to reduce variation and deliver to CRGs which saw a reduction in the dashboards; advise on service reviews; value. number of CRGs. The CRG chairs will, conduct horizon scanning and make CRGs, through their PPV members, for the first time, hold formal, recommendations on innovation; identify also help to ensure that any changes to remunerated positions at NHS England and explore opportunities to reduce the commissioning of specialised and will serve for 3 years. clinical variation in healthcare and deliver services are co-produced with and The guide for CRG members has yet value; and provide specialty-specific involve patients and the public. to be published, despite NHS England’s clinical advice where required. All the CRGs, with the exception of the original commitment to produce this by cross-cutting medicines management the summer. It is particularly concerning CRG, are grouped around and report that the guide is unavailable before new Background into, one of six National Programme of CRGs begin their work programmes. NHS England is responsible for Care (NPoC). Further details on the Nevertheless, it is expected that the commissioning £15.6 billion of current arrangements for CRGs and the guide will have information on CRG specialised services to meet a wide NPoCs they are aligned to can be found subgroups and external stakeholder range of health and care needs. These on the NHS England website. engagement. include a range of services from renal CRG membership currently consists of With regard to the Specialised pain dialysis and secure inpatient mental a chair who is a senior clinician in the CRG, it is now appointed and in post. health services, through to treatments for relevant specialty, up to 14 specialty John Hughes has been reappointed as rare cancers and life-threatening genetic members from ‘Senate’ areas, four PPV chair. There are eight members disorders. Clinical advice and leadership members and four members from representing the four regions, two from is vital to the success of improving the affiliated organisation (such as colleges each, and all from separate senates. commissioning of specialised services and societies). There are three Patient and Public Voice across the NHS. CRG chairs and members do not (PPV) members. Competition for clinical CRGs are an integral part of this and currently receive additional NHS England members was high, and difficult bring together groups of clinicians, honoraria or payments for their work, but decisions had to be made. The affiliate commissioners, public health experts, are supported by their employers to members are currently being patients and carers. They use their participate in CRGs. reappointed. The British Pain Society specific knowledge and expertise to NHS England has listened to feedback (BPS) is one and highly likely to remain. advise NHS England on the best from CRG members and wider stakeholders

152 Pain News l December 2016 Vol 14 No 4

08_PAN677467.indd 152 21/11/2016 5:59:26 PM News

Report on current state of the specialised pain Clinical Reference Group

on how the current system is working the PPV Assurance Group to ensure the CRG membership, for a more through workshops for chairs and PPV CRGs, under NPoC leadership, are streamlined, fully engaged group. members held over the past focused on NHS England priorities 18 months. They also listened to and work within the NHS England During member recruitment, the feedback from CRG members and operating model. following was taken into consideration: wider stakeholders through the 2. CRGs’ chairs to be a formal NHS Investing in Specialised Services public England appointment – with 1. The two regional representatives will consultation in 2015. remuneration at one Programmed come from different senate areas The purpose of revising the specialised Activity (PA) per week (4 hours) – to within each region. commissioning CRG structure was to bring recognition and accountability. 2. CRGs will, where necessary, have respond to this feedback and also to In clinical areas that do not have a appointment requirements applied to ensure that this clinical advisory National Clinical Director or associate ensure there is a mix of expertise. mechanism aligns with the priorities of director, CRG chairs may take a 3. One of the regional members is NHS England as set out within the NHS specialty ‘National Clinical Lead’ role defined as data, information and Mandate, the strategic way forward where NHS England requires this. pricing lead, who will take up a place within the Five-Year Forward View, the 3. Maintaining the CRG working model. on the relevant Health and Social need to ensure best value for patients There is a consensus that improving Care Information Centre (HSCIC) and appropriate clinical advances and the current model rather than Reference Group and NHS innovations. developing a new one is more likely to Improvement. deliver constructive outputs in the 4. One of the regional members is The revisions timescales required. defined as a research lead, who will In January 2016, NHS England agreed to 4. Providing comprehensive coverage of take up a role in the developing engage on proposals to streamline CRGs the specialised commissioning partnership work with National and enhance the support they get so as portfolio. In the proposal to reduce the Institute for Health Research (NIHR) to expand their impact. number of CRGs from 67 to 44, those and other potential research The following guiding principles have CRGs not providing specific support opportunities from the CRGs’ work. underpinned the revisions: to areas that are a responsibility of 5. One of the regional members is specialised service commissioning are defined as a commissioning for value 1. Delivering clinically led commissioning removed, and those that currently lead, who will join the commissioning that is consistent with NHS England cover related commissioned clinical for value work stream. principles and priorities. A services are combined. 6. One of the regional members is competency framework and 5. Simplifying the operation of the CRGs. defined as a National Institute for development programme for CRGs The previously agreed proposal (prior Health and Care Excellence (NICE) will be created with engagement of to consultation) reduces and refreshes liaison lead providing advice to NICE.

December 2016 Vol 14 No 4 l Pain News 153

08_PAN677467.indd 153 21/11/2016 5:59:26 PM 0010.1177/2050449716676985New perspectives on the placebo response: why does giving nothing work so much better than doing nothing?New perspectives on the placebo response: why does giving nothing work so much better than doing nothing? research-article2016

Professional perspectives New perspectives on the placebo Pain News 2016, Vol 14(4) 154–156 response: why does giving nothing © The British Pain Society 2016 work so much better than doing nothing?

Paul Dieppe Emeritus Professor of Health and Wellbeing, University of Exeter Medical School

This article is a transcript of a presentation at Philosophy and Ethics meeting in 2016

Although I Doctor: What’s the point? I don’t do completely ignore the other 75%, or have anything for you – I don’t give you any regard it as a nuisance, and, until recently medicine relatively recently, this was generally learnt a Patient: I need you, Dr Barham. You’re dismissed as just regression to the mean good deal my medicine. and something we don’t have to worry from my Doctor: Oh all right Doris come back in about. reading of three months then. However, if you put in a third group of the book Exit Doris people that you just observe and do Cure a Doctor: That, lad, is the art of medicine! nothing at all with, you do see some Journey effect of natural change, but it’s much into the That was a moment in my life that smaller than what you get with your Science of changed me from a cynical medical student dummy pill. For instance, in studies of Mind over who thought that psychiatry was the only interventions for pain and depression Body by Jo Marchant and a very recent way to go because everything else was so comparing observation only, dummy and article Telecebo: Beyond placebo to an uncaring and led me into understanding real interventions, the effect size of the expanded concept of healing by Larry that you could actually be a caring doctor dummy is around 0.5 to 0.7, which is a Dossey (Explore, 2016),i the influences on even in a teaching hospital environment. good deal bigger than most of the my thinking on the subject go back many That man became my mentor. conventional interventions that we use. years, in fact, to a single experience in the Recently, there have been some attempts 1960s when I was a student at a London to calculate the more difficult problem of teaching hospital. I was sitting in a clinic The placebo ‘effect’ effectiveness (the effect in real-world with Dr Barham, and one of his This completely artificial concept was situations), and the estimate is that about longstanding patients with rheumatoid derived from the randomised trial 75% of the effect of both analgesics and arthritis (RA) came in. She was much paradigm. We measure the effect of a antidepressants is the placebo effect. In improved but instead of discharging her drug in a predetermined way which other words, about 75% of the pain relief after a perfunctory examination, he means that we’ve decided what the effect you achieve with whatever you do has took a few minutes to inquire about is going to be and what to measure rather nothing to do with the specific her dysfunctional family and to tell her than seeing what really happens. And intervention. So, why don’t we worry how well she was looking after herself then to see how much of it is anything to about the 75% instead of the 25%? and how much better her hands do with the drug, we give a dummy drug It beats me as to why the placebo looked. I vividly remember the alongside and see a response. The only effects this wow! factor – isn’t taken conversation at the end of the bit that really interests us is the difference more seriously and given more attention. consultation: between this and the drug response, It does mean that giving nothing can be which in general is about 25%. a very effective intervention, and, as I will Patient: When can I come back, All our subsequent effort goes into try to explain, I think it’s the giving of Dr Barham? trying to enhance that 25%, and we nothing that is the point.

154 Pain News l December 2016 Vol 14 No 4

09_PAN676985.indd 154 21/11/2016 5:59:38 PM Professional perspectives

New perspectives on the placebo response: why does giving nothing work so much better than doing nothing?

determined to be susceptible to really understand or care and can occur suggestion. But we now know that some inadvertently when you think you are people are better at producing a placebo being very empathic and reassuring, for response than others. Trials by Suarez- example, when you say something like Almazor et al. and Kapchuk et al. ‘Oh dont worry, I don’t think there is comparing responses produced by anything much going on here to worry different care-givers giving sham and real about’. That gets interpreted as he does interventions, with no-treatment or not believe me, he thinks there is nothing observation control groups, show that wrong with me. And that can produce a you can train people to be really tremendous nocebo response, is very empathic and optimistic, and sure damaging and is probably happening all enough that results in better responses the time in routine consultations. Greville- on average. But some people can get a Harris research suggests that nocebo is great response even if they are being five times more powerful than placebo. How does placebo work? surly and negative, and some people The importance of meaning in this can’t get a good response even if they context has been championed by Dan are trying to do it properly. Placebo effects curiouser and Moerman, an American anthropologist in It also seems that the good intention of curiouser! his lovely book Meaning, Medicine and the person who is giving the treatment is Placebos do amazing things. They work the ‘Placebo Effect’ (Cambridge Studies). absolutely critical. So intentionality of us on animals, and good intention works on He feels that it is all about finding new as interventionists matters. There are plants as well as cells in culture. Placebo meaning for suffering, often through good examples in the literature of treatment can cure cows of mastitis. In a symbolism or metaphor, and that it is the experiments that have been done by a trial of high fat diet in rabbits, the animals reformation and the reconceptualising of sceptic or a believer in exactly the same whose handler cuddled them got no the story that allows you to improve. But conditions, and the believer gets a good atheroma and the others did. Not all of conventional theories are predominantly result and the sceptic gets no result. So these experiments have been able to be about the power of the mind and almost we can’t believe evidence if it depends repeated, but as some people can do all mean the power of the patients mind: on the intentionality of the person doing these things and some cant, to expect psychological theories about expectation it. I think that probably screws the whole them to be generalisable misses the and conditioning and neurophysiological evidence base of medicine. point. It has been well-documented that theories about activation of descending Maddie Greville-Harris has highlighted healing intention can allow seeds to inhibitory pathways of pain control and the importance of safety in the patient germinate better, seedlings to grow more release of natural endorphins or and professional interaction. Both giver and cellular enzymes to behave neurotransmitters. Most of the recent and receiver must feel safe, which is differently, and the effect is actually research concentrates on the brain using rarely the case at first encounter. Being bigger in plants and cells than in scans which seem to me like safe is about activating the nurturing humans. Stranger still, there is strong 21st-century phrenology and don’t response, which is the exact opposite of evidence in the extrasensory perception explain anything. It all misses a critical the fight or flight response. So no wonder (ESP) literature, from human interactions point. The patients’ brain is clearly an when you tell people that they have with animals, near-death experience and important effector of the change, but cancer, they don’t hear anything else, brain-scanning experiments that the something else needs to happen to because they are immediately in fight or healing response in one living organism activate that change. That is about the flight mode, and then they don’t hear can be induced through the good interactions between individuals and the things properly and you can’t intentions of another at a distance. The contexts in which they take place and communicate with them. Similarly, odds against these being chance within that the space between them: their validation is the key to a good placebo findings in some ESP experiments are words, emotions and behaviours. Recent response and invalidation, a powerful huge, but scientists find them hard to research suggests that the response way of invoking a nocebo effect. accept. (Like Richard Dawkins who said depends on the giver as much as the Validation is about the patient knowing in a radio interview about this subject a receiver. Concentration on the patient that the other person really understands few years ago, ‘I don’t care how much goes back to the old idea that some and cares for them. Invalidation can evidence you give me I’m never going to people are perhaps genetically occur if the patient thinks that you do not believe it!’)

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New perspectives on the placebo response: why does giving nothing work so much better than doing nothing?

There is loads of stuff about animals and consciousness research. Regarding knowing when their owners are about to the non-local mind: within the biomedical come home or mystic mogs who know model, we believe that consciousness is when people are about to die. A palliative generated by the brain, but there is little care doctor who is a friend of mine told or no evidence to support that me that if they didn’t know who was hypothesis, and quite a lot of evidence going to die soon, they just looked to see against it. Many former scholars like Jung whose bed the cat was sitting on, and it didn’t believe in it. Nor indeed do the was always right. Of course it might be quantum mechanics people, and several the smell, but it also might be something of them share Max Planks belief that to do with the weird phenomenology that matter is derived from consciousness I am suggesting. and that there is no matter without Distant synchronisation of activity in consciousness. I have no idea what that brain scans has been demonstrated in the means, but I think that the idea of the subjects of Hawaiian traditional healers non-local mind makes a lot of the who were sending healing intentions from phenomena we see in medicine like the opposite side of the island; this has placebos that we have been talking been repeated by the so-called hyper- about today easier to cope with than our scanning techniques. But this sort of stuff current materialistic, positivist isn’t talked about because it doesn’t fit hypotheses. So the idea is that conventional science. consciousness is out there, and our consciousness out there. And that bit is individual brains are receivers and filters about connectedness. Explanatory frameworks of consciousness, and of course So the question remains: why does One of the proposed explanatory because our brains are different and have giving nothing work so much better than frameworks involves quantum mechanics developed differently, our experiences are doing nothing, and the answer is this: and entanglement, which I don’t claim to all different, and our contributions back because we can connect with each understand. Apparently electrons can be and forth are different with different other. And I just think that’s wonderful. in two different places at once and react people. But we are all trying to connect it in exactly the same way at exactly the in to the bigger picture. Acknowledgements same time. Another involves The schematic below reminds us that, This article is a transcript from a lecture consciousness research and the concept whereby as humans on this earth, we are given by the author at 2016 Philosophy and of the non-local mind. So we seem to body and mind and that dominates Ethics SIG Meeting. have three strands coming together: because it’s about survival, sex and quantum mechanics telling us that it is all tribalism, we also have our soul, our Note as it probably should be, distant healing spiritual side which is the bit that is i. http://www.explorejournal.com/ which has always seemed a bit weird connected with the greater article/S1550-8307(15)00166-4/pdf

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Professional perspectives To heal or not to heal: the Hamlet effect Pain News 2016, Vol 14(4) 157–159 © The British Pain Society 2016 Sarah Goldingay Senior Lecturer, Department of Drama, University of Exeter; Presenter, The Problem of Pain, BBC Radio 4 (http://www.bbc.co.uk/programmes/b061t68w)

This article is a transcript of a presentation at Philosophy and Ethics meeting in 2016

