Osal Fentanyl St Preferred2

For the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain SEPTEMBER 2014 VOLUME 12 ISSUE 3 The decision to use a specific opioid preparation should be based on (in particular) the patient’s preference for an individual preparation1 Association of Palliative Medicine pain news In a survey of user opinions of transmucosal fentanyl a publication of the british pain society product placebos, Abstral was rated most preferred2

It was easier to access, easier to administer and more palatable than the other placebos.

18 responders 6 responders 2 responders Abstral® placebo Effentora® placebo Instanyl® placebo

Because time is precious

PRESCRIBING INFORMATION. Please refer to the full Summary of Product Characteristics before kidney dysfunction. Possible symptoms of withdrawal on cessation are anxiety, tremor, sweating, prescribing. paleness, nausea and vomiting. The development of a potentially life-threatening serotonin Name: Abstral 100 micrograms, Abstral 200 micrograms, Abstral 300 micrograms, Abstral syndrome may occur with the concomitant use of serotonergic drugs. Serotonin syndrome may 400 micrograms, Abstral 600 micrograms, Abstral 800 micrograms sublingual tablets. Active include mental-status changes, autonomic instability, neuromuscular abnormalities, and/or Ingredient: Each tablet contains 100µg, 200µg, 300µg, 400µg, 600µg or 800µg fentanyl (as gastrointestinal symptoms. Discontinue Abstral if serotonin syndrome is suspected. Interactions: citrate). Indication: Management of breakthrough pain in adult patients using opioid therapy for Fentanyl is metabolised by CYP3A4. Use with caution if given concomitantly with CYP3A4 inhibitors chronic cancer pain. Dosage and administration: Only use in patients tolerant to opioid therapy (e.g. macrolide antibiotics, azole antifungal agents, protease inhibitors or grapefruit juice). for persistent cancer pain. Administer directly under the tongue, and allow to dissolve without Concomitant use of other CNS depressants may increase CNS depressant effects. Respiratory chewing, sucking or swallowing the tablet. Adults; Initially 100µg, titrating upwards as necessary to depression, hypotension and sedation may occur. Concomitant use of alcohol or partial opioid establish an appropriate dose. Patients must be monitored closely by a health professional during agonists/antagonists (e.g. buprenorphine, pentazocine) is not recommended. Coadministration titration. Patients should be maintained on this dose and should take no more than 4 doses/day. of a serotoninergic agent, such as a Selective Serotonin Reuptake Inhibitor (SSRI), a Serotonin Social Media – benign inﬂ uence or spin? During titration, patients can use multiples of 100µg and/or 200µg tablets for a single dose, taking Norepinephrine Reuptake Inhibitor (SNRI) or a Monoamine Oxidase Inhibitor (MAOI), may no more than 4 tablets at any one time. During both titration and maintenance patients should increase the risk of serotonin syndrome. Not recommended for use in patients who have received wait at least 2 hours before treating another episode of breakthrough pain. Elderly and patients an MAOI within 14 days. Pregnancy: Safety in pregnancy not established. Long-term treatment Changing attitude towards analgesics with renal and hepatic impairment; Take particular care during titration and observe patients may cause withdrawal symptoms in newborn infant. Do not use during labour and delivery for signs of fentanyl toxicity. Children and adolescents; Must not be used in patients under 18 since fentanyl crosses the placenta and may cause respiratory depression in the fetus or infant. years of age. Adverse effects: The most serious adverse reactions associated with opioid use are Lactation: Fentanyl is excreted into breast milk and should only be used if the benefits clearly Where is your pain? respiratory depression, hypotension and shock. The most frequently observed adverse reactions outweigh the potential risks for mother and child. Contraindications: Hypersensitivity to any of with Abstral include nausea (very common); constipation, somnolence, headache, dizziness, the ingredients; opioid-naïve patients; severe respiratory depression or severe obstructive lung dyspnoea, stomatitis, vomiting, dry mouth, hyperhidrosis and fatigue (common). Other serious conditions. Treatment of acute pain other than breakthrough pain. NHS cost: Abstral 100-400µg 10 Teams in Pain Management but uncommon adverse reactions include: hypersensitivity, tachycardia, bradycardia, hypotension tablets: £49.99. Abstral 100-800µg 30 tablets: £149.70. Legal classification: CD POM. Marketing and drug withdrawal syndrome. Prescribers should consult the summary of product characteristics Authorisation Numbers: PL 16508/0030-35. Marketing Authorisation Holder: ProStrakan Ltd, for further details of side-effects. Precautions: Instruct patients and carers to keep tablets out of Galabank Business Park, Galashiels, Scotland TD1 1QH. Date of prescribing information: July 2014. Spotlight - Antony Chuter reach and sight of children. Ensure patients and carers follow instructions for use and know what action to take in case of overdose. Before starting Abstral, ensure long-acting opioid treatment Adverse events should be reported. Reporting forms and information can be found for persistent pain is stable. Dependence may develop upon repeated administration of opioids. There is a risk of significant respiratory depression. Take particular care during dose titration in at www.mhra.gov.uk/yellowcard. Adverse events should also be reported patients with COPD or other conditions predisposing to respiratory depression. Administer with to UK ProStrakan Ltd. on +44 (0)1896 664000 extreme caution in patients who may be particularly susceptible to the intracranial effects of hyperkapnia. Opioids may mask the clinical course in patients with head injuries. Use with caution References: 1. Davies AN et al. EUR J Pain 2009; 13: 331-8. 2. England R et al. BMJ Supportive in patients with bradyarrhythmias, hypovolaemia, hypotension, mouth wounds or mucositis. & Palliative Care 2011; 1: 349-51. ®Effentora is a registered trademark owned by Teva UK Ltd. Monitor use carefully in elderly, cachectic and debilitated patients, and patients with liver or ®Instanyl is a registered trademark owned by Takeda Pharmaceuticals International GmbH. http://www.britishpainsociety.org/members_newsletter.htm Date of preparation: August 2014. M017/0773(1) ISSN 2050–4497

PAN_cover_sagepub.indd 1 30/08/2014 1:10:49 PM For the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain SEPTEMBER 2014 VOLUME 12 ISSUE 3 The decision to use a specific opioid preparation should be based on (in particular) the patient’s preference for an individual preparation1 Association of Palliative Medicine pain news In a survey of user opinions of transmucosal fentanyl a publication of the british pain society product placebos, Abstral was rated most preferred2

It was easier to access, easier to administer and more palatable than the other placebos.

18 responders 6 responders 2 responders Abstral® placebo Effentora® placebo Instanyl® placebo

Because time is precious

PAN_cover_sagepub.indd 1 30/08/2014 1:10:49 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 SEPTEMBER 2014

Officers Ms Felicia Cox Editor, British Journal of Pain and Regulars Dr William Campbell Representative, RCN President 137 Editorial Prof. Maria Fitzgerald 138 From the President Dr John Goddard Representative: Science Vice President Dr Kate Grady News Dr Andrew Baranowski Representative: Faculty of Pain Medicine Honorary Treasurer Prof. Roger Knaggs 141 Pain Education Study Day Dr Martin Johnson Representative: Pharmacy 143 Forthcoming Annual Scientific Meeting of Interventional Pain Medicine Special Honorary Secretary Prof. Richard Langford Interest Group Representative: National Pain Audit 146 Impressions of a meeting: the Philosophy and Ethics SIG 2014 Compassion in Elected Dr Arasu Rayen Modern Healthcare Mr Neil Berry Editor, Pain News 148 BPS feedback on the 2014 ASM in Manchester Dr Arun Bhaskar Dr Andrew Rice 149 Tips for writing a good abstract for the Annual Scientific Meeting Dr Heather Cameron Representative; IASP 150 Patient information leaflets Mr Paul Cameron 151 Pain News in ‘Have I Got News For You’ Dr Sam Eldabe Prof. Kate Seers Dr Oliver Hart Chair, Scientific Programme Committee Professional perspectives - Margaret Dunham Dr Tim Johnson Dr Austin Leach Secretariat Associate Editor Dr Ann Taylor Jenny Nicholas Secretariat Manager 152 Reflections on changing attitudes towards analgesia 154 What the practice of acupuncture has taught me as a doctor Co-Opted Members Dina Almuli Prof. Sam Ahmedzai Events & Marketing Officer 156 Chronic pain management - a learning experience Representative: Association for Palliative 158 Social media in medicine: benign influence or spin? Ken Obbard Medicine 161 A new enhanced surveillance system for Post-Herpetic Neuralgia in pain clinics Events & Membership Officer Prof. Nick Allcock 163 After Tramadol: a closer look at Codeine ? Chair, Communications Committee Rikke Susgaard-Vigon Events & Communications Officer Mr Antony Chuter Informing practice - Christina Liossi, Associate Editor Chair, Patient Liaison Committee 165 The early days in Seattle and the birth of the IASP: a history of the pain movement Dr Beverly Collett 168 The challenge of pain in older people Representative: CPPC 171 How do musculoskeletal physiotherapists make sense of the language that PAIN NEWS is published quarterly. Circulation The editor welcomes contributions they use when explaining persistent pain to their patients? An Interpretative 1600. For information on advertising including letters, short clinical reports and Phenomenological Analysis please contact news of interest to members, including 174 Where is your pain? Tamara Haq, SAGE Publications, notice of meetings. 176 Teams in pain management 1 Oliver’s Yard, 55 City Road, Next submission deadline : London EC1Y 1SP, UK. 10th October 2014 Tel: +44 (0)20 7324 8601; Book reviews Email: [email protected] Material should be sent to: Disclaimer: Dr Arasu Rayen 180 A nation in pain: healing our biggest health problem The Publisher, Society and Editors cannot PAIN NEWS Editor 181 Mindfulness for health: a practical guide to relieving pain, reducing stress and be held responsible for errors or any The British Pain Society restoring wellbeing 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 End stuff - Ethel Hili, Associate Editor reflect those of the Publisher, Society and Email [email protected] Editors, neither does the publication of 183 Spotlight advertisements constitute any endorsement ISSN 2050-4497 (Print) 185 Word search ISSN 2050-4500 (Online) by the Publisher, Society and Editors of the 186 Allegories of change; the poetry of Ted Hughes and images of the natural world products advertised. Printed by Page Bros., Norwich, UK 189 Snap and chat At SAGE we take sustainability seriously. For the management of breakthrough pain in adult patients using opioid therapy for chronic cancer pain SEPTEMBER 2014 VOLUME 12 ISSUE 3 The decision to use a specific opioid preparation should be based on (in particular) the patient’s preference for an individual preparation1 We print most of our products in the UK. Association of Palliative Medicine pain news These are produced using FSC papers and In a survey of user opinions of transmucosal fentanyl a publication of the british pain society product placebos, Abstral was rated most preferred2 boards. We undertake an annual audit on It was easier to access, easier to administer materials used to ensure that we monitor and more palatable than the other placebos. our sustainability in what we are doing.