The enactment of the clinical encounter doctor–patient encounter from the is a key factor determining a person’s perspective of the physician, and more response to any medical intervention. I’m importantly, how might it help us a performance ethnographer, a understand the prevalence of ‘burn out’? humanities specialist who draws on I’m part of a transdisciplinary team methodological approaches and literature whose members work in medicine, from performance studies. Performance psychology and the humanities. We take studies (PS) is a discipline that takes a a holistic approach to try and understand whole systems approach to how context shapes a person’s healing understanding human-to-human response both positively and negatively.6 interactions by considering the material Our 5-year collaboration has led us to and immaterial processes at work in an the surgery, the doctor carries props and identify four key concepts: (1) human-to- encounter. Underpinned by the so-called wears costumes that signify purity, human interactions matter, (2) context anthropological ‘turn’, PS was developed knowledge and power. The semiotically matters, (3) the whole person and their out of the work of researcher- rich stethoscope and white coat are less community matters and (4) practitioners such as Schechner1 and common now, but scrubs and lanyards communication, reception and Turner2 and has its roots in Aristotelian offer alternative, if more ambiguous, interpretation matters. We believe that and Platonic questions about what it is to signifiers of a person’s role and interactions, predominantly human-to- be human. Combined with a semiotics of associated hierarchy. Once in role, the human, enable the Healing Response, theatre and everyday life,3,4 it analyses healthcare professional asks questions the intrinsic ability of the human organism the performances of the church, or the that follow a pre-existing script or score to self-heal following physical, emotional, street, or the courtroom through shaped by Medicine’s well-established spiritual or social disruption and regain interpretation of costumes, scripts, sets, system and method of ‘taking a patient homoeostasis. In this article, I want to embodied and emotional experiences history’. The mise-en-scène of many of focus on the physician and respond to and knowledge, rituals and narrative these encounters is a consulting room, some of the conversations I’ve had with structures.5 Medical practice, too, readily with desk, computer and sink in plain healthcare professionals about the lends itself to analysis in these terms. sight, and couch half-hidden behind a pressure they are under to ensure The theatre in which a surgeon performs curtain. Both actors (doctor and patient) reproducibility and consistency in every is analogous to that in which an actor play roles that are societally prescribed patient encounter. I reflect on the performs. Elsewhere in the hospital or and take part in joint rituals, such as the impossibility of delivering this imagined clinical examination, in a place with perfection and how that might make a special significance, set apart in space practitioner feel. To do this, I’m going to and time, where acts of healing are turn to the narrative surrounding performed. These rituals also seep out Shakespeare’s play, Hamlet. I’m not and extend into the patient’s life through asserting here that the reality of the the issuing of a pharmaceutical rehearsal room is equal to that of the prescription – a set of stage directions consulting room, nor concluding that which generate a new ritual to be what happens as we explore an embodied three-times-daily through imaginary illness in the one space, is the ingestion or application. So, what might, ‘same’ as that which happens when we taking this viewpoint, tell us about the explore a real illness in another. And yet,

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personal experience of the ‘messiness’ memories of them, skimping some of life, we know that human-to-human details, exaggerating the showy interactions are unpredictable, passages, forgetting the meaning’.12 In changeable and surprising, even when reading this passage again, I was guided by the script of taking the reminded of medical students telling me patient’s history or the performance that they often mirrored the practices of score of a physical examination. There is physicians they observed as part of their therefore, a tension then at the heart of training. They copied their tone of voice, the doctor–patient consultation. The their approach to patients and, because implied reproducibility is not achievable; this was ‘real’, tended to prioritise this what is said is overturned by what is over their ‘classroom’ learning in their the majority of research into the mind/ done. While in the acute model, the RCT professional practice because body implications of the placebo effect is the idealised form for all encounters ‘somewhere, someone has found out (e.g. Benedetti7 and Dieppe8) and into whether at the bench or bedside, with and defined how the play should be the well-established healing powers of this unspoken measure of reproducibility, done … imitating its memories of them, shamanic medicine (e.g. see Levi- the doctor will, on occasion, not meet skimping some details, exaggerating the Strauss,9 Schechner1 and Kaptchuk10) their own expectations of meeting this showy passages, forgetting the suggests, counter-instinctively perhaps, unarticulated, but nevertheless, real meaning’. In part then, this is a theatre of that the intangible, the imaginative and standard. In some way, they will feel reproduction but not a reproduction of the performative call into question some a failure. clinical guidelines, but rather of cultural of our assumptions about what Theatre sees reproducibility differently. practices: constitutes ‘reality’: It asserts that reproducibility is undesirable because it prevents the There is nothing either good or bad, Though this be madness, yet there is conditions for the engagement of this but thinking makes it so. method in’t. particular audience in this particular space and time. Good theatre, even While I can’t declare the eradication of Reproducibility matters in the theatre, though it knows it will fail, sets out to deadly theatre, Brook’s idealistic just as it matters in medicine. But each meet the audience where they are to perspective of theatre’s need to profession’s relationship with the idea of hold open space where someone encounter an audience anew for each reproducibility is rather different. The watching might re-evaluate their performance has become a central delight of The Journal of Irreproducible understanding of the world and even strand of theatre production and actor Results, and the discussion following change their behaviour. The dominant training over the last 40 years. So, how so-called ‘crisis’ of reproducibility in narrative argues that the best theatre is might inverting the idea of reproducibility biomedicine that came to the fore this always responsive. Its subtle story help us better understand the lack of summer, shows that reproducibility is suggests finding a way of making reproducibility in a doctor–patient understood by medics to be contextual interactions uniform night after night interaction? A play like Hamlet is and part of the ‘messiness’ of scientific makes for a ‘Deadly Theatre’. In 1968, repeatedly performed always using the study. Yet, there is another, more subtle theatre director Peter Brook wrote a now same script. What is accepted, story in play, not directly told but implied classic book, The Empty Space, about cherished even in theatre, is that while through cultural-norms, training and the need for a careful re-evaluation, or the script, its words and stage directions practice.11 This story suggests that, just even revolution, of the ways that theatre remain the same on the page, no two like a gold standard randomised was written, taught, theorised and made. performances are ever identical, even if controlled trial (RCT), the medical He coined the term ‘deadly theatre’ to they are performed by the same consultation should be reproducible, that describe successful, commercial, but company on the same day, as with a every encounter could be optimum, ultimately unsatisfying, theatre. In this matinee and evening performance. The every interaction similar and comparable, model, deadly theatre does not change performance blueprint – the text – and, if it isn’t, either the doctor or the its audiences’ understanding of the remains the same, as do the settings and patient is at fault. This perceived fault is world. Instead it ‘approaches the classics the costume, the ensemble and the because either person is failing to follow from the viewpoint that somewhere, building, but its subtle interpretation is a procedure or to fulfil their normalised someone has found out and defined how matter of individual and collective roles. And yet, because of our own the play should be done … imitating its interaction and experience. This

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experience then is akin to that of the to an overworked clinician. This space to versus the absolute of unpredictability. physician, but the way that reproducibility notice what didn’t work so well, might be And, as a binary it is, of course, flawed; is understood, valued and articulated time to return to the guidelines to look for each encounter is unique, some are varies. Actors are trained to look for ways to refine the next encounter, but it closer to the text book or script or variation, nuance, opportunities to create also might be an opportunity to consider rehearsal room that others, while some new avenues of interpretation and not only the expectations the patient might begin predictably but by the end understanding. In this training, self-care brought but also the expectations that have entered new and unexplored is paramount and embodied, and the physician has about failing to meet territory. Much of theatre is carefully emotional knowledge is deemed as an idealised consultation. Noticing the structured, planned, executed time and valuable as reason and cognition. pressure to ‘catch’ everything, observing again with precision, but what it offered is Although taught, not to encourage navel the desire to ‘fix’ the patient, even if, with an acknowledgement of the limits of gazing, of course, that does happen. a chronic condition, all that can be reproducibility and recognises the need Self-reflection, taken from a wider offered is care. for variability. This approach invites a perspective, aims to help the actor Actors take their training with them into different sort of skill set from its understand their cultural predispositions the rehearsal room, like medical students practitioner, one that champions self-care and assumptions to help them take their training into their practice. For through self-reflection. An actor’s training reconsider the bias they might bring to actors, rehearsals are another sort of enables engagement in deep-listening the encounter. In a more specific way, testing ground, experimental and full of with audiences. They seek out the they are also taught to include self- failure, where the slow building of the unexpected to shape their responses reflection as part of the warm-up routine world of the play and repetitious with profound empathy. This deep- that precedes each performance to help explorations of scenes and characters listening is not only aural but also spatial the actor understand their present state investigate the multiple ways that things and embodied. Actors are trained to be and what they bring to this particular might happen in the play. This reflexive about their work, to take their performance by acknowledging their environment is where the apparent physical and emotional care seriously, to ‘here, today, now’.13 Actors are absolute of the play text is interpretation prepare before every encounter and to encouraged to reflect on how they feel through human-to-human interaction. learn through experience. about each session of training rehearsal What happens in the rehearsal room is So far, medical research has been unable and performance, to reflect, respond, analogous to the martial arts dojo, where to explain why interpersonal adjust their practice and honour their daily repetition of katas prepares the body communication and caring is efficacious feelings. In the time-pressured and mind for the improvisation of the and how human interactions heal. Perhaps, environments of surgeries and hospitals, fight. For the actor, the repeated scenes by acknowledging the way the variability in I can see how such a moment of provide a portfolio of responses, helping doctor–patient interactions make the reflection seems a self-indulgent luxury. them deal with the improvisational physician feel, this can help us understand As one of our research group explained, demands of each live performance. And how real-time culturally dependent complex this is true too, in a way, for the interactions can be shaped to create a In our business, we Doctors don’t consultation room. Doctors have medical positive experience for both patient and pay attention to what an encounter training that both prepares them as practitioner. makes us feel. We sit in an analytical individuals and provides real-life frame of mind, trying to figure out experience. However, what is different is References what the diagnosis might be, which the expectation of reproducibility because 1. Schechner, 1988. drug to give, etc., while the patient while different healthcare consultations 2. Turner, 1974. weeps quietly in the other corner of may appear very similar, in particular, if 3. Pavis, 1982. 4. Alter, 1990. the room. We may worry about what each component is considered in a 5. Schechner, 2002. they are feeling, but we never stop to reductionist way, conducted on the same 6. Osteo&Cart + RiDE + Psychaitry. consider what we are feeling day, in the same room, by the same 7. Benedetti, 2012. 8. Dieppe, 2016. 14 ourselves. practitioners, the interaction of ritualised 9. Levi-Strauss, 1968. performance produces different 10. Kaptchuk, 2011 But having permission, either culturally experiences and outcomes. 11. RiDE. 12. Empty Space (1968: 17). or temporally, to take a moment to reflect This model set out in this talk offers a 13. Bella Merlin, 2008. on each encounter might give a little relief binary of the absolute of reproducibility 14. SG fieldnotes 2012.

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Professional perspectives Brief psychological and hypnotic Pain News 2016, Vol 14(4) 160–163 interventions in the management © The British Pain Society 2016 of pain – giving control back to the patient

Dr Ann Williamson

This article is a transcript of a presentation at Philosophy and Ethics meeting in 2016

Often, The first thing I want to do with to be upset or anxious because words when patients with chronic pain is to teach are not the language of the right brain. someone them ways to change their focus of But one can paint a word picture using has chronic attention and help them to become more guided imagery or metaphor. All the great pain, it relaxed. I teach them self-hypnotic teachers of the past have used metaphor tends to be techniques but, first, I have to explain or stories because they are such an their main what hypnosis is and isn’t. A useful effective means of communication – they focus of diagram that I use is featured below. communicate to both types of our attention; I explain that this is a model to help processing, left and right brain, their life understanding, not the truth. intellectual and emotional processing. and their The brain has two cerebral We shift into different levels of identity hemispheres and while in our normal consciousness at different times every defined by their pain. They may be waking state the left tends to be more day, and hypnosis is just a label for a way focused on their pain by hating it, feeling dominant and could be likened to our of doing this deliberately in a similar way angry about it, wanting to deny it exists, ‘conscious mind’. This communicates as meditation. Everyday trance states are expending energy trying to ‘fight’ their verbally and is the more intellectual, common such as getting lost in a good symptoms or simply accept it, feeling rational part of ourselves. When we relax book or driving down a familiar stretch of helpless and hopeless. This article will or become deeply involved in some road with no conscious recollection. demonstrate ways that I use to engage activity, our right brain becomes more Our conscious awareness of our outer the patient in helping themselves to be dominant. The right brain could be seen surroundings versus an inner awareness as fit as they can be and to be more in to be the more emotional, creative part of and focus are on a continuum so, when control of how they feel; they may not be ourselves that communicates with in hypnosis, one’s focus is predominantly able to ‘cure’ the pain but they can find symbols and images, and could be seen internal, but one does not necessarily that they are more than their ‘pain’ and as our ‘unconscious mind’. There is lose all outer awareness. that they can ‘suffer’ less as a result of it. always a difficulty in telling ourselves not Joseph Barber said, ‘Hypnosis is an Another problem is that often the altered state of consciousness health professional cannot determine the characterised by changes in mood, actual physical cause of the pain, and sensation and perception, and allowing the patient may feel that they are for greater access to unconscious disbelieved. This may obviously lead to processes’. Hypnosis in itself is not a anger and resentment on the patient’s therapy but it can be a tool that facilitates side and leave the health professional the delivery of therapy in the same way with a feeling of helplessness (often as a syringe delivers drugs. Hypnosis masked as irritation). Helping patients does not make the impossible possible tolerate uncertainty is often a major goal but can help the patient believe and of the therapeutic intervention. experience what is possible. Once in

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hypnosis, imagery and suggestion can as you cannot not think of a ‘pink also be effective. It is also useful to point be used with good effect. banana’ once it has been mentioned. We out the differences between associated To enter the hypnotic state, one needs need to learn to phrase things in a and dissociated imagery. In associated to focus attention (induction), and this positive manner. imagery, one is ‘in’ the image not merely can be done in many ways. A visual Therefore, the therapeutic interventions looking at it; this increases the emotional focus could be a candle flame or a for a patient with chronic pain are to impact and is used for giving positive computer screen. An auditory focus facilitate a different perspective, engage suggestion. Being removed from the could be music, chanting or using the imagination, focus attention and image and looking at it from a distance mantras. Some inductions are mainly access a ‘being’ state where suggestion (dissociated) reduces the emotional kinaesthetic such as progressive and imagery is more effective. impact and is used when working with muscular relaxation (PMR) or using Numerous controlled studies negative scenarios. ‘involuntary’ (or ideomotor) movement. demonstrate physiological responses I find it useful to teach patients to use One of the easiest is to engage the associated with hypnosis, which are not imagery to help themselves let go of patient’s imagination using revivification demonstrated with role playing and negative feelings and to access their (or re-experiencing) of an experience, a suggestion/expectancy alone. Research strengths and also to construct a special, daydream or fantasy. Hypnosis can be has shown that using imagery in the calm place, where they can go in their used formally in sessions or informally in ‘hypnotic state’ triggers similar brain imagination to ‘recharge their batteries’ conversation by directing the patient’s changes to the ‘real’ experience. and get in touch with their inner strength. focus and engaging their imagination. Kosslyn et al.1 in 2000 gave identical The patient is reminded to explore their A balance needs to be kept between mental imagery suggestions to two imagery using all the senses, to really ‘be validating the patient’s problem and groups, one in hypnosis and one not. there’. Useful questions can be ‘What do focusing on their goals. Sometimes it is Only the hypnosis group showed you get absorbed in? What helps necessary to break into the flow of activation in the colour areas of right and already? What comes to mind as I say negative, problem talk from a patient, left hemispheres when asked to perceive the words calm, relaxing, tranquil?’ and this can be done, without breaking colour. Similar studies have been made Our internal thoughts and ideas about rapport, by interrupting with a cough or a with auditory and olfactory stimuli. ourselves determine how we feel and sneeze, or by dropping your pen and Derbyshire et al.2 in 2004 behave. ‘If we change what we “see” then moving position, then within the next demonstrated this same effect with pain we change what we feel – we are second or two, focusing the conversation from a heat probe and hypnotically whatever we think we are’. By changing towards more positive aspects. imagined pain as shown below. the imagery, we can start to regain control. Health professionals often do not Using imagery, one can help patients realise the power of the words they use, change how they see themselves; from especially when a patient is feeling a ‘victim’ to someone who can cope anxious. In this state, the patient is and who has greater control over how already in a semi-hypnotic state where they feel. the right brain or emotional processing is It can be used to change how patients predominant and therefore any words see others, or a procedure, from may be taken as hypnotic suggestion and threatening and fear-provoking to act more powerfully (and literally) than something that they can cope with expected. Unfortunately the negative is calmly. Positive mental rehearsal is often our default position, emotion makes us helpful – getting the patient to imagine more suggestible and adrenalin ‘fixes’ (associate) with the desired outcome. memories especially negative ones. For example, feeling calm while having a The meaning may not be what you procedure done. This can also often be intended, such as in the story of the patient achieved by suggesting they imagine who was failing to recover as expected themselves somewhere else, maybe in after an Australian Doctor had said post Imagery is not just visual; it can be their special place. operatively, ‘You are going home to-die!!’ auditory, kinaesthetic, olfactory/gustatory, Imagery can be used with some The ‘unconscious’ does not process spatial or simply an ‘awareness’. It is patients to reduce the intensity of pain negatives, so phrases such as ‘Don’t important to mention this to patients who and most can be helped to feel less worry about it!’, ‘This won’t hurt!’ are are not very skilled with visual imagery as distress. I find client-generated imagery experienced negatively in the same way working with ‘just knowing it’s there’ can is often very effective. I ask them to close

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you add water. If they reply in the or secondary gain; a past traumatic affirmative, I suggest that they close their experience; identification – where the eyes and imagine their pain gathered up patient ‘takes on’ the problem of into a crystal. I ask them to tell me what someone close to them, often deceased; colour it is so that I can ensure that they imprint – where a negative suggestion, are doing this. I then ask them to imagine something someone said to them, has pouring healing fluid over the crystal and been internalised and become their truth; watch it dissolve. Once it has dissolved, I and self-punishment – where the patient ask them to rate how comfortable they unconsciously punishes themselves for feel out of 10 and suggest that they can something that they feel guilty about, keep this level of comfort when they whether appropriate or not. their eyes and look at their pain ‘out re-alert. As John Hartland said, ‘Few patients there’. If they could paint a picture of it, Much anxiety and distress is driven by will abandon their symptoms until they feel what would it look like? By asking negative internal dialogue which can be strong enough to do without them’. But various questions about its texture, changed by using auditory imagery, by teaching self-hypnosis and showing colour, motion, size, sound and so on, imagining the dialogue in a cartoon voice the patient how to use imagery and give they are encouraged to really visualise it or in the voice of someone who has themselves positive suggestion, much (hence entering a hypnotic state). I then inhaled helium, and it becomes much can be achieved and no harm is done. ask what change can they make that less believable. would be helpful; that might help it feel Although much can be done with Further useful information can be found at easier? As they describe it, I ask them to simple suggestion and use of imagery in start seeing that change happen and the hypnotic state, many patients have http://www.annwilliamson.co.uk they feed back to me as the process underlying difficulties that need resolution. continues. Some quite marked changes It is beyond the scope of this article to http://www.bscah.com can occur in a short period of time, and elaborate much on these but, in my http://www.scimednet.org before they alert, I suggest that they can experience, many patients with chronic keep the comfort they have achieved pain, especially those with conditions http://bscah.com/about-hypnosis/ and successfully repeat the process at such as fibromyalgia, will not get a lot information-health-professionals home whenever they wish. better unless these are addressed. There are many other hypnotic Underlying ‘causes’ may often be References techniques that can be used but an operating at an unconscious level, and 1. Kosslyn SM, Thompson WL, Constantin-Ferrando MF, et al. Hypnotic visual illusion alters color example of guided imagery that I hypnosis can often be the way to help the processing in the brain. American Journal of sometimes use, especially for headache, patient resolve these issues. They may Psychiatry 2000; 157: 1279–84. is to ask the patient if they have ever include internal conflict; organ language – 2. Derbyshire SW, Whalley MG, Stenger VA, et al. Cerebral activation during hypnotically induced played with copper sulphate crystals as a where the patient’s unconscious is trying and imagined pain. Neuroimage 2004; 23(1): child and watched them dissolve when to tell them something; serving a purpose 392–401.

Revivification – changes focus of attention – uses client-generated imagery Ask the patient to decide on a physical activity such as swimming, skiing, running, horse-riding, cycling, preferably a specific time when they really enjoyed this activity. Ask them to let their eyes close and re-experience it. Ensure they use all their senses – seeing, hearing, feeling and possibly smelling. After a few minutes, when they have finished, they should open their eyes and you can get feedback on how they felt. Most notice that they begin to relax. Alternatively ask the patient to start imagining the activity (swimming) very fast and ask them to gradually slow it down as they feel ready to until they are resting (floating). This matches a high adrenalin state and is often easier to do if the patient suffers from chronic anxiety.

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Breathing focus Observe the breath rather than trying to change it. Notice the rise and fall of the chest. Follow the flow of air in and out. Become aware of slight temperature difference between the air breathed in and that breathed out – as the breath is warmed by its passage through the lungs Re-focus if mind wanders (which of course it tends to). Give a positive suggestion for the future (each time you try this, it will become easier and easier to do; as you practise this you may find yourself becoming calmer and more able to deal with things.

Silent Abreaction – Safe release of strong negative emotion Close your eyes and go in your imagination to a rocky place, miles away from anywhere … There, find a suitable rock to be the anger that you wish to be rid of. And project this anger into the rock, marking it in some way so that you know what it represents … Look around for something that you can use to smash the rock into tiny pieces, maybe a pickaxe, a pneumatic drill … Enjoy smashing the rock up … Decide what you would like to do with the dusty bits left? Then take yourself to a peaceful place and enjoy the feelings of calmness. Re-alert.

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11_PAN676994.indd 163 21/11/2016 6:01:00 PM 0010.1177/2050449716678359Suffering as a guiding call towards transformative change: the movie of pain in the cinema of the mindSuffering as a guiding call towards transformative change: the movie of pain in the cinema of the mind research-article2016

Professional perspectives Suffering as a guiding call towards Pain News 2016, Vol 14(4) 164–170 transformative change: the movie of © The British Pain Society 2016 pain in the cinema of the mind

David Reilly Senior Lecturer in Medicine at Glasgow University and Visiting Professor of Medicine at Maryland University, USA.

This article is a transcript of a presentation at Philosophy and Ethics meeting in 2016

It is millions are finding their later years old maps. In this dehumanisation, as in impossible to blighted by poor health, and on average, the epidemics, we find that our old ways create a people can expect to spend their last are not working well. They palliate, they world that 10 years suffering from health problems. don’t transform. We watch, feeling differs from The burden on people and healthcare is almost helpless, as the tide rises of our enormous, and this cannot be blithely stress and poorer wellbeing in our staff, unquestioned dismissed as a product of medicine’s battering the shore of our therapeutic inner maps of success ‘because we are living longer’ – spaces and hopes. the world. as most are diagnosed under 65 years of David Reilly age, and the ages of onset of many degenerative diseases is getting younger. The fifth wave: changing Lifestyle diabetes is now even appearing responses to changing suffering The call for transformation in children. These epidemics are linked to As circumstances change, so must our Unresolved predicaments are the starting the way we live, they way we treat response. If our current ways were the point for change. Suffering is not an ourselves and the conditions we are answers to these predicaments, we enemy. It is a guiding call towards subject to. The person suffering with would have resolved them, as we have needed transformation. Don’t turn away. chronic pain does so in this shaping with many infectious diseases epidemics. context. These contemporary challenges are not Pain and the epidemics yielding to the power of the medical and When we find ourselves lost, as an expert ‘fix-it’ maps. We need a different individual, a therapist, a system of care, it Dehumanising conditions: the way, we need to change. And for that, behoves us to admit it and question the conversations of a thousand we need to tune our compass in a fresh maps we used to arrive there. hands direction and generate different maps. And we are at a point in history when When we seek professional help with We need to first create the conditions to we may be ready to admit we are lost – these diseases of modernity, we meet a create, before we can create. This lost in an era of unprecedented second equally dense predicament. I call process is scale independent – it applies spreading epidemics and pandemics of this ‘The Conversations of a Thousand in the suffering of a single life, as it does long-term conditions: like obesity and Hands’ to honour the seas of hands to a culture. We turn to ask, ‘What maps diabetes, and depression – and so much raised when I have asked audience in a are driving this suffering, and what is this more, including chronic pain. Over 40% number of countries if they agree that the suffering calling for?’ of the population in my native Scotland human side of care is under The ‘Fifth Wave’ is one dialogue model have a long-term condition – a critical unacceptable strain in today’s care of value in considering our change impairment of contemporary human systems. We have at least now started to process. It characterises the great health wellbeing. This picture is repeated across admit this predicament – a significant gains through the eras of the industrial the industrialised world. And when you step forward – because feeling and revolution as arising from four prodigious have one such condition, you will likely acknowledging suffering is often the waves of public health, each standing on develop more than one. The United prerequisite to invoking a call for change, the shoulders of its predecessors: The Kingdom adults are living longer, but rather than just working harder with our first wave was that of great public works

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Suffering as a guiding call towards transformative change: the movie of pain in the cinema of the mind

and municipalism in the 1800s. Then the our systems and in our cultures? What Let’s distinguish suffering from pain. second wave, building from the early do we do when the fix-it model fails? Pain is a trigger for suffering of course, 1900s, accompanied the refinement of The conclusion adopted in The Fifth but suffering is a mental state. Mental the scientific approach, including the Wave report, chimed with from my own states are internal. They are always up germ theory of disease, the work in ‘the healing shift enquiry’. This for change. To say that nothing can be pharmacological explosion, the growth of new wave will build on, not reject, the done for a human in suffering is forever hospitals and the introduction of new establish four waves and their core nonsense, even if ‘the pain’ itself cannot healthcare professions. The third wave question: ‘What can we do help this be directly modified. But of course, alter after World War II (WWII) saw the situation?’ This is not either/or. The new suffering and en passant pain alters. At restructuring of institutions, welfare wave’s core question will be along the start, it’s us, not suffering that has to reforms, new housing, social security and lines of: ‘What can be done to release shift. Our suffering must cease to be the the birth of the National Health Services capacity – within this person, this enemy to be eliminated. Rather, it (NHSs). This was followed by the fourth community, this situation?’ This shift of presents a guiding call for change: and current wave with a focus on the risk compass immediately shifts the journey indeed, the spot-on signpost towards theory of disease and lifestyle advice (like and the outcome. The shift moves us our transformation and eventual smoking, diet and physical activity). from an orientation of seeking, or acting flourishing. In a storm, sailors do not get The continuing spread of new forms of as, an external expert to intervene far arguing with the wind, the change long-term non-infectious conditions (a ‘cure’ for suffering, obesity, despair, their relationship to it, by turn into it. This evidences the diminishing returns from lifestyle diabetes, loss of meaning etc.), theme of shifting thinking, and so these four waves – and forces us to seek to a path of helping ourselves and others perception, is one that I would like to ‘the Fifth Wave’. This must move us release our innate capacities, and foster explore further together. beyond managing our predicament – to a sustainable developing nurturing actually transforming it. Take the relationship with this. This could sound Relationship: the crucible of transformation of another epidemic from like so much idealism or grand theory. It change another era – and consider the parallels is actually focussed, practical and In all this, safe compassionate to our predicaments. In 18th century potent. Later, I’ll aim to bring this to life a relationship is a crucible of healing Glasgow, thousands would die in those little with a person’s account of their own change: relationship with yourself and years when cholera hit. People struggled transformation and offer some comments your own life and humanity, and, critically to manage, calling for more vital on the catalysts to such change. for us as professional carers, the resources and care for the sick. relationship with a trusted other. At our Comments of the time included saying best, the relationship and safe space we such trouble was just the way it is, an Becoming students of suffering create are catalysts for healing change. inevitable part of modern life, part of the and release human condition. Transformation had to Let us now consider this needed shift in wait until someone dreamed a new relation to chronic pain. The four waves’ Transformation vision, navigated by a fresh map. models work well in acute pain and Subjective Arguments that the new way was not tissue damage, but in chronic pain, they Change feasible, not affordable and would fail show diminishing returns; way too often Within took 25 years to overcome. When Loch tipping over into a negative long-term The Inner World Katrine’s clean water supply was finally impact. To our disappointment, and Of channelled to the city, it cut the deaths to sometimes shame, we have learned Consciousness just double figures when the next cholera painfully slowly that pain killers are not epidemic swept the United Kingdom. the answer to chronic pain. One core At some deep level, when someone reason for this failure is that we have comes to sit with us, they are hoping for been attempting to apply the fix-it model transformation. Our job is to hold the Our shift of vision – inner life, of pain to the domain of suffering. That candle of knowing this potential lies innate strengths map leads us astray. I consider the call dormant; then grow an understanding of What will our equivalents be to Loch now is for us to also become students of the maps that are shaping their journey Katrine’s water for today’s epidemics? suffering and its release, rather than only and the perceptual shifts and so changes What will transform this suffering for pain. Most of us were not trained for this. of heart that lie waiting. ourselves, through our care for others, in We have been learning it ‘on the job’. Such transformative change is very

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Suffering as a guiding call towards transformative change: the movie of pain in the cinema of the mind

concrete in the end; it’s not some ropes? What then? I can hear your mind mind’, be it transmitted from your senses esoteric concept. Human beings and arguing with this idea already, ‘of course by electro-chemical processes and their biology have built-in capacities for they are snakes’ it says. ‘How could filters, and/or, just as powerfully, remarkable shifts. Based on my clinical anyone with this pain view it and life projected from your internal movie learning, I know that that person in front differently? My New York is the real one’. projector and its scripts, its soundtracks of me has the capacity for improvement We can interact with these processes – its network of maps. in their experience of life and their in ways that shift suffering. We can A little exercise: wellbeing, even for transformation. The question our mind’s perception and its enter reflection for a moment and fact I hold that view is already a mental maps of the world. Evolution has consider your true identity by completing catalysing condition. To meet someone created mechanisms to generate mind this sentence: I am … What did you get who recognises your potential to get free and its product of ego. It generates – a name, a role, a gender, is impactful in itself. thought-images all day long, it does this achievements? Now, close your eyes for The puzzle becomes quite different by itself, it doesn’t need us. It scans a few minutes and just be with the two- from the mechanised medical model, below conscious level, drawing its worded sentence: ‘I am’. Let there be a which remains invaluable in its place (if it conclusions and spotting its snakes. This firm full stop at the end. Sit with it, gently works, use it). The puzzle becomes the mind is stronger than us, and we cannot repeating it when you realise your mind releasing of potentials and establishing command mind to not react. But, we can has wandered. This can induce a sense self-sustaining growth of change. deepen a capacity to come to awareness of stillness as the voice in your head The potential for change in peoples’ of the fact that we are in mind’s ceases for a moment. In this silence, you mental state – in their inner world – can soundtrack, immersed in the hypnotic realise that that is who you really are, and be illustrated by twice looking at the movies of the mind. And a whole culture what you are, is alive. You are same identical short video of a taxi ride can be so immersed. This awareness is consciousness, all the rest is a story – round New York. The first time it is the beginning of the shift. The mind sweet and sour, rich and poor, pain-filled accompanied by fast spiky discordant doesn’t want you to get this. ‘Leave it to or free and so on, but don’t think you are jazz. This filmic journey induces a me’ it says, ‘I’ve got reflex brain the story of yourself, your identity or the sensation of tension and anxiety; the mechanisms that evolved over millions of state of your mind or your body; or else, passers-by appear somehow years to deal with the threat, I’ll keep you welcome to suffering. Peace … I am … threatening, the place one tries to safe’. These brain mechanisms don’t That’s what everyone longs for. Deep escape from. The second show, to need what we think of as ‘me’ (in fact, happiness, peace, release. It’s there, soothing classical music, induces a when activated, they suppress ‘top waiting, always. It goes with the bricks of feeling of calm and happiness and the down’ frontal cortex activity). They are being alive, it can’t be removed from a very same people appear reassuringly also ever powerful and present in a person, only obscured. friendly, the city one to explore. So we person’s consultation with you. We don’t But mind doesn’t want you to find this, experience and recall two quite different have to just be the mind’s slave, following because the egoic structure, in that New Yorks. Watching it, you experience its voice. moment of ‘I am’, considers that as a a dramatic shift in your mental state, your moment of annihilation, like a death, and experience, your emotion, your it has to keep you in the story – to keep physiology, your perception, your Our inner world itself alive. processing and how you are going to We’ve all got a voice in our heads – a We are alive in our inner world, and yet perceive and engage with the world. So running commentary. But who is listening must navigate and ‘live’ in the story of what soundtrack are you running in your to it? Pause on that for a moment. See the outer world. To quote one Wisdom head, or your patient or client in theirs? what your vocabulary and models are tradition, to ‘be in the world but not of it’; Say you are out walking in long grass when considering this. Words are to know the mind and its business, its and you stand on a big snake. You inadequate here, and mine may not drives and needs, the things it calls stagger back in terror. Then, as you look match yours; a description of our direct success and achievement and down, only then do you notice that it was conscious experiences is always satisfaction and safety, and eventually to a rope! Your fear reaction dissipates. inadequate. However, you know the be able to say to it, as to a little child: What caused that fear? – not the object universe only through the content and ‘Sweetheart, come here!’ I have found on the ground but the perception and the process of your own consciousness; you that establishing a nurturing relationship movie in your mind it created. What if live in a movie representation of the to life, to our body, to our mind is a key ‘the snakes’ of your life are actually world, playing in the ‘cinema of your for success in releasing suffering, in