18 responders 6 responders 2 responders Abstral® placebo Effentora® placebo Instanyl® placebo When we print overseas, we ensure that

This was a relatively small survey (n=30) and was not blinded, however the results provided valuable information about the practical preferences of patients with cancer pain for transmucosal fentanyl products.2 sustainable papers are used, as measured ® by the Egmont grading system. Because time is precious

PRESCRIBING INFORMATION. Please refer to the full Summary of Product Characteristics before kidney dysfunction. Possible symptoms of withdrawal on cessation are anxiety, tremor, sweating, prescribing. paleness, nausea and vomiting. The development of a potentially life-threatening serotonin Name: Abstral 100 micrograms, Abstral 200 micrograms, Abstral 300 micrograms, Abstral syndrome may occur with the concomitant use of serotonergic drugs. Serotonin syndrome may 400 micrograms, Abstral 600 micrograms, Abstral 800 micrograms sublingual tablets. Active include mental-status changes, autonomic instability, neuromuscular abnormalities, and/or Ingredient: Each tablet contains 100µg, 200µg, 300µg, 400µg, 600µg or 800µg fentanyl (as gastrointestinal symptoms. Discontinue Abstral if serotonin syndrome is suspected. Interactions: Social Media – benign inﬂ uence or spin? citrate). Indication: Management of breakthrough pain in adult patients using opioid therapy for Fentanyl is metabolised by CYP3A4. Use with caution if given concomitantly with CYP3A4 inhibitors chronic cancer pain. Dosage and administration: Only use in patients tolerant to opioid therapy (e.g. macrolide antibiotics, azole antifungal agents, protease inhibitors or grapefruit juice). for persistent cancer pain. Administer directly under the tongue, and allow to dissolve without Concomitant use of other CNS depressants may increase CNS depressant effects. Respiratory Changing attitude towards analgesics chewing, sucking or swallowing the tablet. Adults; Initially 100µg, titrating upwards as necessary to depression, hypotension and sedation may occur. Concomitant use of alcohol or partial opioid establish an appropriate dose. Patients must be monitored closely by a health professional during agonists/antagonists (e.g. buprenorphine, pentazocine) is not recommended. Coadministration Where is your pain? titration. Patients should be maintained on this dose and should take no more than 4 doses/day. of a serotoninergic agent, such as a Selective Serotonin Reuptake Inhibitor (SSRI), a Serotonin During titration, patients can use multiples of 100µg and/or 200µg tablets for a single dose, taking Norepinephrine Reuptake Inhibitor (SNRI) or a Monoamine Oxidase Inhibitor (MAOI), may no more than 4 tablets at any one time. During both titration and maintenance patients should increase the risk of serotonin syndrome. Not recommended for use in patients who have received Teams in Pain Management wait at least 2 hours before treating another episode of breakthrough pain. Elderly and patients an MAOI within 14 days. Pregnancy: Safety in pregnancy not established. Long-term treatment with renal and hepatic impairment; Take particular care during titration and observe patients may cause withdrawal symptoms in newborn infant. Do not use during labour and delivery for signs of fentanyl toxicity. Children and adolescents; Must not be used in patients under 18 since fentanyl crosses the placenta and may cause respiratory depression in the fetus or infant. years of age. Adverse effects: The most serious adverse reactions associated with opioid use are Lactation: Fentanyl is excreted into breast milk and should only be used if the benefits clearly respiratory depression, hypotension and shock. The most frequently observed adverse reactions outweigh the potential risks for mother and child. Contraindications: Hypersensitivity to any of with Abstral include nausea (very common); constipation, somnolence, headache, dizziness, the ingredients; opioid-naïve patients; severe respiratory depression or severe obstructive lung dyspnoea, stomatitis, vomiting, dry mouth, hyperhidrosis and fatigue (common). Other serious conditions. Treatment of acute pain other than breakthrough pain. NHS cost: Abstral 100-400µg 10 but uncommon adverse reactions include: hypersensitivity, tachycardia, bradycardia, hypotension tablets: £49.99. Abstral 100-800µg 30 tablets: £149.70. Legal classification: CD POM. Marketing and drug withdrawal syndrome. Prescribers should consult the summary of product characteristics Authorisation Numbers: PL 16508/0030-35. Marketing Authorisation Holder: ProStrakan Ltd, for further details of side-effects. Precautions: Instruct patients and carers to keep tablets out of Galabank Business Park, Galashiels, Scotland TD1 1QH. Date of prescribing information: July 2014. reach and sight of children. Ensure patients and carers follow instructions for use and know what action to take in case of overdose. Before starting Abstral, ensure long-acting opioid treatment Adverse events should be reported. Reporting forms and information can be found for persistent pain is stable. Dependence may develop upon repeated administration of opioids. There is a risk of significant respiratory depression. Take particular care during dose titration in at www.mhra.gov.uk/yellowcard. Adverse events should also be reported patients with COPD or other conditions predisposing to respiratory depression. Administer with to UK ProStrakan Ltd. on +44 (0)1896 664000 extreme caution in patients who may be particularly susceptible to the intracranial effects of hyperkapnia. Opioids may mask the clinical course in patients with head injuries. Use with caution References: 1. Davies AN et al. EUR J Pain 2009; 13: 331-8. 2. England R et al. BMJ Supportive in patients with bradyarrhythmias, hypovolaemia, hypotension, mouth wounds or mucositis. & Palliative Care 2011; 1: 349-51. ®Effentora is a registered trademark owned by Teva UK Ltd. Monitor use carefully in elderly, cachectic and debilitated patients, and patients with liver or ®Instanyl is a registered trademark owned by Takeda Pharmaceuticals International GmbH.

Date of preparation: August 2014. M017/0773(1) ISSN 2050–4497

PAN_cover_sagepub.indd 1 18/08/2014 12:38:45 PM

PAIN NEWS September 2014 vol 12 No 3 135

00_Prelims.indd 135 09/09/2014 10:29:49 AM Calendar of Events

2014

Interventional Pain Medicine SIG Annual Meeting Friday 17th October Manchester www.britishpainsociety.org/meet_bps_sigs_meeting.htm

Patient Liaison Committee – Annual Seminar Thursday 23rd October Churchill House, London www.britishpainsociety.org/patient_liaison_cmttee.htm

Musculoskeletal Pain (32nd Study Day) Tuesday 28th October Churchill House, London www.britishpainsociety.org/meet_bps_study_days.htm

Faculty of Pain Medicine Annual Meeting: Pain Management in Special Circumstances Friday 14th November Churchill House, London www.rcoa.ac.uk/faculty-of-pain-medicine/events/events-calendar

Pain Education (33rd Study Day) Monday 24th November Churchill House, London www.britishpainsociety.org/meet_bps_study_days.htm

2015

Cancer Pain (34th Study Day) Friday 13th February Churchill House, London www.britishpainsociety.org/meet_bps_study_days.htm

Annual Scientific Meeting Tuesday 21st April – Thursday 23rd April Glasgow www.britishpainsociety.org/meet_ASM.htm

00_Prelims.indd 136 09/09/2014 10:29:49 AM PAN0010.1177/2050449714547996Pain News 547996research-article2014

Editorial

Arasu Rayen Editor, Pain News Pain News [email protected] 2014, Vol 12(3) 137 © The British Pain Society 2014

I have just come were due to pioneers in pain What is QR code? out a severe bout management like John Bonica, Ronald QR code or Quick Response code is a of flu. It was so Melzack and Patrick Wall. In this issue of type of popular barcode used widely severe that I have Pain News John Loeser shares his including train tickets. These codes can lost my sense of experience with John Bonica during be scanned by various mobile operating smell for nearly a those early days of pain management. He systems; Google Goggle is an app, week. As you starts the article with statements ‘The which can be used both in android and know, when you pain world started with one person. That iOS to scan the code. The app will link don’t have sense man was John Bonica’. The article is a it straight to the URL (weblink). of smell, you can’t description of a first hand experience with Windows phone can do the same taste any food. For nearly a week all food legends such as John Bonica. through its Bing search app. tasted the same. I just ate to survive. It Bronwyn Lennox Thompson, in this Blackberry has its own native QR code was so frustrating to be in that position. issue of Pain News, discusses in detail reader. At least I knew that my loss of sense of ‘the pain management team’. In her smell was temporary. During that period article Ms Thompson describes how the of anosmia, I thought about one of my concept of multidisciplinary pain What do you do with friends who lost his olfaction (sense of management teams came along. She QR code? smell) following pituitary surgery. His loss questions who should be in the team and Just open one of the above given QR was permanent. He always commented details the challenges facing the code reader apps and scan the code. that he just ate to survive. teamwork and strategies to improve. The app will take you straight to the Most of our chronic pain patients are in In addition to the above, there are more webpage of Pain News. the same position. They loose so much articles for you to read and enjoy. Please do We have also developed the following in their life because of their pain – read them and send your comments to us. QR code for British Journal of Pain: independence, job, relationships, Finally, from this issue onwards, Pain hobbies, self-esteem, enjoyment of life, News will have the following QR code QR code for British Journal of Pain sleep etc. The loss may sometimes be and web address on the cover page for permanent. They not only have to deal ease of accessing the electronic version with the burden of pain but also have to from the British Pain Society website. deal with this added baggage of losses QR code for Pain News and the consequences. We, as a specialty, understand this very well and manage the chronic pain as a ‘biopsychosocial’ problem rather than ‘just a pain problem’. Chronic pain management which started as a single modality specialty has come a long way. We are a true multidisciplinary specialty. Pain clinics with professionals from relevant disciplines such as medical, nursing, physiotherapy, psychiatry and occupational health, are considered ideal Cover Photo rather than single discipline based clinics. Social media/Multidisciplinary team This understanding and advancement working

September 2014 Vol 12 No 3 l Pain News 137

01_PAN547996.indd 137 03/09/2014 10:00:40 AM PAN0010.1177/2050449714547997Pain News 547997research-article2014

From the President

Dr William Campbell Pain News 2014, Vol 12(3) 138 –139 © The British Pain Society 2014

Firstly I must As advised at the April AGM, at the 10 months. The next stage is for the belatedly July Council meeting it was proposed commissioners to agree the way ahead. congratulate two that the membership fees increase in all Although this work is similar to a mix of individuals. bands by 3% for the year 2015. parts of the NICE CG88 and the British Pete Moore Approval for special resolutions on Pain Society Pathways on this topic, it is was selected as categories of membership, including considerably less restrictive on advice. Pain Champion electronic voting, was made at our last As one of the physiotherapists on the for the year Annual General Meeting held on the 30th group quite rightly said, there are so 2013-2014. April 2014 in Manchester. many ways of managing low back pain Despite close and evidence for each isn’t great. It is competition, the hoped that the Pathfinder for low back e-Learning Pain nominators from pain will replace CG88 until the This project, which started a few years the British Pain replacement NICE guidance becomes back, became an active website early Society, Pain UK available in 2016. this year and now the majority of the and the Chronic Pain Policy Coalition teaching modules are live on the site. (CPPC ) were unanamous in awarding The project has been set up and Pain Consortium this award to Pete for his stirling work co-ordinated via the Faculty of Pain This is an entity established last year over many years, championing patients Medicine, Royal College of Anaesthetists between the British Pain Society, Faculty of causes and providing a wealth of material and the British Pain Society. Yet again I Pain Medicine, Chronic Pain Policy Coalition to enable patients to help themselves. In would wish to thank all the module and CRG Specialist Pain Services. Up to addition, one of our Council members, leaders and authors for their very two representatives from each body sit on Paul Cameron, must also be considerable contributions to this project the Consortium and we tend to meet just congratulated on becoming the Chronic which can be visited at http://www.e-lfh. before each of the British Pain Society Pain Co-ordinator for The Scottish org.uk/programmes/pain-management/. Council meetings. The last meeting was held Government. Well done. nd To access the teaching material it is on 2 July and we covered topics such as necessary to register first as well as the Pain Summit recommendations and British Pain Society having a recognised NHS email address. commissioning. Following the Pain Summit Membership & Special the following work was tasked as follows: Resolutions ratified at last AGM Most of you will reallise by now that the Low Back Pain – Pathfinder Problematic / complex pain (Faculty membership numbers fluctuate at project of Pain Medicine) various times of the year, and currently This project which was initiated last Awareness campaign (Chronic Pain there are 1334 members. September, has reached its conclusion in Policy Coalition) Following our Strategy Day in relation to concensus of clinical opinion Commissioning guidance (Royal December 2013, we decided to set up a from a very wide number of stakeholders, College of General Practice) including the British Pain Society. The new membership working group to Epidemiology of chronic pain (British working group, chaired by Professor review the retention and recruitment of Pain Society) new members. The group are currently Charles Greenough, National Clinical exploring recruitment within primary care, Director for Spinal Disorders, had Professor Gary Macfarlane, Epidemiology physiotherapy and nursing. I am grateful represention from primary care, Group, University of Aberdeen, is to the representatives of these disciplines psychology, physiotherapy, spinal surgery heading up the work stream for our who sit on Council for carrying this topic and many others. It was a credit to Charles Society – entitled Make Pain Count. He forward. that a concensus was reached by all within has planned 3 themes to the work:

138 Pain News l September 2014 Vol 12 No 3

02_PAN547997.indd 138 03/09/2014 10:30:33 AM From the President

Dr William Campbell

- Data sources, including what is may, paradoxically, worsen POFP care pathways in POFP in order to already known and the need for core (Durham et al 2011b). identify areas where the current data (Lead: Gareth Jones) POFP patients are known to use more pathways could be modified, and model - Terminology associated with routine healthcare resource compared to other the estimated impact of change to recording in clinical practice (Lead: dental patients (Aggarwal et al 2008; Glaros determine what changes would improve Cathy Price) et al 1995; White et al 2001), but what is outcomes for patients and use resources unknown is why and where this utilisation more efficiently. Its recruitment stage is - Health Measures (Lead: Candy occurs. Previous research (Durham et al drawing to a close and interim McCabe) 2011b) suggested that a large proportion of preliminary analyses suggest that entry this resource utilisation may occur as a to the study visit costs are by far and This is a substantial amount of work that result of inadequate care pathways for away the largest driver of total Gary has established and the results patients with POFP: cyclical referrals healthcare utilisation costs and that should considerably compliment the accompanied by multiple and unnecessary quality of life measured by EQ-5D-5L is National Pain Audit that has been very consultations which often only serve to comparable to other chronic conditions ably led by Cathy Price over the past few increase confusion and sometimes worsen affecting other areas of the body years. the patient’s complaint. Clearly this is a (Durham et al 2014a & b). costly process for both the patient and the See - Durham et al. BMC Oral Health Orofacial pain health service and therefore in addition to 2014, 14:6 We are well into the IASP and EFIC year delivering more accurate diagnoses and http://www.biomedcentral.com/1472- against orofacial pain. Naturally the treatment, we need to understand how and 6831/14/6. British Pain Society supports this initiative where we can streamline services in order For further information about this work, and work carried out in this area, such as to get patients to the most appropriate care run by Justin Durham see http:// that by Justin Durham who shares some efficiently and effectively at the earliest research.ncl.ac.uk/deepstudy/. of the project information below. possible opportunity, thereby maximising The Society supports this work and Developing Effective and Efficient care the therapeutic potential of any available looks forward to further information on pathways in persistent Pain: DEEP Study. management strategies. this topic. As we are all aware, persistent pain is A simplistic unidimensional a distressing problem for patients (Breivik assessment of the costs of POFP care Finally, Heather Wallace has fought for et al 2006) and can be difficult and pathways is insufficient to capture the pain patients for many years via Pain sometimes distressing to manage for biopsychosocial dynamic relationship of Concern and airing pain. Please take clinicians (Kristiansson et al 2011). POFP and the care received (Suvinen some time to check the Pain Concern Persitent pain affecting the face, mouth et al 2005). A “whole systems website at www.painconcern.org.uk or head (persistent orofacial pain [POFP]) perspective” (Phillips et al 2008) is Many of you may be aware that an is common, affecting an approximated required in order to assess current care e-petition, headed up by Jean Gaffin is 13% of the population (MacFarlane et al pathways and produce patient centred currently active until mid December 2014. 2001). POFP also exerts many of the services “designed around patient’s If 10,000 individuals sign up to this it will same impacts that we see in other needs” (Donaldson 2008). Without trigger a government response, and if persitent pain conditions affecting other identifying where the negative economic, 100,000 sign up there will be a debate in parts of the body (Durham et al 2010, biomedical, and psychosocial impacts Parliament. In order to get a sufficient 2011b; Wolf et al 2006; Nilsson et al exist on the current care pathway from response it will be necessary to get 2011). Diagnosis and treatment for POFP both the consumer and the providers’ patients to sign up as well as healthcare conditions is slowly improving through perspectives, it is impossible to model professionals. Patients have the power, so the institution of new, targeted, new pathways that provide appropriate do encourage your patients, whether in diagnostic tools (Schiffman et al 2014) care in a patient-centred, efficient, primary care, physiotherapy departments, and advances in genomics (Meloto et al efficacious and expedient manner. The etc. to sign up please. 2011), but current care pathways may NIHR funded DEEP study aims to The link for this is - http://epetitions. not maximise therapeutic potential and longitudinally and prospectively examine direct.gov.uk/petitions/58377.

September 2014 Vol 12 No 3 l Pain News 139

02_PAN547997.indd 139 03/09/2014 10:30:34 AM Now accepting primary research papers

Official journal of the British Pain Society The Journal aims to broaden its scope and become a forum for publishing primary research together with brief reports related to pain and pain interventions. Submissions from all over the world have been published and are welcome.

Good reasons to publish in British Journal of Pain… • Published by SAGE since 2012, the journal is now fully online and continues to be published in print. Browse full text online at bjp.sagepub.com • Official journal of the British Pain Society, the journal is peer reviewed, with an international multidisciplinary editorial board • Submit online and track your article on SAGEtrack • High visibility of your paper: the journal is currently free to access and is always free to link to from cited and citing references on HighWire Press, the world’s leading e-content provider www.britishpainsociety.org

Now accepting original research and review papers in these areas: Adjuvant therapies for acute and chronic pain Pain management in the adolescent/young adult Basic science Peripheral regional analgesia Commissioning Pharmacogenomics Local anaesthetics Primary care management Mobile technologies Psychology Neuraxial analgesia for acute pain Psychology of pain Neuropathic pain Service re-design NSAIDs and COX-2 inhibitors Sleep and pain Opioids Therapies including lifestyle orientated treatments Pain management in palliative and end of life care Transition between acute and persistent pain Pain management in patients with HIV

For enquiries about your paper contact [email protected] Submit your paper online on SAGEtrack: http://mc.manuscriptcentral.com/bjpain

02_PAN547997.indd 140 03/09/2014 10:30:34 AM PAN0010.1177/2050449714547998Pain News 547998research-article2014

News

Pain Education Study Day Pain News 2014, Vol 12(3) 141 © The British Pain Society 2014 Sue Jenkins Lecturer, Cardiff School of Infection and Immunity

The Pain Education SIG were delighted London) will be the keynote speaker. to be invited to organise a Study Day as Michele specialises in clinical education Committee Members part of the Society’s learning in Pain and interdisciplinary teaching and learning Emma Briggs (Chair) Series (LIPS). Janet McGowan, Sue and is one of only 40 people in the country Nick Allcock Jenkins and Emma Briggs have to be awarded the status of Principal Michelle Briggs developed an exciting programme that Fellow of the Higher Education Academy. Sarah Henderson will ensure a highly interactive day, Dr Vinette Cross will be presenting the Ethel Hili exploring the principles and practice of findings of a research study on self- clinical, patient and university education. management in chronic low back pain. Geraldine Granath (PLC Representative) The Study Day is appropriate for Dr Cross, Senior Research Fellow at clinicians, educators and anyone who has University of Brighton and University of Sue Jenkins an interest in the delivery of education to Wolverhampton, has been involved in Despina Karargyri patients and healthcare professionals. It the collaborative study with East Sussex Janet McGowan provides an opportunity to consider Healthcare NHS Trust, the Open Pat Roche interactive and novel methods of delivering University and the University of Brighton. Alison Twycross education, to share good practice and to The study has identified a variety of Sharon Wood discuss some of the challenges we face in viewpoints held by both practitioners helping others learn about pain. and patients on what self-management The Study Day will be held at the means to an individual with chronic low British Pain Society in London, on 24th back pain, leading to insights into why •• Patient Education: Patient Choices in November 2014. this approach is sometimes challenging. Self-management The day’s objectives are: The afternoon is made up of a series •• Building a Pain Education Community of engaging masterclasses where (SIG Members) •• to present, consider and discuss delegates and SIG members have the principles and practice of clinical opportunity to consider and discuss how Afternoon Masterclasses education pain education delivery can be improved. •• to explore good practice in educating We hope that you can join us for this •• Challenges and Rewards of Patient patients and healthcare professionals stimulating Study Day. Contributions to Education on pain management the sessions and workshops run by the •• Building an Evidence Base for Pain •• to network with like-minded SIG are also welcome. If you are involved Education (SIG Members) colleagues and discuss ways of in any of the areas covered (listed on the •• Designing and using e-learning building a pain education community itinerary), please contact Janet or Sue. for Pain Education (SIG The outline of the programme is: Members) The morning sessions will introduce the principles and different approaches used in If you want to attend the day, please Morning education. We are pleased that Dr Michele contact Ken Obbard (meetings@ Russell-Westhead (Academic Lead •• Principles and Practice of Clinical britishpainsociety.org) / Tel: 020 Educational Development, King’s College Education 72697840 for an application form.