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fostering flourishing. The way out of Nobody even knows what it would be Imagine … we had four hundred years suffering is not a war, it is way of a like to have the slightest idea about of research on the inner world, the nurturing peace. how anything material could be mysteries of mind, soul, and Over the centuries of scientific growth, conscious. (Jerry Fodor, Philosopher, consciousness … instead of how much have we been studying this 1992) researching the science of matter … inner world and its ways (rather than just (Henri Bergson) describing its derangement) in our Consciousness manifest, in the medical and healthcare system? Let me deepest sense, is who we are, but trying And that was written in 1913, so now go back before the customary quoting of to explain or analyse it is well-nigh it’s 500 years. We continue to approach Descartes to Galileo: impossible. There are two models: the human suffering in a fix-it manner; by first and dominant model, the emergent external objectification. This can be a … if the perceiving creatures are view, postulates that the brain produces wonderful thing and it’s not a question of removed, all of these qualities (tastes, consciousness as an epiphenomenon. either/or, but there are a lot of people for odours, colours etc) would be The second model, the non-emergent whom the toolkit is inadequate. We are annihilated and abolished from view, suggests that the brain transmits grateful for the former ways of the existence. (Galileo 1623) consciousness – which is ‘latent in the external expert coming up with a deep structure of nature: before brain, solution: the clean water supply, new This centrality of consciousness is not mind was’ (William James. 1898). It has structures, drugs and so on, but so often the reductionist materialism that followed been suggested that the effects on in the modern epidemics that’s not and came to dominate what we have functioning from damage to or working. We need to see the strength called science – and science’s active stimulation of parts of the brain support within the individual and how it can be discarding of subjectivity. We have an the former, but this is tantamount to released. I don’t know what makes impoverished method. The overriding third saying that because cutting some wires plants grow, but I can begin to person objective view has little time for the in a TV affects its function, it must be understand the conditions that affect it first person subjective, never mind the the origin of the things occurring on it. and can get quite expert at gardening. deep listen and consideration of a hardly The non-emergent view suggests that But that doesn’t solve the mystery of spoken of ‘second person’ perspective. there must be a mechanism for what life is and why seeds germinate. As an aside, Galileo’s quote might transmission of consciousness pre- A plant knows how to grow, and we have guided us into enquiry of what the existing the biological apparatus which don’t have to know (but crawling on our spiritual traditions would call emptiness. only acts as a filter. Fascinating scientific hands and knees we, forever, (The ego is terrified of that, of that silent speculation, but as Bob Dylan might can try and inch forward). The key thing ‘I am’.) We have sure avoided that. And have said if he had thought about it, We for us is to set up the right conditions in the same century and from another are matter, the stars are matter, but it and then we see it unfold in front of us tradition: doesn’t matter. From our point of view, like a mystery. I find this a very releasing our engagement is practical, empirical, image of what we are doing when we sit What counts is ‘the heaven of the seeking what works in the relief of with that individual and drop that god interior life’, not ‘external devotions’. suffering. And suffering lives in the inner complex – or that sense of failure when The important thing is learning ‘the world – or do you have another view we are hitting the problem with a spiritual philosophy. Others may study where it is? hammer and it’s not going in. natural philosophy and learn to know Can you see any links in all this stuff to It is impossible to create a world that the things of nature but do not learn the maps that we have used to navigate differs from your inner unquestioned map to know themselves’. St Joseph of ‘pain management’ and maybe hints of of the world. You are up against evolution Copertino – 17th Century others we could use? and biology. Functional magnetic I have found these themes to be resonance imaging (fMRI) scans show We may now have some clues on central in my work with patients whom that the same brain areas are activated mechanisms and effects of all this, but the pain clinic has failed to help. That by the world ‘out there’ and the world ‘in that said, we don’t have a clue what was my training ground and much of my here’. If your deep belief is that your New consciousness is: clinical practice – sitting with people York remains a place of threat, or your stuck in chronic pain and suffering. It felt ropes are all snakes, then despite Nobody has the slightest idea how like I started from a place of uncharted therapies, you will still be living in hell. But anything material could be conscious. territory: this invites the response: ‘what does this

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Suffering as a guiding call towards transformative change: the movie of pain in the cinema of the mind

man know about my life? – in my case phenomenon where the body is rejecting journey. What is that? Through our it’s a real snake!’ To achieve the attempt to turn off what it sees as the struggle, as our better hidden self is transformation, we have to get to some protective fire alarm and saying ‘you rediscovered, our inner resources are of these maps and mechanisms and be need this pain because it is your safety found and mobilised. part of the processes that facilitate the signal because you are in danger; they’ve The teenage explosion of brain growth is shift. There is a physiological mechanism missed something, your spine is more of a pruning: cutting back what involved: the more you think a thought, crumbling …’. So any prescription is a hadn’t been brought out. If not taken into the more it becomes ‘hard wired’; myelin threat. An fMRI study1 of ‘hallucinated’ imaginative stories or given visions of hope, is laid down on initially small connections, pain suggested under hypnosis showed these circuits will atrophy, and those of increasing the rate of transmission activity in the same areas as with threat-survival will be strengthened, as the thousands of times, so that the thoughts physically induced pain. But when brain adapts to the sort of jungle it finds are now embodied. So the journey may subjects were asked to just ‘imagine’ itself in. However, its plasticity allows for be long, difficult and relapsing as the old pain, there was only minimal activation. later change as we begin to live differently, soundtracks keep reasserting Of course there is no such thing as by different values, by re-emphasising a themselves, as we work to try to imagined pain because that is a fresh compass. It is often fresh stories that re-myelinate, to strengthen, to grow and subjective experience. But we can be shift our understanding and inspire us to to re-model our minds – and thus brains. trapped within the movie. It is possible to act differently. The brain is a dynamic living organ experience pain in the absence of direct I maintained a focus over 20 years of responding to how it is used and who is stimulation, and there is evidence of one-to-one encounters as a doctor of a using it. You have the virtual-self of the possible direct cortical involvement in conscious enquiry into learning about mind – the stories and movies that are some clinical functional pain disorders, human healing capacity, and what blocks using it all the time, but there is a deeper but it is nonsense to suggest that people it and releases it. Then in 2004, I began self that can look at it with gentleness suffering these are weak or manipulative. to research if I could apply the principles and patience and kindness and So conditions must be created that I had learned into a group setting, using understanding. Shouting at it won’t make it safe for the person to discover a model of TheWEL programme and later change it. Sheer willpower won’t and reveal their current maps and the StaffWEL. The results show rich re-myelinate it or re-model it. So we all movies. In fact a rule: Unless this ‘old gains for people in wellbeing measures live with the experience of snakes in our story’ is honoured, there will be no and, in subgroup observations, lives. Your ego is always central in the seeding of a ‘new story’. Around all that correlated objective shifts. This will be movies of your mind. This is the world of therefore is what we have been learning reflected in ‘Carol’s’ story that follows. As the person sitting in front of you – the about creating what I’ve thought of as a StaffWEL group participant (once a New York they are in. Just like me. I use ‘therapeutic encounter’. I have to explore week for four half days, with home-study that as a very important and humbling this elsewhere, for example, http://www. materials supplied) she would be guided mantra in my work. thehealingshift.org, where you can into a journey of change, beginning from Many people come to a pain clinic with download an iteration of my six part where she was, how she view the world, direct iatrogenesis … ‘things are fine, a Student BMJ series. In the limited space what is important to her, what her values wee line on your X-ray … your spine is here, I will now rely towards the end of are, using universally accessible crumbling. you will need long-term this article on a first person witness language, until she is in a place safe drugs’ and other snake-invoking litanies, account of a healing shift and a enough to shift off her usual maps. This evoking the first New York reaction. And transformative change. I see such is done with all the delicacy of a that is a biological mechanism. The experiences as the core substance of our therapeutic encounter. She was then person may be reluctant to acknowledge study of what I’ve seen as the human offered a fresh story, metaphor and this and emphasise that they are positive, healing response. vision, backed up with support practices, but in the back of their mind a voice is aimed primarily at triggering her self- saying ‘it’s a snake … it’s snake’. And compassion as a foundation for a unless you try to unlock that situation, Transformation in practice change in her self-care. you will be wasting your time. Transforming story Occasionally you encounter what I have So we are talking about being change nicknamed ‘sentinel side-effects’, where agents, involved in the issue of suffering A story of transformation a person has an adverse reaction to and release, and so necessarily involved ‘Carol’ had suffered bouts of depression everything you give them. I think this is a in the question of the transformative every year for the last 36 years, which

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were as troughs in an overall pretty Her transformation has been 5. The Dance: Honouring their old story, miserable existence. She had used anti- maintained at 9 and 12 month follow- we work together to seed the new story. depressants on a seasonal basis. She ups. This transformation has lifted her A core aim is to achieve an activation of had experienced periods when she was out of the medical models of the four compassion-based self-care. unable to leave the house for months. waves and went well beyond the horizon 6. The Germination: We hold awareness She was anxious all the time, and ‘fear’ is we currently work to too often. She, like of the shift processes, flowing through a central theme in her life. She had the majority of participants (including all these steps, as the seed begins to suffered panic attacks that could involve many with chronic pain), also improved grow. urinary incontinence and vomiting. She on a range of subjective and objective 7. The Journey: Now in the subsequent was subject to paranoia and self- measures, backing up their core (hero’s) journey, we chart together the loathing. Not many people knew how narratives of healing change. Some fuller states, but especially the stages, of much she had suffered as she could ‘put details of the evaluation results can be the change, and tune our interval on a face’. Re-interviewed 3 months after followed from the references. support and re-activation as need be, TheWEL, her manner and bearing was as their journey skills grow. upbeat and she spoke of a deep The nature of transformation transformation in herself as a person in A portent or miracle ‘does not occur the world. Her life had changed: her work contrary to nature, but contrary to and relationships with colleagues, her what is known about nature’. family life and her attitude towards food. (St Augustine’s City of God, 5th century) She was off anti-depressants. But what was most apparent was her changed It’s hard to understand such awareness and ways of being with transformations, never mind mechanisms herself. In her own words, and the complex system of cause and This is an alive complex self-organising effect. It seems wise for now to root into It’s totally different. The whole way I system of changing process. The empirical study, working with the look and see things and feel things … conditions matter often more than the phenomena of direct accounts of healing I keep pinching myself that I’m not actions. In the dance, there is no single change and practice, avoiding premature dreaming all this… I’m not afraid correct thing to do. We each will have or over-inclusive theory and explanation. anymore … this confidence is coming different gifts and skills to offer. Monitor from inside it’s not just a phase … this closely, however, and you’ll feel when When I’m myself now, I’m quite happy The conditions for transformation – you have stood on their foot – and need with who I am. creating therapeutic encounter to make a correction. Touch well one At a practical level we can begin to chart good domino and others tend to fall. Its I’m healing, I see myself as healing. the key ingredients needed for such growth is shaped by context and care: This is just a personal thing, I’ve seen shifts to occur. Here is a sketch of key your intentionality, your authenticity, your myself with like an open wound that’s elements as I currently understand them: presence, your focus, your caring, your never healing, and now I can see it’s listening, your building of the empathy, of closing down you know it’s like, you 1. Vision: Holding a vision of the safety, the opening of compassion. know how if you’ve got a scar it’s person’s power and release. As we listen to the old soundtrack, the open, so now this is closing in, its 2. Conditions: We set the conditions to old story it helps validate, honour their healing, that’s how I feel. It’s not open optimise the coming encounter and experience – but often this only at the anymore. change process (e.g. your inner state, start of the encounter process, and you and theirs, the external environment). don’t have to get all the details of past Note her language and the inner world 3. Beginnings & Presence: We aim to traumas. Sufficient for them to hear their working with image and metaphor. That’s begin well – with aware alertness in story and know you have too. Repetition why arts work. She generated, from the the opening moments, building from without new perspective risks myelinating depths of herself, this image of a wound there, coming gradually to presence. their old story, re-traumatising. that is closing, an image of what she 4. Join-Up: Our aim is to creating ‘join-up’ At the pivot point when new story is naturally called healing. The more you – through opening safe space, working seeded, I find metaphors of nature attune to these spontaneous languages, towards a tangible human connection powerful (likely preverbal domains are the deeper the communication. (which brings its own shifts). activated). For example, you might ask,

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‘Would you treat a dog the way treat Society for inviting me to speak at their 5. Hanlon P and Carlisle S. AfterNow: yourself? Would you say that to a child? 2016 Annual Meeting: The Power of the What Next for a Healthy Scotland? If you were a plant, what shape are you Mind in Pain, and thanks to Dr Peter Argyll: Argyle Publishing, 2012. in? What does this plant need? How is Wemyss-Gorman for transcribing that talk The Healing Shift Enquiry and TheWEL. your self-gardening?’ Such images and so allowing it to be shaped into this article. ‘Carol’s’ case was one of many would be rebuffed as trite in ordinary 1. Downloaded summary results. studied by my research colleagues who encounter, but in therapeutic safe space, Available online at http://www. evaluated TheWEL: Maria Higgins, Patrick they become myths – non-literal stories Quinn, Desiree Cox and Fiona Smith, thewel.org/theWEL/Results.html bearing deeper truth. supported by the Scottish Government and 2. Reilly D. The healing shift enquiry – TheWEL Charity. I wish to express my Creating a shift in healthcare. Journal gratitude to the many patients from whom I of Holistic Healthcare 2013; 10(1): Healing and wholeness learned in my 38 years as a doctor and to 9–14. Returning to Carol’s use of the word the NHS Centre for Integrative Care in 3. Reilly D. We need a new vision to healing, it’s time to reclaim this term, not Glasgow for acting as an inspiring centre of meet the new challenges of our times. leave it side-lined to esoteric ideas or non- care and learning. Journal of Holistic Healthcare 2013; local effects. As she shows, it is needed 10(1): 4. to discuss powerful everyday experiences Some sources mentioned in this article Healing and Creating Therapeutic – you cut yourself and it heals, you break and Further Reading Encounter. your heart and it works towards healing. This is a natural profound capacity lying The Epidemics 1. Reilly D. Enhancing human healing. within each individual, because it is 1. The World Health Organization. The BMJ 2001; 322(7279): 120–1. inherent in life itself. Global Burden of Disease (As reported 2. Reilly D. Creative consulting part 0 – You We started with stuck predicaments from 195 countries and territories can make a difference student. BMJ suffering and a search for a new wave of between 1990 and 2015). Available 2001; 9: 305–56. First of a six part health creation. This took us into the online at http://www.who.int/topics/ series. An iterated compilation of this mysteries of inner life, of consciousness, of global_burden_of_disease/en/ series is available as a download here healing relationship and encounter, of 2. http://www.scotland.gov.uk/Topics/ http://www.davidreilly.net/Healing change and transformation. Then we Health/Services/Long-Term-Conditions Shift/Teaching_Downloads.html listened to Carol and her release. I find along with other learning materials. myself wondering if some of Carol’s The Fifth Wave and The New Public Consciousness and The Inner World. experiences and new ways of being Health. correspond to the goal of many of the 1. Compiled by Andrew Lyon. The Fifth 1. Derbyshire SWG, Whalley MG, traditional spiritual paths to finding peace. Wave – Searching for Health in Stenger VA, et al. Cerebral activation It’s interesting that these altered states, Scotland. Scottish Council during hypnotically induced and these hard won spiritual paths, correspond Foundation, 2003. Available online at imagined pain. NeuroImage 2004; 27: to that state of being when ‘psychological http://www.davidreilly.net/ 969–78. functions like thinking, sensing, feeling and HealingShift/5th_wave.html 2. Schilbach L, Timmermans B, Reddy intuiting become “unified,” complementary 2. Davies SC, Winpenny E, Ball S, et al. V, et al. Toward a second-person and mutually enhancing; a movement For debate: A new wave in public neuroscience. Behavioral and Brain towards psychosynthesis – this oneness health improvement. Lancet 2014; Sciences 2013; 36(4): 393–414. of being rooted in consciousness’ (Grosso, 384(9957): 1889–95. Available online at https://www.ncbi. 2016). This state is one which probably all 3. 2015 Review of Public Health in nlm.nih.gov/pubmed/23883742 of us are privileged to have at some Scotland: Strengthening the 3. Grosso M. The Man Who Could Fly: moments in our lives, and many have Function and Re-Focusing Action St. Joseph of Copertino and the described to me as arising during an for a Healthier Scotland, 2016, Mystery of Levitation (A fascinating effective therapeutic encounter together. pp. 13–4. Available online at http:// and scholarly enquiry into It’s a good compass point. www.gov.scot/ consciousness, conventional and Publications/2016/02/8475 otherwise. The source of the quotes Acknowledgements 4. Extensive articles and summaries. here from St Joseph of Copertino, My thanks to the Philosophy & Ethics Available online at http://www. and spiritual integration). London: Special Interest Group of the British Pain afternow.co.uk Rowan and Littlefield, 2016.