Article of interest The following article presents an interesting discussion on the factors influencing practice and the need for pain education and is co-authored by SIG member and former committee member, Dr Willy Notcutt. Notcutt, W. and Gibbs, G. 2010. Inadequate pain management: myth, stigma and professional fear. Postgrad Med J 86:453e-458e.

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03_PAN547998.indd 141 04/09/2014 11:12:58 AM The British Pain Society Learning in Pain series Pain Education Study Day Monday 24th November 2014, London

Pain Education Study Day

This study day has been organised by the Pain Education SIG for the Society.

This will be an exciting and interactive study day exploring the principles and practice of

clinical, patient and university education. A great opportunity to meet with like-minded

colleagues who want to improve pain management through education. The day creates

opportunities for interactive learning, sharing ideas, best practice and addressing the

challenges.

CPD points applied for.

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News

Forthcoming Annual Scientific Meeting Pain News 2014, Vol 12(3) 143 –144 of Interventional Pain Medicine Special © The British Pain Society 2014 Interest Group

Neil Collighan Consultant in Anaesthesia and Pain Management, IPM SIG Treasurer

As an office-bearer of the British Pain •• Cordotomy for cancer pain: Evidence neuromodulation centres across this Society Intervention Pain Medicine and progress on Registry study. Prof country and in the world. This has Special Interest Group it fell to me to Matthew Makin (Wrexham). expanded the number of patients who organise the upcoming SIG Annual •• ‘Lumbar Chemical Sympathectomy: would be suitable for neuromodulation Scientific Meeting. I have always felt the it time to abandon?’ Dr Dudley Bush and moved the exciting field of SIG is a forward looking group, open to (Leeds) interventional pain medicine forward in new developments in interventional pain •• Good practice guidelines (Lumbar leaps and bounds. medicine throughout the world, but not Radiofrequency): Dr Neil Collighan The meeting invited posters for the first following the latest fashion unless a good (Kent)/ Dr Sanjeeva Gupta (Bradford) time to encourage more engagement evidence based approach has been used •• Update on research feasibility group; with SIG members to support their audits in the process. Being hard-nosed about Progress so far: Dr Vivek Mehta and to be shared with wider audience. new innovation has also brought on (London) These posters were published as retrospection about interventions already •• Translational Research: Evidence proceedings of the Annual Scientific delivered. A groundswell has occurred driven clues for optimizing Meeting of IPM SIG in the British Journal over recent years to produce good NeuroStimulation solutions for pain: of Pain, supported by British Pain Society. evidence for what we already provide, Dr Greg Molnar, Medtronic (USA) Following deliberation and guidelines and some long delivered procedures •• Role of Interventional Pain Medicine publication, the use of chemical lumbar have fallen by the wayside when the high in Palliative care: Palliative care sympathectomy has receded as it was quality evidence was found wanting. perspective. Prof Sam Ahmedzai unsupported by evidence. In an effort to produce an interesting (Sheffield) In 2012, the SIG submitted proposals and educational programme I thought it •• Absolute alcohol and Neurolysis for to the BPS for two good practice to be a good idea to look back at cancer pain: Indications, technique guidelines to be prepared by the IPM previous years’ programmes and the and Outcome: Dr Arun Bhaskar SIG: impact on clinical practice. (Manchester) ‘Good Practice Guidelines for Medial In 2012, for the Annual Meeting Branch Block and Radiofrequency organised by Dr Manohar Sharma, the What did we learn and what Denervation for Lumbar Facet Joint Pain’ topics included: happened next? ‘Good Practice Guidelines for For many years neuromodulation was Percutaneous Spinal intervention •• ‘Dorsal root ganglion stimulation: delivered by standard placement of Procedures (excluding epidural). Indications, evidence and experience’ epidural leads with conventional Currently the first guideline has now delivered by Dr Liong Liem (Netherlands). stimulation parameters. Over the recent been published and the second guideline •• ‘High frequency dorsal column years novel methods of delivering is now in full draft form awaiting final stimulation: Indications, evidence and neuromodulation, either by high editing by myself, the working party and experience:’ by Dr Iris Smet (Belgium). frequency or alternative placement with Faculty of Pain Medicine and British •• ‘Neurosurgery, Pain and peripherally or on the dorsal root Pain Society’s support. Neuroablation; When to refer to ganglion have been studied. These In 2011, the IPM SIG set up a research Neurosurgeon?’ by Mr Paul Eldridge newer methods have now been feasibility group under the leadership of (Liverpool). introduced into the armamentarium of Dr Simon Thomson and Dr Tony

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Forthcoming Annual Scientific Meeting of Interventional Pain Medicine Special Interest Group

Hammond to help enhance the evidence •• ‘Radiofrequency Registry, Again, the SIG was looking to the future base behind our many procedures. The introduction and progress’ Dr T and how to collect data to support group has rapidly established its research Haag, (Wrexham) continuing practice. Here this included a credentials and a recent feasibility study •• ‘Investigating central sensitisation presentation on a radiofrequency registry on facet joint injections has been given following DRG block- a prospective to help in the accumulation of reproducible approval and the study is about to start. study’ Dr V Mehta, (London) information. The registry is now very close This is great news for research •• ‘A progress on EX Stim Development’ to fruition and many of the SIG members possibilities in interventional pain. This Dr T Goroszeniuk, (London) have shown interest in being part of it. The work has been led by Prof. Richard •• ‘Chronic Pancreatitis, When to refer ultimate aim is for all episodes of Langford and Dr Vivek Mehta. to a specialist Unit? Specialist MDT radiofrequency use to be recorded. It was noted that collaboration between management including surgery’ Mr A Again, the newer novel palliative care and pain medicine had not Smith, (Leeds) neuromodulation techniques were been as strong as previously and efforts •• ‘Interventional Pain management for examined to ensure the evidence base have been made (including inviting them chronic pancreatitis’ Dr S Tordoff, remains strong. to present at our meetings!) to (Leicester) re-establish those links. Interventions in malignant pain can be significantly life This meeting was enlivened by the So, what have we got in store prolonging as it has been stated that we articulate delivery on the treatment of for this year? cannot allow procedures to not be ACNES. As a concept it is still open to This time we are concentrating on some available to this cohort of patients. debate in surgical circles but one applied anatomy and physiology, CRPS In 2013, for the Annual Meeting couldn’t help but be enthralled by the and Pelvic pain. As always there is a look organised by Dr Ganesan Baranidharan, two presentations. With the recent to the future and especially as we deliver the topics included: updates on neuromodulation there has DRG stimulation now after talking about it now been established a treatment two years ago. Maybe Genicular branch •• ‘ACNES (anterior cutaneous nerve pathway for this situation from simple radiofrequency for knee pain will be next. entrapment syndrome) and its injection, through surgery all the way to Below you will see the full treatment’ Dr R Roumen dorsal root ganglion stimulation. programme and we hope you can (Netherlands). It could be thought that Low Back come and join us to get involved in •• ‘Pain management after inguinal Pain and Pancreatitis was a bit old hat what promises to be a lively debate. hernias and caesarean section but the SIG again was able to cover old We have a very strong panel of related scar pain’ Dr M Scheltinga and new issues to enable appropriate speakers (excluding my own short bit), (Netherlands). evidence based treatments for these again giving a counterpoint from •• ‘Alternatives to manage ACNES and diverse problems. Newer procedures, European experience. Input has been Neuropathic post-surgical pain’ Dr A including radiofrequency denervation of taken from IPM SIG Executive Gulve, (Middlesbrough) the splanchnic nerve on the body of T12, committee members and BPS Council •• ‘Diagnostic work up for Low were presented in an easy stepwise member liaison for IPM SIG for all these Back Pain: Dr S Ward, (Haywards fashion allowing members to have all the events, and attendance has grown Heath) information required to know if they steadily over the last 3 years. •• ‘Surgery and Low back pain, when to wished to pursue gaining further Dr Manohar Sharma, the SIG operate?’ Neurosurgeon, (Leeds) experience in the procedure to be able to Chairman, Dr Ganesan Baranidharan the •• ‘Neuromodulation for Low Back Pain’ deliver to their local population. It is SIG Secretary, myself and the IPM SIG Dr A Alkaisy, (London) surprising how your own concerns can Executive Committee look forward to •• ‘Audit of Vertebroplasty in cancer evaporate when a well delivered ‘how to’ welcoming you all to Manchester on 17th pain’ Dr A Magdy, (Burnley) guide is presented well. October 2014.

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IPM SIG Annual Scientific Meeting, 17th October, 2014 Radisson Blu Hotel, Manchester Airport

08.30 - 09.25 Registrations 09.25 - 09.30 Welcome and Introduction: Dr Manohar Sharma

1st session Applied Anatomy and Pathophysiology Chair: Dr Kate Grady, Manchester 09:30 - 10:10 Sciatica and Low Back Pain, "back to the roots": Prof Gerbrand Groen, Netherland 10:10 - 10:45 Neuromodulation for Pelvic Pain: Dr Jean-Pierre Van Buyten, Belgium 10:45 - 11:00 Discussion/Questions

11.00 - 11.30 Coffee / Tea

2nd session Recent advances in CRPS Chair: Dr Rajesh Munglani, Cambridge 11:30 - 12:00 What is around the corner in CRPS management: Dr Andreas Goebel, Liverpool 12:00 - 12.30 Neuromodulation for CRPS (evidence & effectiveness): Dr Simon Thompson, Basildon 12.30 - 12:50 Discussion/Questions 12.50 - 13.00 Update on Lumbar Medial Branch Block and RF /Good practice guidelines: Dr Neil Collighan, Canterbury

13.00 - 14.00 Lunch

3rd Session Science and evolution in pain management Chair: Dr Sanjeeva Gupta, Bradford 14:00 - 14:30 Pelvic Pain – a surgeon’s perspective : Mr Neil Harris, Leeds 14:30 - 15:00 Pelvic Pain: Pain Clinic's role: Dr A Ravenscroft, Nottingham 15:00 - 15:15 Discussion/Questions

15.15 - 15.45 Coffee / Tea

4th Session New Developments in Interventional Pain Medicine Chair: Dr Neil Collighan, Canterbury 15:45 - 16:00 Neuromodulation, what is on the horizon? Dr G Baranidharan, Leeds 16:00 - 16:15 New Disc procedures and outcomes: Dr Tony Hammond, Maidstone 16:15 - 16:30 Genicular Branch blocks and Radiofrequency, technique and outcomes: Dr Jacek Sobocinski, London 16:30 - 16:45 Cordotomy registry update on outcomes?: Dr Marlise Poolman, Bangor 16:45 - 16:55 Discussion/Questions

16.55 - 17.15 Business meeting IPM SIG members (Chair: Dr Manohar Sharma)

17.15 Close of meeting

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News

Impressions of a meeting: the Pain News 2014, Vol 12(3) 146 –147 Philosophy and Ethics SIG 2014 © The British Pain Society 2014 Compassion in Modern Healthcare

Katherine Irene Pettus

The author attended the recent the managerial from the “professional” agreement on the fact that clinicians Philosophy and Ethics SIG meeting for ethos, oriented toward the good of the need to have enough time to listen, to the first time. This presents the author’s patient as the foundation of the common connect at a deep level with their opinion about the meeting. good. The reverse does not necessarily patients’ stories, to diagnose and follow: health systems constructed to experiment with different courses of “When reason and mercy have fled out of meet ends focused on financial, rather treatment or care plans. Insufficient time the world there is nothing like a manual” than wellness-related outcomes, produce for real attention generates suboptimal Virginia Woolf, among other writers, multiple health “bads.” Much outcomes, leaving the complexities of stated that in the face of pain, language constructive discussion in the group chronic pain unaddressed. “runs dry.” It can only be described focused on how to infuse the systemic Papers and lively discussion from the through metaphor. Yet at this year’s BPS imperatives of the NHS with a culture of floor cited cases of successes achieved ethics and philosophy SIG, pain itself compassion to counterbalance the where clinicians took the time to listen was the metaphor describing clinicians’ dominant priorities of cost-effectiveness and connect, to “be with” a person in sense of failure to alleviate significant and targets. their suffering in order to alleviate it. patient suffering. The pain of the physicians/clinicians Several presenters cited Simone Weil, The SIG programme consisted of a themselves, who have been forced to who commented that: heady mix of topics in philosophy, relinquish their calling, their vocation, to practice, and ethics chosen by a group the logic of the market and the political “The capacity to pay attention to an of committed professionals for their flavour of the month, was palpable. The afflicted person is something very potential to generate multiple, main constraint on their ability to properly rare, very difficult; it is nearly a miracle. overlapping conversations. The setting work as clinicians is time, for the simple It is a miracle. Nearly all those who was Rydal Hall in the justly famous reason that lack of time reduces believe they have this capacity do not. English Lake District, and the majority of clinicians’ ability to respond appropriately Warmth, movements of the heart, and those present were pain physicians, to their patients’ pain. Participants in the pity are not sufficient.1” although there were a few palliative care discussion were reporting and professionals, physiotherapists and expressing what is also known in the field The point being that resonance and psychologists. All of us are people who as “moral distress.” Rather than taking healing begin in the capacity to pay all think deeply about our vocations in on a victim role, though, the spirit of the attention — not necessarily “cure,” but the wilderness of pain, a universal meeting was to inquire into the nature of healing, which finds a new equilibrium for phenomenon that is poorly diagnosed, this system-induced pain, and to engage the damaged system. As a recent treated, and alleviated, despite the best in conversations about strategies that experiment run by a participant and most dedicated efforts of might alleviate it. demonstrated, listening itself generates compassionate clinicians, top of the line Discussions were generally non- wellbeing for the person being listened hospitals, research, and pharmaceutical adversarial, although there was some to. All participants and groups in the products in some parts of the world. friction over about the inherent virtues of study confirmed the transformative Papers and discussions distinguished “professionalism.” There was broad power of being heard. Another free paper

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Impressions of a meeting: the Philosophy and Ethics SIG 2014 Compassion in Modern Healthcare

discussed the low-tech intervention of integrated approach similar to that highlights the importance of including the therapeutic knitting, which has beneficial characteristic of best practice palliative medical humanities in the training effects on both chronic pain and care. Such attention to language, which curricula of pain physicians. memory.2 can be pathologising or healing, Serious discussions peopled by Kant, Many papers and attendant depending on the skill with which it is Spinoza, Simone Weil, and Etty Hillesum, discussions centered on neuroplasticity, handled, is just another indication of how were offset by long rambles through the as both proven biological fact and the paradigm might be shifted and better peerless countryside during the metaphor. The science now shows that, all round metrics achieved. afternoon, break, and relaxing evenings just as brain cells can be damaged Themes of the SIG were attention to at the local Badger pub or the Rydal Hall through traumatic physical, social, language, and commitment to bar. The SIG was four days of great emotional, and spiritual injury, so can intentionality and presence in the face of professional company, fabulous food at sufficient support, clinical skill, and pain and suffering, including the pain and the communal tables, and a sense that attention generate and maintain new, suffering of colleagues and communities. focused discussion grounded in resilient pathways in the brain. Stories This was entirely fitting in the landscape attention, skill, and care can bend the can be changed: the damage narrative loved by William Wordsworth, Beatrix evolutionary curve of healthcare systems can be shifted to one of courage and Potter, Samuel Coleridge and other toward justice and compassion. endurance, which will eventually become luminaries of the romantic movement, part of the fabric of the person’s being. whose attention to language has left Notes One suggestion that came out of the future generations with a rich body of 1. Simone Weil, Waiting for God meeting was to rename “pain clinics” literature that remains a source of 2. Corkhill, Betsan, et al. "Knitting and “wellbeing centres,” which would shift inspiration and joy for many. As Well-being." Textile: The Journal of the focus from the object of chronic pain colleagues emphasised, attention to Cloth and Culture 12.1 (2014): 34-57. itself to a more whole-person centred, words, poetry, images and narrative

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BPS feedback on the 2014 ASM Pain News 2014, Vol 12(3) 148 in Manchester © The British Pain Society 2014

Prof. Kate Seers Chair, BPS Scientific Programme Committee; Professor of Health Research, Director Royal College of Nursing Research Institute

I would like to introduce myself to those We have listened to the feedback and •• Over half felt the ASM changed members I have yet to meet. I am Kate will be making some changes. At times something in their practice Seers, Professor of Health Research it was clear some people really liked a •• Early starts to the programme were and Director of the Royal College of session or aspect of the meeting and generally not welcome, and we have Nursing Research Institute at Warwick others were less keen, so we were not addressed this. Medical School. I’ve worked in able to respond to every comment. •• Although 70% would be happy with a research related to pain since I In summary, the main points of the paper free meeting, 30% would obtained my PhD looking at pain, feedback were: prefer paper copies of the anxiety and recovery after surgery in programme. We continue to explore 1987. My research has addressed •• It was noted that in some workshops, options in providing a ‘paper-light’ chronic non-malignant and post- content did not reflect the title – we meeting for delegates, with stepped surgical pain. I’ve undertaken both will be issuing specific guidance for changes being introduced over the quantitative and qualitative systematic workshop speakers to ensure they next couple of years. reviews, RCTs, mixed methods studies stick to the title •• There were a range of comments and a range of qualitative research. I •• Poster exhibition – it was noted that about the social event, and we have have been feedback editor for the space and angles of the poster lined up an excellent social event in Cochrane Pain, Palliative & Supportive area was too cramped, email Glasgow which should have wide Care Group (PaPaS) since 2009. I was addresses were needed on posters appeal, will enable discussion with a co-opted member of Pain Society and judging of the posters was colleagues, and have some more Council from 1991-1994, and an unclear. All these issues will be substantial food and a ceilidh. The elected council member 1994-1997. I addressed in Glasgow. party will be held at Òran Mór, Gaelic have been on the Scientific Committee •• Ask plenary speakers to include for ‘great melody of life’ or ‘big song’, for both EFIC and IASP and have been science that is translatable to day to and a thriving arts & entertainment on the Pain Society Scientific day care, and ensure there is a take venue in the heart of Glasgow’s West Programme Committee since 2012 and home message. This will be End http://www.oran-mor.co.uk/. am delighted to be chairing this addressed in guidance to plenary Committee for the next three years. speakers. Thank you once again for submitting •• Comments on the standard and your feedback. This is your meeting and ASM feedback variety of lunches and the quality of we welcome your views on how we can We had plenty of feedback from coffee have been noted and options make the Annual Scientific Meeting the delegates (92 pages), which was will be explored for 2015 in Glasgow go to event! incredibly helpful. Every single comment •• Most people felt the number of was read and we really appreciate the workshops was about right If you have ideas about or comments on time taken to provide the feedback. •• Most people felt the length of the the Annual Scientific Meeting, please do Thank you. meeting was about right get in touch [email protected].

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Tips for writing a good abstract for Pain News 2014, Vol 12(3) 149 the Annual Scientific Meeting © The British Pain Society 2014

Prof. Kate Seers Chair, BPS Scientific Programme Committee; Professor of Health Research, Director Royal College of Nursing Research Institute

We would like to accept as many high •• Provide a summary of your main •• Delegates have said it is helpful if quality posters as we can for the Annual results or findings – it is essential that you add your email address to the Scientific Meeting. Many delegates really there is data in this section so it is poster. value the discussions that take place and clear what you will be presenting. •• Resist the temptation to fill every new contacts they make when viewing •• Conclusions are important and should space – think about the main the posters. Make sure your poster is follow from the data presented. What message you want to get across. A one of the ones on display. All types of have you found and what is the well designed poster should act as a high quality research relevant to pain are importance of your findings? catalyst for discussion with interested welcome. •• Audits should be well conducted using delegates, and may engage a recognised audit method, and delegates who didn’t think they were provide new information or knowledge. interested! Tips •• It can be helpful to get someone else •• Follow the poster abstract to read your abstract to make sure it submission guidelines http://www. The Scientific Programme Committee is clear. britishpainsociety.org/meet_asm_ looks forward to reading you abstract, poster.htm. and we hope to see you with your poster •• Provide a concise background that When you come to design your poster: in Glasgow in 2015! shows why what you are doing is important. •• Many people will scan your poster You will be able to submit your poster •• Make sure you clearly state the aims and read the aims and conclusion abstract online from September 23rd, of your research. before deciding whether to read closing date 10th December 2014. We •• Give a concise description of your more, so the conclusion needs to will let you know whether your poster main methods, including sample, make sense without Having to read has been accepted by mid-January what you did and your analysis the whole poster. 2015.

Clulow Research Grant 2015 The British Pain Society invites proposals for the 2015 Clulow Research Grant competition. We invite submissions from BPS members from a wide range of disciplines; from basic science to clinical services. A grant of up to £50,000 will be awarded. The funds may be awarded for a variety of purposes in support of a research project (e.g. small project grant, salary support, capital equipment purchase, running costs or additional funding to an existing grant). However, should the Grant be awarded to cover a proportion of the total costs of a research project, it will not be released until funds covering the full costs of the project are in place. Applications will be peer reviewed and a decision made by the British Pain Society Science and Research Committee by October 2015. A copy of the Society’s research grant conditions can be downloaded from the British Pain Society website at www.britishpainsociety. org/members_grants.htm. Applications must be made online at www.britishpainsociety.org/mbc/mbc_form.htm. Closing date is Monday 11 May 2015.