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Professional perspectives The misuse of gabapentinoids Pain News 2016, Vol 14(4) 171–172 © The British Pain Society 2016 Dr Sandeep Kapur Consultant in Pain Medicine & Anaesthesia, University Hospital Birmingham, Birmingham, UK

In 2013, the gabapentin to lead to abuse or Pregabalin may have a higher abuse general dependence. It is important for potential than gabapentin due to its practitioner prescribers to have a complete list of rapid absorption and faster onset of (GP) and medications (including any over-the- action and higher potency. Pregabalin medical counter products or illicit drugs) that causes a ‘high’ or elevated mood in writer Dr Des patients are taking so that hazardous users; the side effects may include Spence,1 drug interactions can be minimised chest pain, wheezing, vision changes writing in the or avoided. and less commonly, hallucinations. BMJ, raised Gabapentin can produce feelings of concerns If there are features in the patient’s relaxation, calmness and euphoria. regarding history that increase the likelihood of Some users have reported that the pregabalin and gabapentin. He noted pregabalin and gabapentin being ‘high’ from snorted gabapentin can be that in just 5 years, prescriptions of misused, these should be discussed similar to taking a stimulant. When pregabalin had increased by 350% and openly with the patient and the used in combination with other of gabapentin by 150%. He highlighted rationale for prescribing suggestions depressants, they can cause the psychotropic effects of these drugs and decisions should be discussed drowsiness, sedation, respiratory and the growing black market for them, fully and documented.2 failure and death. including through online pharmacies. Dr Spence cautioned that pain and anxiety In January 2016, following a review of Noting that pregabalin and gabapentin’s symptoms are subjective, and though gabapentin and pregabalin by the potential for abuse is similar to that of the use of gabapentinoids is backed by Advisory Council on the Misuse of Drugs tramadol, the ACMD recommended ‘gold plated evidence of benefit’ in (ACMD), Prof. Leslie Iversen – Chair of that both these drugs be controlled as neuropathic pain, many prescribers have the ACMD – wrote to the Home Office Class C substances and listed as taken the National Institute for Health and highlighting their concerns about the schedule 3 drugs ‘so as not to preclude Clinical Excellence (NICE) and Cochrane potential for misuse of these drugs.3 legitimate use on prescription’. Prof. endorsements as carte blanche to Quoting data from the Office for National Iversen’s letter also recommended, ‘It prescribe these medications freely. statistics (ONS) that, in 2014, 26 deaths should be an obligation of the Presciently, he asked whether it was time were attributed to gabapentin and 38 to prescriber to undertake a proportionate to tackle ‘the rise and rise of gabapentin pregabalin on the deceased’s death risk benefit assessment prior to the and pregabalin prescribing’.1 certificate, Prof. Iversen stated, prescribing and repeat prescription of Seized of the issue, Public Health either drug’.3 England and National Health Service Dr Des Spence, in September 2016, (NHS) England jointly issued a wrote again on the issue in the GP journal document in December 2014 entitled ‘Pulse’. In a piece titled ‘Gabapentinoids- ‘Advice for prescribers on the risk of the the new diazepam?’, he stated, misuse of pregabalin and gabapentin’. The document stated, Do we have a problem with gabapentinoid abuse? If it quacks Patients should be told about the like a duck and looks like a duck, potential for pregabalin and then it’s a ducking duck. Pregabalin

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is already a controlled medication in Which brings us to our responsibilities References the US and there is debate about as pain specialists: is a modicum of soul 1. Spence D. Bad medicine: Gabapentin and pregabalin. BMJ 2013; 347: f6747. controls in the UK. The research searching in order? Have the increased 2. https://www.gov.uk/government/uploads/system/ base for the benefits of concerns about opioids and nonsteroidal uploads/attachment_data/file/385791/PHE-NHS_ gabapentinoids is of short duration anti-inflammatory drugs (NSAIDs) led to England_pregabalin_and_gabapentin_advice_ Dec_2014.pdf and in a small, defined population an undue reliance on gabapentinoids? In 3. https://www.gov.uk/government/uploads/system/ where as few as one in 10 benefits. my view, it’s high time to rein in the uploads/attachment_data/file/491854/ACMD_ We need to change our prescribing prescribing of pregabalin and gabapentin Advice_-_Pregabalin_and_gabapentin.pdf 4. http://www.pulsetoday.co.uk/views/blogs/ policy now and limit the use of and I, for one, will be taking a good, hard gabapentinoidsthenewdiazepam/20032721 gabapentinoids.4 look at my own clinical practice. .blog

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Professional perspectives Apps, Bots and Wearables: the future Pain News 2016, Vol 14(4) 173–176 is here at present © The British Pain Society 2016

Dr Stephen Humble Consultant Pain Medicine & Anaesthesia, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London Dr Damien Smith Consultant Pain Medicine & Anaesthesia, The Hillingdon Hospitals NHS Foundation Trust, Middlesex Dr Arun Bhaskar Consultant Pain Medicine & Anaesthesia, Chair, Communications Committee, Elected Council Member, The British Pain Society

Introduction familiar to all smartphone users, the use intensity, location and type of pain. It also William Shatner and more recently Chris of which are undertaken for a variety of produces a PDF file, which the patient Pine has immortalised Captain James T everyday purposes including messaging, can share with their physician. Kirk of the USS Enterprise from the sci-fi ordering a taxi, reading the news as well FibroMapp is an App designed for series Star Trek, which has a cult as more bizarre ones such as the Human people with Fibromyalgia and monitors following of at least three generations. to Cat Translator and the Sheep Counter. pain, activity levels, sleep, flare-ups, Some of the ‘senior’ readers may Health-related Apps are becoming medication and mood. It is easy to see remember that it started as a small increasingly popular and have been how large amounts of contemporaneous television show which debuted in 1966 utilised to provide daily reminders and data could be potentially obtained in a and ran for only three seasons before prompts for medications or appointments relatively painless, timely and cost- being axed in 1969 due to low ratings. and/or to monitor diet and exercise effective manner, and this could be used The pioneering original show went boldly (Vardeh and Eccleston, 2013). Notable for assessing clinical outcomes for into the galaxy of the 23rd century, using examples include the Couch to 5K, clinical research trials. an array of space-age technology to which helps the so-called couch Apps are also being used to improve explore strange new worlds and seek out potatoes to become runners over healthcare provision both in the United new civilisations. We were witness to Kirk approximately a 2-month period through Kingdom and all over the world. While far and his crew benefitting from numerous voice commands and a graduated from being a panacea, telemedicine has futuristic devices including mobile exercise regime. Strava is an app used almost certainly improved access to communicators, voice recognition, to log users’ activity including; route, healthcare and specialist opinions for universal translators, videoconferencing, elevation, speed, time and energy. Users patients living in remote areas such as automatic doors, handheld computers can share their data with friends and parts of the Highlands and Islands of and of course laser beams. Later, compare their performance with others Scotland. Separately, telemedicine can scientists and engineers adopted these online. also be used to share world-class ideas enabling contemporary society to Of specific relevance to pain medicine, expertise with countries experiencing benefit from these state-of-the-art Apps for pain patients have started to severe shortages of trained health devices that are now often taken for emerge such as the Pain Toolkit, workers. VirtualDoctors.org provides a granted. Apps, Bots and Wearables are developed by our own Pete Moore sophisticated, yet easy to use integral to many of these technological alongside health professionals. The Pain telemedicine service to rural Zambia via devices. Toolkit helps patients engage with active smartphone Apps. This enables management strategies such as pacing, healthcare workers in Zambia to send goal setting, relaxation and building a electronic clinical data to volunteer Apps support team in order to eventually move doctors in the United Kingdom for advice An App (or Application) is a computer away from being a patient and to regarding diagnosis and treatment. With programme or a piece of software that become a regular citizen again. My Pain reference to evidence-based medicine, has been designed for a specific Diary is a pain ‘tracker’ including studies are still underway to determine purpose. Apps will be immediately calendar and the ability to describe the best way to utilise Apps for health

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management. The limited evidence appropriate medication dosages. For a available currently suggests that Apps subscription fee, members may also may be a useful adjunct for both access live videoconferencing with monitoring symptoms and delivering clinicians of various disciplines. This interactive pain management approaches approach is part of a growing trend in in a responsive and cost-effective the United States and a number of other manner (Anderson et al., 2016; Dahlberg Telemedicine providers currently exist et al., 2016; Vardeh and Eccleston, around the world. However, this 2013). approach is not without controversy, and concerns have been raised by some Bots people contest parking tickets. The regarding safety, privacy, accountability programme asks a series of questions to and quality of care (American Medical Bots are Internet robots and have been decide whether an appeal is possible Association). It seems that Bots have yet described as the next frontier (The and then guides the user through the to find their optimum position within Economist, 2016). They are software appeals process. This artificial healthcare, but it is likely that they will be programmes that perform automated intelligence Chatbot lawyer has taken on adopted increasingly in relation to tasks via the worldwide web. Bots are 250,000 cases (in London and New marketing, and this is likely to involve the used typically for simple repetitive tasks York) and won 160,000 of them realm of Independent practice. However, that, via automation, can be carried out (~US$4 million worth of parking tickets). Bots and Wearables may also be vital to at a far higher rate than it would be An example of more relevance to the realisation of virtual reality (CNBC), possible to achieve by a human. A healthcare is HealthTap, which uses which has the potential to lead to the common example of a Bot is a Chatbot. Facebook Messenger Bots in order to development of ever-more immersive Chatbots simulate conversation with provide expert answers from physicians therapeutic experiences (Chen, 2016; Li people using artificial intelligence and can directly to patients within a social et al., 2011). Firsthand and scientists alter the way users interact with the network model. Users can obtain the from the University of Washington Internet to make it a more conversational answers to specific questions about developed SnowWorld, a virtual reality approach. Most of us with a modern medical symptoms they may have and experience for managing procedural iPhone will be aware of Siri, the in-built whether or not they merit medical pain. The New York Times thus wrote voice-controlled personal assistant. attention as well as checking on about the technology: Rather than typing into a search engine, users simply speak into the phone and the personal assistant does the rest. This may not immediately be everyone’s preference, but is in fact a big improvement over listening to muzak (piped instrumental music played) while on hold on the telephone 10 minutes after Pressing 1 to speak to a customer service agent. Indeed, many companies are developing user-friendly Bots to help with standard queries or to assist consumers shop for specific items via interactive websites (BBC). Separately, Bot-based messaging Apps are becoming increasingly popular and potentially used more than social media sites such as Twitter and Facebook. Some of us have read or heard about the famous, or perhaps infamous, Bot DoNotPay. It was created by a second- year Stanford University student to help

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SnowWorld puts Pixar-like animation structured and graded exercise and to medical use in a virtual video game rehabilitation programmes to optimise that relieves the pain of burn victims. function in novel ways, which would be Try it. It is completely absorbing to extremely relevant to the management of pelt woolly mammoths and penguins many chronic pain patients. This with snowballs while your ears are information could potentially be shared filled with the irresistible strains of with clinicians or peers in a support (Paul Simon’s) Graceland. group and would facilitate active management with ongoing support and encouragement. This technology is Wearables available now and, if used appropriately, Wearable technology refers to devices could be beneficial for many of our that are worn on the body, which may patients as an adjunct to face-to-face take the form of electronics, transmitters, using Wearable technology to monitor care at a time when the National Health software and sensors. Early examples the fitness of their employees and Service (NHS) continues to explore include hearing aids and calculator rewarding or penalising them based on strange new world’s beset by watches, while a more recent whether or not they met their fitness uncompromising enemies and a flagging development is the contentious Google targets (McGee, 2015). Nevertheless, engine. In the words immortalised by Glass optical head-mounted display, Wearables can be an excellent way to Scotty, chief engineer of the USS which have been used during surgery stimulate people that would not normally Enterprise, ‘She cannae take any more, and interventional radiology (Nosta, exercise regularly to engage with more Captain! She’s gonna blow!’ 2013; Haslam and Mafield 2013) and healthy behaviours. The underlying basis for these devices may be controlled by voice-activation. References Smart clothes are also in development, is nanotechnology, which refers to the https://www.quora.com/Why-did-Star-Trek-the-original- and early examples of these include manipulation of matter sized between series-end-after-only-three-seasons-and-Star- T-shirts, bras and shorts that can collect 1 and 100 nm. An early proponent of this Trek-Enterprise-end-after-four-while-the-other- three-series-each-went-on-to-do-seven-seasons biometric data such as heart rate, stride field was the Nobel Prize–winning https://www.theguardian.com/technology/2016/ length, pelvic rotation and contact time physicist Richard Feynman who jun/28/chatbot-ai-lawyer-donotpay-parking- with the ground (Edwards, 2016) and discussed the concept in his 1959 tickets-london-new-york http://www.telegraph.co.uk/news/health/ sync with mobile devices. Separately, the lecture at Caltech: There’s plenty of news/10851116/First-operation-streamed-live- Apple Watch allows users to make Room at the Bottom. Inspired by with-surgeon-wearing-Google-glass.html telephone calls in a way that is highly Feynman, Eric Drexler expanded and Anderson K, Burford O, and Emmerton L. Mobile health apps to facilitate self-care: A qualitative study of reminiscent of the wrist-based popularised the field (Drexler, 1986), user experiences. PLoS ONE 2016; 11(5): communication device that Captain Kirk encouraging the development of smaller e0156164. employed in Gene Roddenberry’s epic and smaller systems. The rate of Chen CC. Multimedia virtualized environment for shoulder pain rehabilitation. Journal of Physical series, which was first broadcast progress in this area over the last few Therapy Science 2016; 28(4): 1349–54. 50 years ago. It also has numerous other decades has been staggering and has Dahlberg LE, Grahn D, Dahlberg JE, et al. A web-based features including activity tracking and impacted dramatically on daily life, platform for patients with osteoarthritis of the hip and knee: A pilot study. JMIR Research Protocols Apps to assist with specific fitness goals. leading to the casual use of technologies 2016; 5(2): e115. Similar wrist-based fitness-oriented that were considered, previously, to be Li A, Montaño Z, Chen VJ, et al. Virtual reality and pain devices include FitBit, Jawbone, Garmin unobtainable until significantly later in management: Current trends and future directions. Pain Management 2011; 1(2): 147–57. and NikeFuel. These Wearables allow human development. These Vardeh D, and Eccleston C. There’s an app for that: owners to record steps walked, distance developments have huge implications for Mobile technology is a new advantage in managing covered, calories burned, heart rate and the future of healthcare, diagnostics and chronic pain. Pain 2013; 21(6): 1–8. Drexler KE. Engines of Creation. Garden City, NY: sleep pattern. Data such as these are of disease management. Anchor Press/Doubleday, 1986. course of interest to large business and Feynman RP. There’s plenty of room at the bottom health insurance companies. Indeed, (Caltech Lecture, 29 December), 1959. Conclusion American Medical Association (AMA). Press release, 13 some users may be able to receive So what does this mean for Pain June 2016. Available online at http://www.ama- discounts on health insurance bills. Medicine? The combination of Apps, assn.org/ama/pub/news/news/2016/2016-06-13- Controversially, some large employers Bots and Wearables has the potential to new-ethical-guidance-telemedicine.page American Medical Association (AMA). Report 7 of the have taken the concept a step further by promote the type of personalised, Council on Medical Service (A-14) coverage of and