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Patient information leaflets Pain News 2014, Vol 12(3) 150 © The British Pain Society 2014

The Faculty of Pain Medicine of Royal College of Anaesthetists, British Pain Society, Royal College of Nursing, Royal Pharmaceutical Society and Pain UK have developed patient information leaflets for medications used in pain management. They are currently available online to download free from http://www.fpm.ac.uk/faculty-of-pain-medicine/patient-information.

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Pain News in ‘Have I Got Pain News 2014, Vol 12(3) 151 News For You’ © The British Pain Society 2014

Pain News had featured in the missing word section of recent ‘Have I got News For You’, a satirical comedy show at BBC. It was broadcast on 30th May 2014.

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Professional perspective

Reflections on changing attitudes Pain News 2014, Vol 12(3) 152 –153 towards analgesia © The British Pain Society 2014

Margaret M. Dunham Associate Editor, Pain News, Lecturer in Nursing & Pain Management Sheffield Hallam University [email protected]

I remember asking a Somali student one of their presenter’s abilities to parallel what he was chewing, thinking it might park a vehicle. The number of attempts be chewing gum and was told “….it’s like and cones knocked over were tea, we use it all the time as a mild contrasted with the presenter’s ability stimulant….”. Is Khat ever used as an before imbibing the small beer. Perhaps analgesic or just a substitute for alcohol the increasing number of cars on the in societies where alcohol is illegal? I’ve road had meant that introducing the certainly since heard of Khat parties. alcohol limit was a way of reducing car However, Khat when chewed releases accidents and road deaths alongside the cathonine, which can have an effect akin introduction of a speed limit to the new to a mild amphetamine1. It has been motorways1. identified as having a contributory effect Opiates and their derivatives were in psychiatric disorders2 and may have once legally unregulated and freely unfortunate cardiac effects3. And now available in Britain. The fictional character Khat is a banned substance, which in Sherlock Holmes used various addictive itself is not without controversy4. substances including cocaine and Learning about this recent restriction opium. However, Sir Arthur Conan Doyle, naturally made me think about remedies rather than promoting the use of these or drugs, which are on the borderline substances, was only reflecting the 19th with legality. Notably, many things used century society in which he practised as to be legal and were used commonly a surgeon. Indeed, substances including before someone decided to ban them. cocaine and laudanum (tincture of opium) Also, the legality and availability of many were widely and commonly available with substances varies from country to access via the ‘poisons register’ at many never underestimate the popular lobby country. So I think we have to consider local pharmacies in the UK. This practice as some practices become culturally what is the evidence of greater harm was initially regulated by the Poisons Act unacceptable. Indeed, caffeine is an than benefit? The sad thing is that it is 1908 but was still widely accessible until example of this. Over the counter not always the evidence, which informs after the end of the First World War with preparations may contain a variety of these decisions but the politics of control the introduction Dangerous Drugs Act additions including caffeine, which as yet and/or the popular lobby of society. 1922. It was an accepted and normal remain legal but this may change. I am old enough to recall people not part of the UK’s pre-NHS health care Caffeine in cold remedies and other worrying about drinking and driving, even provision: even the wonderful Florence medication may be the next target, after though a ban was introduced in the early Nightingale may have used opiates for all the US FDA is considering regulating 1960s, and there was even a kind of chronic pain. its use and we tend to follow where the machismo about evading getting caught. We cannot guarantee the future US leads. I recall a television programme in the availability of well-used current health If the legal may become illegal then 1970s that had a special feature on the care preparations. Research may some currently illegal substances may effects of a very small amount of beer on establish more effective remedies but prove to have beneficial effects.

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Reflections on changing attitudes towards analgesia

Moreover, what of cannabis and fortunate to have a choice of strong 2. Warfa N, Klein A, Bhui K, Leavey G, Craig T, and cannabinoids? In the not so distant past analgesic in contrast with many Stansfeld SA. (2007) Khat use and mental illness: A critical review. Social Science & Medicine 65(2): cannabis and its derivatives were hailed developing countries where their use is 309–318 as having great potential to solve many legally restricted or prohibited by 3. Al-Motarreb A, Briancon S, Al-Jaber N, Al-Adhi B, problems with chronic pain. However, poverty. Al-Jailani F, Salek MS, and Broadley KJ. (2005) Khat chewing is a risk factor for acute myocardial their use has not become as infarction: a case-control study. British Journal of widespread as was predicted5. The Note Clinical Pharmacology 59(5): 574–581 major issue is that, despite innovations 1. The motorway system in the UK initially 4. Klein A. (2013) The khat ban in the UK What about the ‘scientific’ evidence? Anthropology Today and good quality small trials, new drug had no speed limit and the 70mph limit 29(5): 6–8 development is slow and costs a lot of was introduced as an experiment in 5. Hazekamp A, Ware MA, Muller-Vahl KR, money6. Investment in developing new 1965. Abrams D, and Grotenhermen F. (2013) The Medicinal Use of Cannabis and Cannabinoids-An analgesics will always be of less International Cross-Sectional Survey on importance than many other References Administration Forms. Journal of Psychoactive 1. Nezar Al-Hebshi N, and Skaug N. (2005) Khat pharmaceutical remedies. However, in Drugs. 45(3): 199–210 (Catha edulis) -an updated review. Addiction 6. Power A. (2011) An update on analgesics. British the developed world we are still very Biology 10(4): 299–307 Journal of Anaesthesia 107(1): 19–24

Redefining the landscape of pain management Pain Care

For further information please contact: Teva UK Limited Ridings Point, Whistler Drive, Castleford, WF10 5HX T: 01977 628500 F: 01977 628799 www.tevauk.com ©2014 Teva UK Limited. All Rights Reserved UK/PNC/13/0036 Date of Preparation: January 2014

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Professional perspective

What the practice of acupuncture Pain News 2014, Vol 12(3) 154 –155 has taught me as a doctor © The British Pain Society 2014

Dr V R Alladi Tameside General Hospital, Ashton under Lyne, Member of the Council, the Royal College of Anaesthetists

classifying patients into groups and gives me a chance to give appropriate generalising their treatment based on advice and also gives the patient a signs and symptoms and investigations chance to ask questions and confirm can be inaccurate. Acupuncture taught what they were told. me that the body has several of its own I realised the importance of right defences and several of them are posture, minimal exercise (e.g. dormant. They have to be stimulated by swimming), the need for relaxation and some means or the other. Generalisation the role of nutrition in maintaining health. of anything in medicine is wrong and These are not emphasised and taught putting patients into groups whilst well in the regular medical curriculum. advising similar treatment to two different We need to develop a tolerance to all individuals may not be appropriate. modes of treatment especially the ones Creation of a sense of well-being that have stood the test of time. We should be a part of every treatment as should not refuse treatment purely on every lesion has a psychological lack of evidence. We should however component to it in terms of effect and give the benefit of the doubt to that affect. The sense of well-being treatment and study it concurrently. One of the lucky things that happened to acupuncture engenders goes a long way An effect of my studies is that I started me as a medical professional is my to alleviate the misery of the disease. As listening to patients more closely. I accidental introduction to, and doctors we need to spend more time in believe that it is essential to recognise involvement in acupuncture. The reassuring patients, calming them and that it is more important to do what a experience has given me tremendous treating them as people with emotional patient expects than do what the doctor personal satisfaction and made me effects. wants to do. This may be a contentious aware of the unknown factors that exist The importance of touch and palpation viewpoint and goes against many in diagnosis, efficacy of drugs and for tenseness and tenderness is not practitioners attitude of ‘I know best’ but treatment and patients’ perspective of given any significance in conventional I have found it to be effective. disease, which I would otherwise not medicine. They are very important in We should start publishing articles have appreciated. assessing pain and determining the written by patients indicating the whole As medical students we are trained to patients’ emotional state. course of their disease with their look at everything in medicine as cause Communicating with the patient, comments on the treatment given to and effect and possibly our patients as assessing tone, eliciting reflexes and them. This will be a great source of bodies with a bunch of chemicals and sensory impairment are valuable in education and CPD for more organs interacting with each other. locating lesions and making anatomical experienced doctors. Doctors need to Acupuncture gave me a different diagnoses. know and appreciate patients’ perspective; it made me look at patients As doctors we see patients once perspective of treatment. individually as separate entities and not probably extensively then do not see The importance of symptomatic relief as anatomical or physiological groups. I them often enough to discuss and should not be underestimated. Patients have also learnt that the response to determine management and follow them of course look for cures but in certain treatment varies from individual to up. The advantage I have is that I see my conditions patients are seeking individual and the treatment needs also patients on at least four occasions and temporary easing especially for chronic vary enormously. This means that develop that all important relationship. It pain. This tends to break the vicious

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What the practice of acupuncture has taught me as a doctor

cycle of pain and resulting frustration. makes a great adjunct to other said that not all patients die early and Acupuncture can give considerable treatments by potentiating their effects. some get better or get back to normal. temporary relief. The creation of well-being following He also said that even if one patient gets I believe that we may be doing treatment goes a long way in creating better it is more satisfying. I realised what disservice to patients by prescribing confidence in patients. he said later on when I started treating potent drugs like gabalins, non-steroidal One of the best vocations in life is to patients with chronic pain. It is indeed anti-inflammatories and powerful opiates alleviate pain. If it is acute and severe it is very satisfying even if I make one to musculoskeletal pains that need so rewarding to the patient and thrilling patient’s life comfortable especially with a physical therapies. It is such a waste of to the therapist and if the pain is chronic, treatment like acupuncture. It also made time and if the drug treatment does not then relieving it for any length of time is me realise how little we know about how give meaningful relief, there is the even more rewarding. This is what the body works, or better said, how possibility of side effects. acupuncture can do. much there is to know. I am not too sure what people mean The lessons I have learnt from It amazes me every time I see a by placebos. Do they mean inert practising acupuncture are the unknown strong reaction when a patient bursts treatments or non-specific treatments? In factors in disease and the reality of into laughter or cries (or even goes to relation to acupuncture as there are no miraculous or unexpected effects of sleep) after inserting a needle. This chemicals involved we are trying to treatment. The importance of confirms that the body has its own account for its action in terms of what symptomatic relief even if it is temporary defences and it is the imbalance of needling does to physiology and and its impact on general well-being, the forces that causes disease. The role of stimulation of dermatomes and need for patient follow-ups in establishing the therapist is to detect this deficiency autonomic nervous system. This shows the all important relationship with the and correct the imbalance. If a that mere stimulation of already existing patient whilst treating the whole patient, treatment stands the test of time and if bodily mechanisms have a role to play in and the consequences of the lesion on the patient thinks it works we should healing. the person, relatives and their life in make it available even if there is no Practising acupuncture is such a general. convincing scientific evidence to that pleasurable experience to the patient and I remember asking one of my friends effect and research concurrently. It is therapist as there is mystery and who got into oncology why he chose the not wise to deny the treatment unpredictability to its effect (because speciality forty years ago when the especially if there are no side effects and most of the effects are immediate). It prognosis for cancers was very poor. He the patient is benefitting from it.