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payment for telemedicine (Reference Committee A), 2016. Available online at http://www.cnbc. google-glass-in-the-operating- 2014. Available online at http://www.jonesday. com/2016/04/13/facebook-f8-from-virtual- room/#307bb1dd5d61 com/files/upload/AMA%20Policy%20on%20 reality-to-bots-all-the-announcements- Edwards L. Best smart clothes: Wearables to improve Telehealth%20(June%202014).PDF explained.html; http://www.virtualdoctors.org; your life. Pocket-lint, 25 May 2016. Available The Economist, 9 April 2016. Available online at http:// http://www.healthtap.com online at http://www.pocket-lint.com/ www.economist.com/news/business-and- Haslam P, and Mafield S. Google glass: Finding true news/131980-best-smart-clothes-wearables- finance/21696477-market-apps-maturing-now- clinical value. Which Medical Device, 31 October to-improve-your-life one-text-based-services-or-chatbots-looks-poised 2013. Available online at http://www. McGee S. How employers tracking your health can Lee D. Facebook’s next big thing: Bots for Messenger. whichmedicaldevice.com/editorial/article/390/ cross the line and become Big Brother The BBC, 12 April 2016. Available online at http:// google-glass-finding-true-clinical-value Guardian, 1 May 2015. Available online at https:// www.bbc.co.uk/news/technology-36021889 Nosta J. Inside the operating room with Google glass. www.theguardian.com/lifeandstyle/us-money- Kharpal A. Facebook F8: From virtual reality to bots, all Forbes, 21 June 2013. Available online at http:// blog/2015/may/01/employers-tracking-health- the announcements explained. CNBC, 13 April www.forbes.com/sites/johnnosta/2013/06/21/ fitbit-apple-watch-big-brother

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Informing practice Experience of managing patients in a Pain News 2016, Vol 14(4) 177–181 joint pain and substance misuse clinic © The British Pain Society 2016

Dr Nilu Bhadra Consultant in Pain Management and Anaesthetics Blackpool Teaching Hospitals NHS Trust Foundation Trust Dr Susie White Specialist Clinical Psychologist in Chronic Pain Dr. Ashutosh Kaushal Consultant Psychiatrist Early Intervention Service (Central and West Lancs) Lancashire Care NHS Foundation Trust Dr John Richmond Clinical Lead Delphi Medical Ltd

for change. It harbingers fear leading to behaviours to gain relief. The presence of both conditions can result in a reorganisation of neural pathways in the brain with possible effect of wind-up phenomenon and sensitisation, both of which may result in increased pain perception. Chronic use of addictive drugs may also affect the processing of pain stimuli through sympathetic A Laughton (Sister in Delphi), stimulation, hypothalamic–pituitary– S Melrose (Sister in Delphi) adrenal axis dysregulation and opioid tolerance. In pain medicine, a prevailing Chronic pain affects between 8% and assumption is that ‘the pain is what the 60% of the population.1 High-risk drug patient says it is’; in addicted individuals, misuse is estimated to affect the situation is potentially more complex plan for responding to non-compliance approximately 1% of the population.2 as there are two pathways at play. The or if outcomes are not met. Chronic pain is common in patients with interdependence between addiction and Liaison between the addiction and the substance misuse problems but chronic pain symptoms, biopsychosocial pain service is recommended to provide undertreated because of lack of aspects and various neurobiological the best care for this group of patients. evidence, lack of expertise, poor pathways of both syndrome complexes Addicted patients in pain tend not to communication between different health suggests that both of them need to be recognise that their addiction disorder has professionals and preconceived negative treated and addressed together as trying a bearing on their experience of pain and attitudes towards these patients. to address just one or another would not may be more likely to expect drugs to be While chronic pain and addiction are be effective. the main, and possibly only, solution. They different syndrome complexes, several Several guidelines suggest joint may also have a prejudice that the clinic comparisons can be drawn between management of patients suffering from may be limiting their access to analgesia them. Both addiction and pain are addiction as well as chronic pain. Their specifically because of their addiction influenced by biological, social, main recommendations include a full joint disorder, which can interfere with the psychological and environmental factors. assessment and investigation, a jointly educative process around pain Drugs of abuse evoke reward pathways, agreed treatment plan, non- management. They may well not want to which adapt and develop tolerance and pharmacological and pharmacological attend the addiction service if they see result in the phenomenon of withdrawal interventions, adequate dosing of their primary problem as pain, and at the on cessation. Withdrawal produces fear replacement opioid, a single prescriber same time, previous poor experience leading to behaviours to gain relief. with regular reviews, urine drug screening while in hospital may stop the patients Chronic pain is an emotional experience, as needed, adequate social support, from fully buying in to what the pain which acts as a strong motivational driver financial advice, housing advice and a service has to offer. Joint working

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Table 1. Outcomes for selected patients managed in a joint pain and substance misuse clinic at the Blackpool Victoria Hospital

Measures Sleep Hours Sensory Affective Total Pain Anxiety Depression Psychological Physical Quality quality of pain pain pain self- health (TOPs) health of life sleep score efficacy (TOPs) (TOPs)

Number of 2 2 4 3 5 5 3 4 3 3 3 patients who improved Number of 1 0 2 1 1 1 3 0 1 1 0 patients who declined No change 4 4 0 2 0 1 1 3 0 0 1 No data 1 2 2 2 2 1 1 1 4 4 4

TOPs: treatment outcome profiles.

between the addiction and pain teams of various social factors. All pain male. Patients visited the clinic on helps to circumvent some of the issues treatments, non-pharmacological as average four times. Of the eight patients, and helps in better comprehension and well pharmacological, are optimised. results indicated that five showed hence acceptance of what is on offer. This Psychological support is offered and improvement in their overall pain. Four hopefully leads to a more rehabilitative, is considered a necessary part of had reduced symptoms of depression functional approach, with less reliance on engagement with the service. and increased self-efficacy. Anxiety for medications including opioids. Immediate three patients increased. Sleep quality 2. Commitment to stop illicit drugs and, access to drug screening helps the team and quantity displayed limited change. Of potentially, opioid replacement with decision-making and removes doubt the four patients who completed the therapy (ORT) as well, if necessary – as to whether the patient is complying treatment outcome profiles (TOPs) at the Patients are asked to commit to stop with the treatment plan as recommended first and last appointments, three patients using illicit drugs as with continued by the team. A multidisciplinary approach noted improvements in their use it is not possible to measure to treat these patients has been psychological, physical and overall treatment response and, if ready, are recommended. quality of life scores. Two patients were weaned off their opioid maintenance Blackpool has a high incidence of able to come off their ORT successfully. regime if this was not providing patients with high-risk drug misuse, One was able to reduce their adequate pain relief. After optimising significant numbers of which experience buprenorphine dose. Two patients who all the pain treatment, opioids in much chronic pain. Here, we report our use of refrained from illicit drug use relapsed smaller doses were offered if needed, a multidisciplinary team approach for after discharge. One patient had to be appropriate and necessary but under eight patients who were seen in the clinic discharged from the clinic due to non- the ORT pathway. and were demonstrating motivation to attendance (see Table 1). stop using illicit drugs. Our team consists 3. Relapse prevention strategy – of Pain and Substance Misuse Combining expertise from the Discussion Consultant, Lead Recovery Nurse, substance misuse and pain to develop Guidelines have been published Psychologist and patient’s Recovery Key a relapse prevention strategy plays a regarding managing pain in patients with Worker. Our aim is to optimise patient’s fundamental role for the success of addiction, but we have found there is no pain relief while encouraging the patients the clinic. As addiction is known to be absolute ‘right way’ of managing these to stop illicit drug use. a chronic relapsing disease, a plan patients.3,4 There are issues related to Our Strategy consists of the following: must be there in case of relapse. the addiction itself, drug interactions and 1. Comprehensive assessment and co-morbidities of the patient. The drug treatment – This includes assessment Our experience misuser experiences immediate relief of of pain and substance misuse Eight patients were seen in clinic. The distress when using illicit drugs which problems, led by pain and substance patients ranged in age from 38 to leads to an unrealistic expectation that misuse consultants, and assessment 60 years; two were female and six were the ‘correct’ drug for pain will give rapid

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and complete pain relief. This or weaning off ORT for suitable patients. services. Our data indicate that expectation is in sharp contrast to the With addiction in remission and optimal inter-agency management could be very crux of the pain management functioning, the uptake of pain effective in decreasing pain and drug mantra. These patients also have management rehabilitative approach use, alleviating depression and improving impaired control over their drug use and techniques can be appreciated. Opioids confidence. We plan to continue to their lives. It may be prudent to include are used as a last resort only when develop the service, and our aim has external control (a clear opioid pathway needed, exercising the opioid pathway. been to stop not only illicit drug use but written agreement and the use of illicit This approach does need to be also ORT and facilitate integration back drug testing) in the strategy to manage supported by relapse prevention which is into society. We propose that relapse risks in these patients. This group of the third pillar of our strategy. These prevention is an important part of the patients have usually been maintained on patients are at high risk of relapse as treatment care plan for these patients, ORT for at least 2 years and the evidence addiction is a recurring disease. and we intend to develop this further. base for ORT promotes doses of Preventing relapse is most important for 60–120 mg of methadone to reduce illicit effective treatment in patients with References use. Also, the traditional response to pain substance misuse disorder in remission, 1. Elliott AM, Smith BH, Penny KI, et al. The in this patient group has been to increase and even more when treating these epidemiology of chronic pain in the community. 11 Lancet 1999; 354(9186): 1248–52. the total opioid dose, as a sole response, patients’ pain with opioids. Our relapse 2. United Kingdom drug situation: UK focal point on as they have either been seen separately strategy consists of various measures drugs annual report to European Monitoring Centre or not in a site with easy access to the bundled together using pain team for Drugs and Drug Addiction (EMCDDA, 2014 edition). Available online at: http://www.nta.nhs.uk/ multidisciplinary approach needed. expertise, substance misuse team uploads/uk-focal-point-report-2014.pdf But long-term data regarding opioid expertise and existing community 3. Bell J, Stannard C, Reed K, et al. The management use in patients with chronic pain suggest support networks that already exist of pain in people with a past or current history of addiction, January 2013. Available online at: http:// not only lack of efficacy but also within both. An important aspect of this www.actiononaddiction.org.uk/Documents/The- increased risk of harm as well as some is to arm the patients with techniques Management-of-Pain-in-People-with-a-Past-or-Cu.aspx evidence of increased mortality.5–8 that include cognitive and behavioural 4. Pain and substance misuse: Improving the patient experience – A consensus statement prepared by Among various other risks, there is a aspects not only to deal with high-risk the British Pain Society in collaboration with the known risk of opioid-induced situations but also to implement positive Royal College of Psychiatrists, the Royal College of hyperalgesia.9 There is some evidence life style changes to maximise their gain general practitioners and the advisory council on misuse of drugs. Available online at: https://www. that patients addicted to heroin may also from pain management strategies. We britishpainsociety.org/static/uploads/resources/ suffer from hyperalgesia.10 There is also a encourage patients to keep a diary of misuse_0307_v13_FINAL.pdf stronger drive from substance misuse pain, quality of life, sleep and activities. 5. Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with services now for the rehabilitation of their This not only enables patients to reflect nonmalignant pain. Archives of Internal Medicine patients towards abstinence, trying to on the difference any intervention has 2011; 171(7): 686–91. avoid leaving people on long-term ORT made but also allows clinicians to 6. Ray WA, Chung CP, Murray KT, et al. Prescription of long-acting opioids and mortality in patients with who may be able to live drug-free lives. measure effects of the same. If relapse chronic noncancer pain. JAMA 2016; 315(22): A combination of the different approach does occur, careful review of the relapse 2415–23. and strategy in substance misuse episode can be helpful. Without deep 7. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy services for rehabilitation of this group of understanding of addiction as a chronic for chronic pain: A systematic review for a National patients, as well as a lack of efficacy of relapsing disease, patients are in danger Institutes of Health Pathways to Prevention opioid medications in long-term of being discharged, pushing them back Workshop. Annals of Internal Medicine 2015; 162: 276–86. management of chronic pain, does into addictive behaviours. Hence, a 8. McCarthy M. Opioids should be last resort to treat suggest that opioids in ever-increasing relapse management strategy and having chronic pain, says draft CDC guideline. British doses are not the only solution in this addiction expertise or support in place Medical Journal 2015; 351: h6905. 9. Lee M, Silverman SM, Manchikanti L, et al. A group of patients. are essential. comprehensive review of opioid-induced Our strategy is trifold: complete Treating chronic pain in patients hyperalgesia. Pain Physician 2011; 14: 145–61. assessment of patient, supportive suffering from substance misuse disorder 10. Compton P, Canamar CP, Hillhouse M, et al. Hyperalgesia in heroin dependent patients and the treatment with maximisation of is challenging. We believe these patients effects of opioid substitution therapy. Journal of pharmacological and non- need an individualised, structured and Pain 2012; 13(4): 401–9. pharmacological treatment, and supportive treatment care plan provided 11. Chang Y-P, and Compton P. Management of chronic pain with chronic opioid therapy in patients encouragement to stop using illicit drugs by combined expertise from both the with substance use disorders. Addiction Science & including the use of detox facilities and/ pain management and addiction Clinical Practice 2013; 8(1): 21.

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15_PAN677453.indd 179 22/11/2016 6:55:18 PM TREATMENT OUTCOMES PROFILE CLIENT ID KEYWORKER

SEX TREATMENT STAGE MALE FEMALE START REVIEW EXIT POST-TREATMENT DOB INTERVIEW DATE DD / MM / YYYY DD / MM / YYYY Use ‘NA’ only if the client does not disclose information or does not answer Total for 1 SUBSTANCE USE NDTMS return Record the number of using days in each of the past four weeks, and the average amount used on a using day WEEK 4 WEEK 3 WEEK 2 WEEK 1 AVERAGE PER DAY

A. ALCOHOL 0-7 0-7 0-7 0-7 UNITS 0-28

B. OPIATES/OPIOIDS (ILLICIT) 0-7 0-7 0-7 0-7 G 0-28 Includes street heroin and any non-prescribed opioid, such as methadone and buprenorphine

C. CRACK 0-7 0-7 0-7 0-7 G 0-28

D. COCAINE 0-7 0-7 0-7 0-7 G 0-28

E. AMPHETAMINES 0-7 0-7 0-7 0-7 G 0-28

F. CANNABIS 0-7 0-7 0-7 0-7 SPLIFFS 0-28

G. OTHER SUBSTANCE. SPECIFY: 0-7 0-7 0-7 0-7 G 0-28

H. TOBACCO 0-7 0-7 0-7 0-7 0-28 Includes ready-made and hand-rolled cigarettes, cannabis joints with tobacco, cigars, pipe tobacco, shisha/waterpipes, etc 2 INJECTING RISK BEHAVIOUR

Record the number of days the client injected non-prescribed drugs during the past four weeks WEEK 4 WEEK 3 WEEK 2 WEEK 1 0-28 A. INJECTED 0-7 0-7 0-7 0-7

B. INJECTED WITH A NEEDLE OR SYRINGE YES NO USED BY SOMEBODY ELSE Y or N C. INJECTED USING A SPOON, WATER OR YES NO (Y if either FILTER USED BY SOMEBODY ELSE is yes) 3 CRIME

Record the number of days of shoplifting, drug selling and other categories committed during the past four weeks WEEK 4 WEEK 3 WEEK 2 WEEK 1 0-28 A. SHOPLIFTING 0-7 0-7 0-7 0-7 0-28 B. SELLING DRUGS 0-7 0-7 0-7 0-7

C. THEFT FROM OR OF A VEHICLE YES NO Y or N D. OTHER PROPERTY THEFT OR BURGLARY YES NO (Y IF EITHER E. FRAUD, FORGERY OR HANDLING YES NO IS YES) STOLEN GOODS Y or N F. COMMITTING ASSAULT OR VIOLENCE YES NO 4 HEALTH & SOCIAL FUNCTIONING

A. CLIENT’S RATING: PSYCHOLOGICAL 012345678910 11 12 13 14 15 16 17 18 19 20 HEALTH 0-20 (Anxiety, depression, problem emotions and feelings) POOR GOOD

Record days worked, or at college or school in the past four weeks WEEK 4 WEEK 3 WEEK 2 WEEK 1 B. DAYS IN PAID WORK 0-7 0-7 0-7 0-7 0-28

C. DAYS ATTENDED COLLEGE OR SCHOOL 0-7 0-7 0-7 0-7 0-28

D. CLIENT’S RATING: PHYSICAL HEALTH 012345678910 11 12 13 14 15 16 17 18 19 20 (Extent of physical symptoms and bothered by illness) 0-20 POOR GOOD Record accommodation status for the past four weeks E. ACUTE HOUSING PROBLEM YES NO Y or N

F. AT RISK OF EVICTION YES NO Y or N

G. CLIENT’S RATING: OVERALL QUALITY 012345678910 11 12 13 14 15 16 17 18 19 20 OF LIFE 0-20 GOOD (Able to enjoy life, gets on with family and partner, etc) POOR

PHE TOP v1.1 February 2016

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ABOUT THE TOP The Treatment Outcomes Profile (TOP) is the national outcome monitoring tool for substance misuse services. It is a simple set of questions that can aid improvements in clinical practice by enhancing assessment and care plan reviews. It can also help to ensure that each service user’s recovery care plan identifies and addresses his or her needs and treatment goals. Outcome reports are compiled centrally within Public Health England (PHE) via the National Drug Treatment Monitoring System (NDTMS). Keyworkers should complete the TOP within two weeks either side (+/- two weeks) of the first modality start date at the beginning of each service user’s treatment journey. This provides a baseline record of behaviour in the month leading up to starting a new treatment journey. If the treatment start TOP is completed after the first modality start date, it should focus on the 28 days before this date. It is good practice to review a service user’s recovery care plan every 12 weeks, and it is recommended that the TOP is completed at these reviews. However, this may be more or less frequent depending on individual need. Also complete the TOP at treatment exit. Some services may want to use the TOP to measure post treatment exit outcomes. HOW TO COMPLETE THE TOP START BY ENTERING: • Client ID, date of birth and gender • Completion date • Keyworker name • Date of assessment • Treatment stage – treatment start, review, treatment exit, or post-treatment exit. TYPES OF RESPONSES: • Timeline – invite the client to recall the number of days in each of the past four weeks on which they did something, for example, the number of days they used heroin. You then add these to create a total for the past four weeks in the red NDTMS box • Yes and no – a simple tick for yes or no, then a ‘Y’ or ‘N’ in the red NDTMS box • Rating scale – a 21-point scale from poor to good. Together with the client, mark the scale in an appropriate place and then write the equivalent score in the red NDTMS box. A FEW THINGS TO REMEMBER • The red shaded boxes are the only information that gets sent to PHE • Week 4 is the most recent week; week 1 is the least recent • The Treatment Start TOP should always capture pre-treatment drug use, so it is important that the recall period is the 28 days before the treatment start date. Not doing this will skew outcomes as there is likely to be a lower baseline. THE PROTOCOL FOR TOP REPORTING

Treatment start 1st review TOP 2nd review TOP 3rd review TOP Review TOPs TOP required +/- anchored to the anchored to the anchored to the continue in two weeks of the treatment start treatment start treatment start 26-week cycles treatment start date, and date, and date, and until the client exits date completed at any completed at any completed at any the treatment time during the time during the time during the system 5-26 week period 27-52 week period 53-78 week period

Date of rst – two + two 1st review: 5-26 weeks 2nd review: 27-52 weeks 3rd review: 53-78 weeks Continue review cycle weeks treatment weeks start

Treatment exit TOP, -/+ two weeks of discharge date

Alcohol units converter Drink %ABV Units Drink %ABV Units Pint ordinary strength lager, beer or cider 3.5 2 Glass of wine (175ml) 12 2 Pint strong lager, beer or cider 5 3 Large glass of wine (250ml) 12 3 440ml can ordinary strength lager 3.5 1.5 Bottle of wine (750ml) 12 10 440ml can strong lager, beer or cider 5 2 Single measure of spirits (25ml) 40 1 440ml can super strength lager or cider 9 4 Bottle of spirits (750ml) 40 30 1 litre bottle ordinary strength cider 5 5 275ml bottle alcopops 5 1.5 1 litre bottle strong cider 9 9

THANK YOU FOR USING THE TOP AND CONTRIBUTING TO NDTMS

15_PAN677453.indd 181 22/11/2016 6:55:19 PM 0010.1177/2050449716677456Why should fear lead to suffering for 80% of the world’s population?Why should fear lead to suffering for 80% of the world’s population? research-article2016

Informing practice Why should fear lead to suffering Pain News 2016, Vol 14(4) 182–183 for 80% of the world’s population? © The British Pain Society 2016

Dr Chris Ford Clinical Director Sebastian Saville Executive Director http://www.idhdp.com

It is shock when United Nations system. It was the event recognised they heard the that was going to draft proposals for that figure of 20%. United Nations General Assembly controlled Even among Special Session on Drugs (UNGASS), to substances doctors this which we had been working towards for such as information is the past 3 years. morphine are sadly lacking. For the first time ‘access to controlled indispensable At a specific medications for medical use’ was added for the relief study day at to the consensus document between all of pain and the Royal the nations. Many palliative care and pain suffering. College of General Practitioners (RCGP) organisations had been striving for this about pain, where the campaign had a for many years and we had focused on soft launch, less than 2% of the this in our campaign leading up to International Doctors for Healthier Drug delegates had any knowledge of this UNGASS. Policies (‘IDHDP’) launched a campaign appalling situation. We felt that if more The campaign recognises how earlier this year, ‘Striving for equity in the people knew about this inequity, it would information and training are needed in treatment of pain’ (http://idhdp.com/en/ help a great deal in changing the many countries. Even those where effort campaigns/pain.aspx), with the purpose situation. has been made to address the excessive of highlighting the dreadful inequity that Regulations (http://idhdp.com/en/ red tape to prescribe controlled allows 80% of the world’s population to resources/news/pain/fear-and-confusion. medicines, there are still significant suffer unspeakable pain while dying from aspx) to prevent the use of drugs like training needs for medical staff, painful conditions such as cancer and heroin have unnecessarily created an particularly in the area of effective end-stage AIDS, suffering during labour atmosphere of fear when it comes to palliative care and treatment of pain. or after enduring serious injuries. This, prescribing what are in essence similar Kenya is one country that has made while the richest 20% take it for granted drugs for the treatment of pain. There great strides with organisations like that these controlled medicines will be should be no reason why it is not Kenya Hospice and Palliative Care readily available in such circumstances. possible to reduce the harm created Association (KEHPRA; http://kehpca The idea for the campaign came by the misuse of drugs like heroin, while .org/). Organisations like Worldwide largely from our realisation of how few ensuring that drugs like morphine are Hospice Palliative Care Alliance (WHPCA; people knew that the vast majority of the readily available for the treatment of http://thewhpca.org/) have been world’s population are denied pain pain irrespective of which country the working tirelessly for years and have medication that the richest countries take patient lives. achieved a great deal recently co-hosting for granted. Although only anecdotal we As part of the campaign IDHDP put on with African Palliative Care Association would ask at conferences and other a side session about the campaign at (https://www.africanpalliativecare.org/) events what percentage of the Commission on Narcotic Drugs (CND), the 5th International African Palliative population had access to proper pain which occurs annually and is the central Care Conference in August titled management and there was always drug policy-making body within the ‘Differentiated care for diverse

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Why should fear lead to suffering for 80% of the world’s population?

communities’ (https://africanpalliativecare. Kenya Hospices and Palliative Care Policymakers must be made aware that org/conference2016/index.php). Association: doctors from all over the world want to see Perhaps of greatest importance is a access to pain medications for all and global public information programme on However, I have witnessed cancer health becomes much more prominent in the basic human right of access to patients who have no access to future drug policies. Using the IDHDP medicine to alleviate otherwise intolerable appropriate pain medication. We are newsletter (http://idhdp.com/en/ pain. IDHDP created a short film (http:// living in a time where we talk about resources/newsletter.aspx) to idhdp.com/en/campaigns/pain.aspx) to best standards of care, of human disseminate stories about the interface highlight the current inequity. For people rights, equal opportunities. Let us join between practice and policy, we attract who have had a loved one dying from a our efforts to ensure opioids are doctors to the website where there is a painful condition mitigated by the use of available to relive pain not just in the great deal of information on the importance medicines like morphine, it is unimaginable developed world, but globally. Pain of doctors advocating for change. what it would have been like without. The relief is a human right. IDHDP is launching phase 2 of its campaign wants these people to ask why campaign in the next few months it is that a highly effective and cheap The UN General Assembly Special ‘Striving for equity in access to controlled medicine is denied to so many. Session (‘UNGASS’) on the ‘World Drug drugs in the treatment of dependence’. ‘Fear rules us. It robs us of our reason’, Problem’ took place in April 2016, the Medicines like methadone and says Dr MR Rajagopal, chairman of the first for nearly 20 years. Some weeks buprenorphine are on the World Health Pallium India charitable trust: before, IDHDP co-hosted a side session Organization (WHO) essential medicines list on the inequity of pain relief at the to treat drug dependency. The evidence for Doctors, drug regulators and Commission Narcotic Drugs in Vienna. their use in preventing drug-related deaths, legislators are in shocked fear when Another side session (http://idhdp.com/ reducing HIV transmission and improving they think of the possibility of their en/resources/news/march-2016/side- the physical and mental health of offspring getting addicted to a drug. event-at-59th-session-of-the- dependent opioid users is overwhelming. Because they do not stop to learn commission-on-narcotic-drugs- However, even though injecting drug use enough, they put in unrealistic vienna-march-2016.aspx) focusing on takes place in over 150 countries (https:// restrictions. The result – failure of the the same issue was hosted by IAHPC. www.hri.global/files/2015/02/16/ purpose, and needless pain and After years of campaigning by WHPCA GSHR2014.pdf), only 80 countries provide suffering, the extent of which is and other organisations, access to Opioid Substitution Treatment (OST). beyond our power of imagination. controlled medications was supported by Your role in both phase 1 and 2 is all countries and added to the outcome crucial to the success of this campaign – ‘I hate to imagine what cancer pain is document endorsed at UNGASS. so please support the campaigns and like, I have not experienced it’, adds What is now essential is that we help join IDHDP (http://idhdp.com/en/ Dr Zipporah Ali, Executive Director of ensure this becomes reality on the ground. support-us/join-now.aspx) now.

December 2016 Vol 14 No 4 l Pain News 183

16_PAN677456.indd 183 21/11/2016 6:02:49 PM 0010.1177/2050449716677457Educating secondary school students about paediatric chronic painEducating secondary school students about paediatric chronic pain research-article2016

Informing practice Educating secondary school students Pain News 2016, Vol 14(4) 184–186 about paediatric chronic pain © The British Pain Society 2016

Polly Louise Langdon PhD Candidate, University of Southampton Cynthia Graham Professor of Sexual and Reproductive Health, University of Southampton Christina Liossi Professor of Paediatric Psychology, University of Southampton; Honorary Consultant Paediatric Psychologist, Great Ormond Street Hospital Foundation Trust

debilitating, difficulty of experiencing chronic pain, paediatric chronic re-starting full-time education can be pain highlight the tiring and stressful following periods of need to fully frequent or long-term absences.3 understand the Children often have to ‘catch up’ with impact of chronic their peers, and common triggers of pain pain on school include the school environment (e.g. functioning. It is heavy school bags), school work and Paediatric pain and school important to consider not only school lack of sleep.9 In addition, chronic pain functioning attendance and performance but also can be all-consuming. Research Paediatric chronic or recurrent pain is a how school personnel, teachers and suggests that children with chronic pain significant public health issue.1 Up to other students respond to pain display an attentional bias towards pain- 10 88% of children and adolescents problems. Interactions with both school related words and that pain-related experience, often debilitating, chronic staff and peers can have a considerable information is more easily remembered 11 pain2 which can have a profound, influence on pain behaviours, including than neutral information. 6 negative impact on all aspects of life.3 school avoidance. School functioning, however, is not Data from a large representative sample The inverse relationship between limited to attendance and academic of Flemmish school children and paediatric chronic pain and academic achievement. Social interactions with adolescents (n = 10,650; aged performance is well documented. other students and participation in 10–21 years) found that headache Evidence suggests that this association extracurricular activities are also often 3 (47.6%), abdominal (47.5), back (38.6%) is due to a combination of various factors negatively impacted by chronic pain. For and musculoskeletal pain (38.6%) were including absenteeism; pain-related example, 71% of children in one the most commonly reported chronic impairments in cognitive functions such particular pain clinic sample were unable pain locations within this age group.4 as attention, concentration and memory; to take part in physical education (PE) 12 Children with chronic headache, and sleep disturbance. Chronic pain has because of their pain. Considering the abdominal, limb and back pain have a significant impact on children and high prevalence of school absences, 1 reported limitations to hobby adolescents’ cognitive function, decline in academic performance and engagement, social interactions with academic performance (decline in limitations to school activities, it is not 5–7 peers, sleep and school attendance.5 grades) and school attendance. Pain- surprising that peer relationships can 3 From a young age, children spend a related school absences are highly also suffer. A systematic review of 33 6 significant amount of time at school – a prevalent, with over half (51%) of a studies investigating peer relationships of time which is important for a young clinical sample of Dutch children children and adolescents with chronic person’s cognitive, social and (8–18 years) reporting short-term pain showed that overall, children and psychological development.3 The absences (1–3 days per month) and 14% adolescents with pain reported feeling 13 importance of these school experiences reporting long-term absenteeism of more misunderstood and isolated. The 8 and the high prevalence of, often than 3 months. In addition to the reactions of significant others to youth

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Educating secondary school students about paediatric chronic pain

Adults with a significance within a child’s The Brilliant Club life (parents, teachers) are also important The Brilliant Club (http://www. in helping children to manage their pain thebrilliantclub.org/) is a (UK) national effectively.17 charity set up to challenge the difference between children from low and high socio-economic status (SES) obtaining Pain education places at prestigious, Russel Group, Previous research has emphasised the universities. Almost half (48%) of private importance of teachers’ knowledge school educated children gain a place at about their students’ chronic pain a highly selective university, compared to conditions and ability to manage it just 2% of children eligible for free school effectively in reducing pain-related meals. Considering that university fees absenteeism.18 Teachers themselves are now approximately £9,000 per year, have reported a need for more it is particularly important to challenge knowledge and guidance from this disparity and encourage high- healthcare professionals regarding how achieving pupils from state schools in to manage their students’ pain low SES areas to consider higher symptoms and pain-related behaviour in education. The Brilliant Club aims to school.19 School personnel asked for (a) address this issue by working with definitions, descriptions and knowledge schools and universities all over England, of what to expect; (b) increased from Cornwall to Newcastle. PhD tutors communication with medical from highly selective universities, with chronic pain can have an important professionals; (c) guidance/directives including the University of Southampton, influence on their pain experience and from the medical team; and (d) a more are recruited and trained to develop and how they cope with it.14 For example, collaborative approach to dealing with deliver modules based on their PhD school avoidance has the potential to be their students’ pain in the school setting. research. impacted by the involvement of Teachers also reported a sense of significant others in the life of the child isolation, confusion and uncertainty including family members, peers, school including how to respond when their Chronic pain in childhood and personnel, and the medical team and students report pain. Participants also adolescence their responses to the child’s pain.15 In a expressed concerns about the effects of My (Polly Langdon) module, titled group of Canadian school students (aged a student with chronic pain on ‘chronic pain in childhood and 12–15), peers influenced how classmates. They reported confusion adolescence’, aimed to provide students adolescents communicated about pain. about how to provide other students with detailed understandings of the Interestingly, adolescents were not with correct and helpful information and following: (a) pain across childhood and tolerant of peers’ pain behaviours when how to manage any emotional reactions adolescence, (b) the importance of they did not perceive the cause of the (e.g. if classmates become distressed or researching pain within these age pain as severe. Adolescents discussed worried about the child in pain). These groups, (c) how chronic pain impacts all their peers’ pain experiences in terms of findings, along with those showing aspects of life for young people and their whether or not the pain was perceived as children’s feelings of being families and (d) how researchers can ‘real’,16 a finding that further helps to misunderstood and isolated by peers develop interventions to improve the explain why adolescents with chronic and the importance of pain-related social quality of life (QoL) for children and pain conditions report having fewer interactions, highlight the need for adolescents living with pain. Each friends.13 An understanding of childhood/ increased education about chronic pain tutorial, lasting approximately 60 minutes, adolescent pain should include the way in schools. One way that we have gave students a brief overview of pain in in which the family, teachers and peers attempted to disseminate information childhood/adolescence including respond to that situation. How peers about chronic pain to UK secondary activities and class discussions. Students communicate attitudes and perceptions school students is through one of us, were also directed to further information of pain, analgesics and management Polly Langdon, becoming a PhD Tutor sources at the end of each tutorial to influences the adolescents with pain.16 with the Brilliant Club. encourage independent reading.