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Professional perspective

Chronic pain management - a Pain News 2014, Vol 12(3) 156 –157 learning experience © The British Pain Society 2014

Dr Umesh Ramesh ST3 Anaesthetics Trainee in North Wales

bandwagon and get an epidural steroid managing and living as best and injection. Many patients would still have functionally as possible, even with the pain, and would probably switch doctors pain. at that point, expecting a miracle cure. All 2. Pain is a separate entity this happened with no input from the patient and no lifestyle/social The concept of pain always being a modifications on their part. It was not symptom of something bad happening in entirely the patient’s fault. We, as the body is an old idea. It no longer holds members of the Pain Team, were equally true, especially, in the chronic pain to blame for leading him up the ladder as setting. Pain is a system on its own, an a passive recipient. At this juncture, I entity on its own; to be respected for For any article/literature to be engrossing should emphasise that I do not speak what it is! It is not always possible to find (or at least readable) a background is about Pain Management generally in an underlying cause for the pain. usually essential. To this end, I present to India. Whatever I describe pertains to the 3. Multi-disciplinary approach you my two-liner CV! Allow me to take region where I trained at that particular you through the contrasting (yet similar) time. This was my idea of pain I learnt a lot about team-working and the worlds of chronic pain management that management until recently. My crucial role of various disciplines. I I have travelled through. perception changed significantly after my expected Physiotherapists and Specialist I completed my anaesthetic training in first Pain Module in North Wales in 2013. Nurses, along with Anaesthetists would India between 2006 and 2009. I started After seeing the type of patients that play a key role. What surprised me was working in the NHS in 2010 as a walk through the doors of the Chronic the impact and the role of the Clinical Specialty Doctor in Obstetrics/Intensive Pain Clinic, I have become more and Psychologist. I was struck by the way Care and entered specialty training in UK more convinced about managing it more psychological aspects of the human in 2013 as an ST3. There… That’s done. holistically. I have realised that brain was intertwined with our perception Where I come from in India, chronic management is about finding the right of chronic pain. I was fascinated by the pain was invariably seen as amenable to balance between the various approaches way the Clinical Psychologists worked intervention and manageable with and disciplines. This does not mean to their way through the maze of thoughts medications and injections. This is where say that I have suddenly become averse of the patient, and more often than not, the anaesthetist would come into the to interventions and injections. They have managed to get through successfully. picture. For example, if there was a their own place. But, in isolation, they are To take the same example of the patient with severe low back pain, he not the only way to manage chronic pain. patient with chronic low back pain, the would be managed with routine pain Here are some striking and key things I management aspects are pretty similar killers, stepped up to oral morphine (with learnt in my module in Chronic Pain from the medical side of things. But, it or without adjuvants like gabapentin). Management: differs markedly in that there is a lot of Physiotherapy would play an integral part encouragement for the patient to take an 1. The Patient is at the centre of it all throughout. The patient was very much a active role in their pain management. passive participant, expecting that we It is important the patient understands There is greater emphasis on would treat him and make the pain go that the pain is often not going to go biopsychosocial conditioning and away. Eventually, the patient would reach away completely. It is about reducing the modifications. And I think, rightly so. I a breaking point. He/she would join the pain. But, more importantly, it is about have seen passive patients here as well.

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Chronic pain management - a learning experience

But, the great majority understand the To conclude, after the Pain Module, I at it in a more holistic manner. I learnt concepts of chronic pain management, have awoken myself to the various various team-working skills from all the take an active role in their pain aspects of pain management. I don’t think members of the multi-disciplinary team. It management and respond very well to of pain management purely as an was an enriching learning experience, and the multidisciplinary approach. Anaesthetist/Pain Doctor, but try to look it will stay with me for the rest of my life.

LowLIPS-dose Intravenous Immunoglobulin Treatment for Complex Regional Pain Syndrome

This trial is led by Dr Andreas Goebel, Consultant in Pain Medicine at the Walton Centre NHS Trust and is managed by the King’s Clinical Trials Unit (UKCRC) London. It is funded by MRC/NIHR (EME). Inclusion/ Exclusion Criteria: Recruiting investigators are:  Patients with a diagnosis of complex regional pain syndrome I or II according to Budapest ANDREAS GOEBEL criteria The Walton Centre NHS Trust, Liverpool

CANDIDA MCCABE  Moderate or severe pain BATH Royal National Hospital for Rheumatic Diseases, Bath

 Aged 18 years and above NICHOLAS SHENKER CAMBRIDGE Addenbrookes Hospital Cambridge

 Disease duration of between 1-5 years GLASGOW MICK SERPELL,

Gartnavel General Hospital, Glasgow  No other significant chronic pains, or unstable LIVERPOOL (LEAD) medical conditions. NICK PADFIELD Guy's and St Thomas' Hospital, London LONDON  Willing and able to travel to a recruiting site MARK SANDERS

NORFOLK & NORWICH Norfolk and Norwich University Hospital, Norwich (if you are uncertain of any of the study requirements please contact us to discuss) KARIM SHOUKREY LEICESTER University Hospital of Leicester NHS Trust.

All participants for the study need a referral letter from their GP or Pain Specialist. This should include all relevant clinic letters. If you have a patient who wishes to take part and you would like a referral template, or for any other queries about the study please contact Miss Holly Milligan on [email protected], or on 0151 529 5835.

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Professional perspective

Social media in medicine: benign Pain News 2014, Vol 12(3) 158 –160 influence or spin? © The British Pain Society 2014

Dr Trish Groves Deputy Editor, BMJ & Editor-in-Chief BMJ Open

It’s difficult to predict the future and technologies often come out of the blue. We could never have expected to have more computing power in our pockets than the Apollo moon rockets. In the 1960’s we had mainframe computing and now they are talking about everyday wearable computing and glasses that will project what you want from the Internet straight into your eye. This has driven how we communicate with each other. In the 1990’s people danced at pop concerts – now they video, click, share and tweet each other. It’s not surprising that India is second in world Internet usage; back in the 1990’s I was writing articles in the BMJ about the need to get telephone lines to people in their homes and in hospitals so that doctors and healthcare workers could get easy access to information from books and journals by wired internet, but mobile phones have completely leapfrogged that. Social media have been variously The first definition is about the LinkedIn. People can use LinkedIn to defined as: technology, the second is about people, share their work profiles etc; it is used but the third is about the tools that allow enormously in India and, apparently, Applications that build on ideological & them to interact and to exploit and increasingly here. technological foundations of Web 2.0 celebrate our social nature. These things A survey by the consultancy survey & allow creation & exchange of user- are just tools; the medium is not the ranked the usage of various media generated content (Alqvist et al, 2008) message - what’s important is what we internationally. Facebook, YouTube and do with them. Twitter came way out top and there were Interactions in which people create, The General Medical Council has a some at the bottom which are being share, & exchange information & ideas social media policy which covers blogs increasingly used by the young, such as in virtual communities & networks and micro blogs such as Twitter and Tumblr which is huge amongst teenagers (Kaplan AM, Haenlein M, 2010) Internet forums e.g. doctors.net and the mostly for sharing images and blogs and BMJ’s Doc2Doc, which doctors use to Instagram which is an app which allows Information tools that both exploit & talk to each other; content communities you to share photos to which you can celebrate our social nature (Coiera such as YouTube and Flickr and social add effects. These things generally go in 2013) networking sites such as Facebook and and out of fashion.

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Social media in medicine: benign influence or spin?

Twitter can be narrative because within There is increasing evidence that chronic, those 140 characters you can attach a lifestyle type diseases do spread within link which can be as long as you want. social networks. This seems to accord There is a tool called Storify with which, with the concept of Homophily. Recent for instance you’ve sent a lot of Tweets controlled experiments suggest that not at a conference, you can pull all of them only do people tend to have friends who into Storify and drag in your tweets and it are similar to them but, individuals alter turns them into a blog, and a nice story their behaviours to match those of their of the conference has written itself in peers. seconds. Coeira suggests that you can intervene in networks, using the tools I was talking about. You can intervene between Blogs and Facebook individuals; ‘champions’ central to a There are lots of blogs; the BMJ has a network can increase diffusion of very active blog site, Doc2Doc. We get evidence based practices. If you want to bloggers from all over the world. People intervene in groups, such as multi- will share information through different Twitter professional teams, for instance to media. The cardiologists in the US have The great and powerful thing about Twitter improve hospital safety or perhaps a huge network with closed areas where is that you can share links to articles and quality of nursing care, you can look at they can consult one another about websites etc. I use it all day and everyday social interactions as well as professional patients, as well as forums for discussing and get all my information from Twitter interactions to change behaviour. academic issues. I think there is an now – I’ve given up on reading journals. ‘Network induction’: spreading industry site where industry can get The way it works is you join and have your information by word of mouth, feedback from sponsorship. Discussions own profile. The trouble with emails (my snowballing and viral interventions, can in Doc2Doc cover a wide range of email inbox which always contains about be facilitated if you understand how the subjects, recently including Why do 600 emails and I simply cannot answer group functions socially, as with HIV medical students behave badly; Why do them all) is that you feel obliged to answer prevention messages among peers. doctors prescribe expensive drugs; every one, whereas you can eyeball ‘Network alteration’, for instance in the Should castration of sex offenders be Twitter and see immediately if you are management of alcohol or drug use, banned; Ignorant doctors and blood interested or not. It is a stream which you involves removing someone from a group pressure and Should unconscious can step in and out of and if something who is a particularly bad influence, or patients be tested for HIV? whizzes past and looks interesting you changing the nature of connections. This I only use Facebook for family but lots can click on it. It’s the equivalent of a may seem rather obvious but we have of companies, journals, hospitals patient ticker at the bottom of the TV screen academic studies which show how to do groups – you name it – do use it and it is which gives you the news headlines. You this in a planned way. One on-line a great way to tell people what you are can look to see who has picked up or support group has reached someone doing. re-used the tweets you have sent. It’s not living with severe FMS in a remote time-wasting – it’s actually parsimonious. farmstead in South Africa. People take Twitter seriously and the LSE Interaction Crowd-sourcing was used by has by far the best guide ‘Using Twitter in Enrico Coeira, a Professor of Medical astronomers without the time to analyse university research, teaching and impact Technology, argues that we can use all the data from the Hubble telescope to activities, a guide for academics and social media to improve patient care, enrol lots of amateurs in finding new researchers’, published in 2011, http:// particularly with what have been called nebulae using their home computers and blogs.lse.ac.uk/. It is concise but very social shape diseases. He describes the to define the structure of a protein, by informative and contains lots of different concept of social contagion: that putting images on the internet and telling ways of using Twitter. If you only contact illnesses and health states can be people what patterns to look for, and has the Internet twice a day on your home transmitted socially. For instance, it is been similarly used with great success in computer then Twitter may not be for you, known that people tend to marry others cancer research. An Italian patient did and it is probably much more useful if you with similar rates of heart disease or this with his own brain tumour: he had a have a phone or a tablet that you can use diabetes. But it also includes things like rare one and there was something about ‘on the go’. poverty, education, diet and smoking. his clinical test data that his doctors were