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Educating secondary school students about paediatric chronic pain

potential study. European Journal of Pain 2008; Box 1. Tutorial 3 – pain in childhood (0–11 years). 12: 1090–101. 8. Konijnenberg A, Uiterwaal C, Kimpen J, et al. Children with unexplained chronic pain: Substantial Today’s key question(s): impairment in everyday life. Archives of Disease in How do children understand health and illness? Childhood 2005; 90: 680–6. What conditions are associated with chronic pain in childhood? 9. Haraldstad K, Sørum R, Eide H, et al. Pain in children and adolescents: Prevalence, impact on How does childhood chronic pain impact on children’s quality of life? daily life, and parents’ perception, a school survey. How does childhood chronic pain impact on the child’s family? Scandinavian Journal of Caring Sciences 2011; 25: Learning outcome(s): 27–36. 10. Boyer MC, Compas BE, Stanger C, et al. By the end of this session, you will be able to Attentional biases to pain and social threat in Consider how developmental theory helps us to better understand children’s children with recurrent abdominal pain. Journal of understanding of pain Pediatric Psychology 2006; 31: 209–20. Identify various common conditions that are associated with childhood chronic 11. Koutantji M, Pearce SA, Oakley DA, et al. Children in pain: An investigation of selective memory for pain pain and psychological adjustment. Pain 1999; 81: Think about childhood pain from a biopsychosocial perspective 237–44. Identify various ways in which childhood chronic pain could interfere with a 12. Chalkiadis GA. Management of chronic pain in children. The Medical Journal of Australia 2001; child’s quality of life 175: 476–9. Identify various ways in which childhood chronic pain could impact on their 13. Forgeron PA, King S, Stinson JN, et al. Social family’s life functioning and peer relationships in children and Compare and contrast how chronic pain impacts differently the lives of children adolescents with chronic pain: A systematic review. Pain Research and Management 2010; 15: and adolescents 27–41. 14. Logan DE, Simons LE, and Carpino EA. Too sick for school? Parent influences on school functioning among children with chronic pain. Pain 2012; 153: My module comprised five learning References 437–43. tutorials, a final assignment and a 1. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld 15. Sato AF, Hainsworth KR, Khan KA, et al. School JA, et al. Pain in children and adolescents: A absenteeism in pediatric chronic pain: Identifying feedback tutorial. Tutorial title, key common experience. Pain 2000; 87: 51–8. lessons learned from the general school questions and learning outcomes are 2. King S, Chambers CT, Huguet A, et al. The absenteeism literature. Children’s Health Care detailed for Tutorial 3 in Box 1. epidemiology of chronic pain in children and 2007; 36: 355–72. adolescents revisited: A systematic review. Pain 16. Hatchette JE, McGrath PJ, Murray M, et al. The All students provided positive 2011; 152: 2729–38. role of peer communication in the socialization of feedback about the course, often 3. Chan E, Piira T, and Betts G. The school adolescents’ pain experiences: A qualitative reporting that they found the topic functioning of children with chronic and recurrent investigation. BMC Pediatrics 2008; 8: 2. pain. Pediatric Pain Letter 2005; 7: 11–6. 17. Meldrum ML, Tsao JCI, and Zeltzer LK. ‘I can’t be interesting and thought-provoking. As a 4. Vervoort T, Logan DE, Goubert L, et al. Severity of what I want to be’: Children’s narratives of chronic tutor, I found that students engaged pediatric pain in relation to school-related pain experiences and treatment outcomes. Pain well with the course content and functioning and teacher support: An Medicine 2009; 10: 1018–34. epidemiological study among school-aged children 18. Koontz K, Short AD, Kalinyak K, et al. produced excellent group discussions and adolescents. Pain 2014; 155: 1118–27. A randomized, controlled pilot trial of a surrounding pain-related topics and 5. Roth-Isigkeit A, Thyen U, Stöven H, et al. Pain school intervention for children with sickle cell assignments. As a researcher, I also among children and adolescents: Restrictions in anemia. Journal of Pediatric Psychology 2004; daily living and triggering factors. Pediatrics 2005; 29: 7–17. benefited from hearing adolescents’ 115: e152–62. 19. Logan DE, and Curran JA. Adolescent chronic views about chronic pain as students 6. Logan DE, Simons LE, Stein MJ, et al. School pain problems in the school setting: Exploring had a personal insight into how a impairment in adolescents with chronic pain. The the experiences and beliefs of selected Journal of Pain 2008; 9: 407–16. school personnel through focus group chronic pain condition might affect 7. Zohsel K, Hohmeister J, Flor H, et al. Altered pain methodology. Journal of Adolescent Health someone of their age. processing in children with migraine: An evoked 2005; 37: 281–8.

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Junior Physiotherapist when I regularly The preface states that the book ‘was saw patients post-surgery or in the gym designed to be a comprehensive, at the old General Hospital in extensively illustrated textbook about the Birmingham. rehabilitation of common musculoskeletal Luckily for me I also work along a conditions that effect athletes-from the fantastic team of physiotherapists who professional competitor to the occasional also were able to give me some participant’. It also claims to be the first constructive feedback and whom have of its kind to bring together surgeons, vastly more experience than me therapists and athletic trainers to address working within the world of sport; so injuries and judging by the extensive list here goes … of contributors from varying backgrounds The title of the book is ‘Orthopaedic and professions; I’m totally inclined to Rehabilitation of The Athlete-Getting believe them! Back in the Game’ and in essence it The book is split into chapters does exactly what it says on the tin. depending on the body area. These Be warned; it is a rather large and include Shoulder, Elbow, Forearm, Wrist heavy piece of the literature and wouldn’t and Hand, Spine, Hip and Thigh, Knee, feel out of place next to your Grey’s Leg, Ankle, Foot. Anatomy on the book shelf. It would be Within these chapters are sections Bruce Reider, George Davies and excellent to keep in the department as a which cover the main conditions that can Matthew Provencher. Orthopaedic reference tool but using it as a portable affect that particular region, for example, Rehabilitation of the Athlete: Getting handbook wouldn’t be realistic. However, the ‘knee’ section covers extensor Back in the Game, Elsevier, modern technology does allow us mechanism injuries/meniscus injuries/ Philadelphia, PA, 2015. ISBN: access via eBook format. articular cartilage injuries and ligament 9781455727803 The authors of the book are Bruce injuries and within these sections are Reider (a Professor of Orthopaedic subsections where the authors explore Reviewed by Rebecca Pardoe, Lead Surgery in Chicago), George Davies both non-operative rehabilitation and Physiotherapist Pain Management, (a Professor at the Department of post-operative rehabilitation and then go City Hospital, Birmingham, UK Rehabilitative Sciences Programme in on to describe a ‘beyond basic Physical Therapy in Georgia) and rehabilitation programme’. This involves When I was asked to review this book, Matthew Provencher (Chief of Sports targeting a particular sport following a I was slightly nervous to say the least; Medicine and Surgery at Massachusetts specific injury; an example of this is I was not a book connoisseur and had Hospital). All three authors have a return to skiing after treatment of a tibial never been asked to review a book significant amount of experience within shaft fracture. They also explore literature before. the area of sports team medical around the area of rehabilitation for this Even more daunting was that this management. particular injury and finish by asking five book was about athletes – I have worked There is additional reference to a huge multiple choice questions in order to test in the area of pain management within number of contributors including your new knowledge and understanding the National Health Service (NHS) for last representatives from the medical world (or not!). 20 years, so have come across very few as well as the athletic world; the majority For the purposes of this review, I have athletes in this period; with an increasing based in the United States. These decided to look more closely at fifth feeling of trepidation, I realised I would include athletic coaches/occupational metatarsal fractures as this is an injury have to try and recollect my time as a therapists and educators. that is fairly common in athletic

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Book review

individuals. The chapter opens by treatment which enables the reader to and personal trainers. Additionally, I am a describing epidemiology and view clearly the ‘direction of travel’ for the prime example of how it could be a pathophysiology and relates these patient including expected timescales; useful tool to those of us who aren’t specifically to particular athletes; it then there are also photographs depicting the specialist in sport rehabilitation but need goes on to describe the clinical exercises/stretches described. to ‘dip-in’ from time to time. presentation including what to expect to Post-operative rehabilitation follows a What are the possible downsides to find during the physical examination and similar phased approach to therapeutic this book? In my view the only two also gives some x-ray examples training and gradual return to sport with downsides to this book were first the demonstrating the different fractures sections describing the indications for occasional use of dated references. including an acute Jones fracture and a surgical intervention, a brief summary However, as with any hard literature, it is styloid avulsion fracture. of the surgery and ensuing virtually impossible to maintain current A very useful aspect of the book, management. research once published. especially for more junior clinicians, looks So what did I like about this book? And second, it was possible biased at differential diagnosis. For example, it I felt that it was very user friendly with towards the US athlete and medical explains that a fifth metatarsal fracture clear, logical sections and a good system (I only spotted a few European presentation can also be mimicked by selection of pictures to help explain contributors) and although we could fifth metatarsal apophysis or demonstrate various exercises as well as apply the majority of the principles to the osperoneum. some fascinating pictures of the various United Kingdom, this may prove difficult The chapter then goes on to explain surgical procedures (not for the faint with certain procedures within our non-operative treatments as well as hearted!). different health economies. exploring the possible surgical In addition, the radiographic In conclusion, I felt that his book indications. Some evidence is referenced photographs also helped to clearly perfectly achieved what it says it wants throughout; however, some of these explain the condition/surgery/clinical to do, that is, the rehabilitation of the references are relatively old (e.g. Clapper presentation which I feel is invaluable for athlete back to their sport. The overall et al., 1995) and I am therefore the more novice and inexperienced writing style and presentation was at a presuming the literature referenced is clinicians among us. level that provided the reader with a clear well known and/or a respected study in I also loved the ‘clinical pearls’ of management plan with contained the orthopaedic world. wisdom that were scattered throughout enough information for more junior Again, the chapter concludes by the book. clinicians to feel competent at providing asking the reader five multiple choice During my journey as ‘book reviewer’, appropriate and effective clinical input. questions. I also asked a number of my colleagues I have already made reference to it for Subsequent chapters include more their professional opinion; all of which my daughters’ university assignment on detail on non-operative rehabilitation of reiterated the above positive views. quadriceps muscle rehabilitation and it fifth metatarsal fractures which includes I see it being most useful for medical came in very useful following a friends’ appropriate advice concerning the and physiotherapy students or newly netball injury during a training session in management of pain and swelling and qualified clinicians. I also see it being July so thank-you Dr Reider, Dr Davies adopting a phased approach to used within the field of sports therapy and Dr Provencher!

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19_PAN677656.indd 189 22/11/2016 6:55:01 PM New Members ratified since September 2016

Name Current Post Place of work

Dr Shoma Khan Counselling Psychologist National Hospital for Neurology and Neurosurgery

Dr Samantha Owen Senior Clinical Psychologist Abergele Hospital

Miss Charlotte Sear Pain Specialist Nurse Stoke Mandeville Hospital

Dr Mohamed Eid ST7 Anaesthesia Royal Victoria Infirmary

Mr James Odell PhD student University Bournemouth

Dr Abigail Olubola Taiwo Lecturer University of Wolverhampton

Mrs Kate Thompson Senior Physiotherapy Lecturer Leeds Beckett University

Dr Sarah Gibb Locum Consultant Sunderland Royal Infirmary

Mrs Wendy Ballington Pain Specialist Nurse Frimley Health NHS Trust

Dr Michael Jones Advanced Pain Trainee/ST7 anaesthetics Belfast City Hospital

Join our Special Interest Groups (SIGs)

The British Pain Society recognises the importance of providing members who have specific interests with a forum (Special Interest Groups) to discuss their interest in more depth. The Society actively encourages and supports the development of such Special Interest Groups, as they are an important element of our multidisciplinary Society and are a key member benefit. There are currently 14 SIGs;

-Acute Pain -Clinical Information -Headache -Information Communication Technology -Interventional Pain Medicine -Medicolegal -Neuropathic Pain -Pain Education -Pain in Children -Pain in Developing Countries -Pain in Older People -Pain Management Programmes -Philosophy & Ethics -Primary & Community Care

For more information about any of our SIGs and how to join please visit: https://www.britishpainsociety.org/for-members/special-interest- groups/

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Philosophy and Ethics Special Interest Group Annual Meeting Rydall Hall, Cumbria 26th – 29th June 2017

Living Well Right to the End

Living Well Right to the End ….sounds impossible…

How to live well at all can prove elusive and has been much debated for thousands of years

Is it to do with physical health or pleasure or a general sense of wellbeing or happiness or fulfilment or meaning or is it merely the absence of suffering??

Can we somehow enable those we care for to achieve a level of wellbeing even as they decline into terminal illness or perhaps face the simple fact of old age and the prospect of death?

Can we achieve a measure of wellbeing in our own lives?

Our meeting this year takes place in the beautiful surroundings of Rydal Hall amongst the lakes and fells of Cumbria where we will be considering all of these issues.

Our speakers include Prof. Karol Sikora, Dean of Buckingham Medical School speaking on ‘Living With the Uncertainty of Cancer’. Dr Sara Booth, Lecturer at Cambridge University and at King’s College in London who has researched breathlessness and has an interest in the characteristics of wellbeing. Kate Binnie is a music therapist who uses music and song in her work to relieve suffering. Steve Johnson is a Buddhist teacher, mindfulness trainer and healthcare chaplain in hospital and hospice settings. Dr Emmylou Rahtz has a PhD in Psychiatry and is interested in how healing can be achieved. Fr Andy Graydon will speak about the concept of ‘deep acceptance’ around living and dying and Dr Jeremy Swayne’s talk ‘Coming Alive at Last’ will deal with enrichment and wholeness despite serious or even terminal illness.

www.britishpainsociety.org/mediacentre/events/

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Pain Management Programmes SIG Biennial Conference Glasgow Caledonian University, Scotland 14th & 15th September 2017

“Gonnae no dae that!” – exploring patient and clinician fears

Speakers including: Amanda C-de-C Williams, Tamar Pincus, David Gillanders and Johannes Vlaeyen.

Social events:

 Wednesday evening: drinks reception in the iconic Glasgow City Chambers.  Thursday evening: Scottish gin and real ale tasting, plus the chance to play the bagpipes at the National Piping Centre!

Should you have any queries about the event, or require more information on travel or hotels in Glasgow please contact [email protected]

www.britishpainsociety.org/mediacentre/events/

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