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Social media in medicine: benign influence or spin?

puzzled about. So he put it on the have a private Twitter account which in the SIG. It’s like Chinese whispers – Internet as a blog and asked if anyone only allows people you have chosen to you tell somebody who tells somebody could help solve the puzzle, and was follow you. who tells somebody. Amazingly, in one successful in this. There is also an issue regarding meeting at the BMJ the three of us litigation. Twitter is a publishing platform. tweeting reached 22,000 people all The simple rule with libel is if you put round the world. Privacy something into the public domain in any You might say you haven’t time for all There are rules governing identity and way that can lower the reputation of the that but many people do and if you want the prohibition of defamatory material. person in peoples’ eyes, that is to share what you are doing these tools Your trust has a gagging clause. You potentially libel, and in the UK the onus is are very powerful, and much more useful can make it safe: you can premoderate on you to prove that it wasn’t libel. In than a print newsletter as they are and postmoderate things like blogs. most other countries it’s the other way interactive. Psychiatrists are using the You can have a private page on the round; the person libelled has to make Internet and social networks as cognitive Internet where patients can post their the case. tools. Doctors are using social media to comments and a member of staff or Social media can be used to educate one another. Whatever will come another trusted person can monitor propagate ideas and change people’s next….? this. All of these social media tools have thinking by various means including a This is the transcript from the author’s privacy settings and it’s important that Facebook page. You can share articles talk in Philosophy and Ethics SIG you know how to use them. You can that might be interesting to other people meeting at Launde Abbey.

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Professional perspectives

A new enhanced surveillance system Pain News 2014, Vol 12(3) 161 –162 for Post-Herpetic Neuralgia in © The British Pain Society 2014 Pain Clinics

Philip Keel Scientist (Epidemiology), Public Health England, Immunisation, Hepatitis and Blood Safety Department, London

In 2010, the Joint Committee on PHN is therefore recently introduced a number Vaccination and Immunisation (JCVI) specifically of new enhanced surveillance systems recommended that routine immunisation focused in for shingles and PHN in light of the new for Herpes Zoster (Shingles) should be the area zoster vaccination programme. introduced into the UK schedule,1 and affected by Although it is accepted that PHN will following this recommendation, this shingles often be managed in primary care, more occurred on 1 September 2013. The first and may be severe cases require referral to group of people eligible for routine a constant specialists in pain clinics. Surveillance vaccination were those aged 70 years on burning, partnerships, with pain clinics in England, 1 September (born between 2 itching, were developed to monitor the impact of September 1942 and 1 September stabbing or the shingles vaccination campaign in 1943), this was alongside a catch up aching preventing PHN. campaign for those aged 79 years on this pain, which is extremely sensitive to In an initial scoping exercise, pain date (those born between 02 September touch and is not routinely relieved by clinics in England were contacted last 1933 and 01 September 1934). common pain killers. The risk and year asking for information on overall Shingles is an infection that is typically severity of PHN increases with age, with clinic numbers, attendance for PHN, characterised by a unilateral vesicular one-third of suffers over the age of 80 staffing levels and an expression of rash involving a single dermatome, with years experiencing intense pain. The interest in being involved in the enhanced the diagnosis being predominantly made annual incidence of herpes zoster surveillance of PHN. The response to this clinically in primary care. It is caused by infection is about 8 per 1,000 persons in contact, and the number of cases of the reactivation of latent varicella zoster those aged over 70 years (data from the PHN seen in pain clinics, meant that the virus infection (chickenpox). Once a Royal College of General Practitioners implementation of such a surveillance person has recovered from chickenpox, sentinel surveillance scheme). In England system would be possible. the varicella zoster virus lies dormant in and Wales, it is estimated that Therefore, beginning in September the nerve cells and can reactivate at a approximately 14,000 cases develop 2013 to coincide with the start of the later stage when the immune system is PHN and 1,400 cases are hospitalised shingles vaccination campaign, a weakened. Reactivation of the virus is each year. surveillance system was setup in thought to be associated with While incidence rates for shingles are partnership with a number of pain clinics immunosuppression as a result of a captured by various sentinel primary across England. This enhanced decline in cell-mediated immunity due to care data sources, there is no surveillance has three main objectives: old age, immunosuppressant therapy or established routine national surveillance HIV infection.2 of shingles or PHN. Public Health 1. Estimate the overall impact of the An important and significant England (PHE) has a duty to monitor vaccination programme on reducing complication of shingles is persistent communicable disease and the impact PHN in the vaccine targeted age pain continuing after the rash has gone, and effectiveness of all routine cohorts (those aged 70 and 79 years known as post-herpetic neuralgia (PHN). vaccination programmes and has old on 1 September 2013);

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A new enhanced surveillance system for Post-Herpetic Neuralgia in Pain Clinics

2. Estimate the effectiveness (the level of above, who have attended participating continuing support in this new protection to the individual) of shingles pain clinics in England over the past year, surveillance scheme. The first two vaccination against PHN in the will be conducted to obtain a baseline quarters of data have now been targeted cohort; estimate of overall case numbers. Given collected, and while the response rate 3. Compare the severity of PHN in those the time lag to develop PHN and be was good, we would like to encourage vaccinated and those unvaccinated in referred to a pain clinic for specialist any clinics that did sign up but were the targeted cohort. management, the data returns for the unable to report in these first data first two quarters of 2014 will provide collection periods to try and do so for From 31 January 2014, quarterly additional baseline data as these the next quarter (1 April to 30 June return forms have been sent to all individuals are likely to have developed 2014) so that we can begin to analyse participating pain clinics in England shingles and PHN prior to the the impact of this new vaccination asking healthcare professionals whether introduction of the vaccination campaign against a severe and they have seen any cases of PHN in programme. The size of each clinic will debilitating condition. patients aged 70 years or older. The be estimated based on the overall annual If your clinic has not yet signed up but healthcare professional will tick either Yes attendance for any condition. would like to be part of the new or No and provide a minimum dataset The Immunisation, Hepatitis and Blood surveillance network, or would like more where they have indicated seeing a case. Safety department, PHE Colindale will information on the new surveillance This will include patient initials, age, produce reports on the evaluation of the system, please contact the team at PHE gender, hospital number, clinician and vaccination programme. Information on by email at [email protected] pain clinic name in order to link this to a PHN incidence and other data of interest Full details of the shingles vaccination further enhanced questionnaire. on PHN will be provided as part of this programme are available from https:// Any clinician or healthcare professional reporting. These reports will be sent www.gov.uk/government/organisations/ who returns the card with a positive directly by PHE Colindale to the public-health-england/series/shingles- response will then be sent a more participating pain clinics. vaccination-programme detailed PHN enhanced surveillance The British Pain Society has endorsed questionnaire for completion for each the PHE proposal to establish a new References 1. Joint Committee on Vaccination and Immunisation. individual patient. These questionnaires surveillance system for PHN. While the Statement on varicella and herpes zoster vaccines will be returned to the Immunisation, surveillance is now up and running, we 29 March 2013. Available online at http:// Hepatitis and Blood Safety department, would still like to encourage any pain webarchive.nationalarchives.gov. uk/20130107105354/http://www.dh.gov.uk/prod_ PHE Colindale for further analysis and clinic not signed up to consider doing so. consum_dh/groups/dh_digitalassets/@dh/@ab/ collation of data nationally. The data that The more clinics that sign up, the documents/digitalasset/dh_133599.pdf (2010, will be collected will fall into the following stronger the surveillance system will be accessed 17 April 2013) 2. Department of Health. Immunisation against categories: Demographic detail, Clinical and the greater the potential benefit to Infectious Diseases: Shingles Chapter. TSO details, Co-morbidities, Vaccination patients. Publishing, Crown Copyright, 2013. Available history and Pain clinic details. We would also like to take this online at https://www.gov.uk/government/ organisations/public-health-england/series/ An initial retrospective review of cases opportunity to thank our participating immunisation-against-infectious-disease-the- of PHN in those aged 70 years and clinics greatly for their involvement and green-book

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Professional perspectives

After Tramadol: a closer Pain News 2014, Vol 12(3) 163 –164 look at Codeine ? © The British Pain Society 2014

Sandeep Kapur Consultant in Pain Management & Anaesthesia, Dudley NHS Foundation Trust

Between 2003 overdose deaths from oxycodone It is worth noting that the annual and 2009, deaths (52.1%). Florida’s experience eloquently number of deaths attributable to codeine attributed to drug demonstrated the effectiveness of strict has almost tripled, from 46 in 2001 to overdose regulation and monitoring of the 120 in 2012, compared to the 154 increased by 61% prescribing and dispensing of controlled deaths caused by Tramadol in 2011 in Florida, with substances in reducing prescription drug (rising to 175 in 2012), though the especially large overdose deaths.1 majority of Tramadol related deaths are in increases in In contrast to prescribed and illicit cases where it has been obtained illicitly. deaths caused by drugs, non-prescription, or over-the- Now that Tramadol (as of 10 June 2014) Oxycodone. counter (OTC) medicines are generally has been reclassified as a schedule 3 Florida became perceived to be relatively safe. However, controlled drug, it begs the question: notorious while easy access to OTC medications What is the future of codeine? However, because of the proliferation of what were has helped empower patients, there is OTC painkillers are big business to the euphemistically named ‘pain clinics’- in also increasing concern about the pharmaceutical industry: in 2013, sales reality, no more than ‘Pill Mills’- that were potential for OTC medicines to cause of painkillers hit an all-time high of more prescribing (and dispensing) large harm associated with codeine addiction than 25 million packs-at least 754 million quantities of opioid analgesics with and side effects of additional ingredients, pills.4 Big Pharma are therefore likely to impunity and virtually no oversight. These such as ibuprofen and paracetamol, mount a vigorous campaign to prevent ‘pain clinics’ drew hordes of people, which have led to fatalities. A study any changes to the status quo. some of whom travelled hundreds of found that OTC medicine addiction often So how do we reconcile our duty of miles for a ‘Oxy’ prescription (the media arises from genuine medical reasons and care with the potential risk of harm? pejoratively termed them ‘Pillbillies’). is maintained by the ease with which Evidence from the USA (in addition to the During that period, Florida had the these drugs can be obtained.2 Florida example) demonstrates that dubious distinction of being home to 98 While the scale of the problem is prescription monitoring programmes of the 100 physicians who dispensed the unclear, a report by the National Treatment (databases that contain prescriber and highest quantities of oxycodone in the Agency for Substance Misuse (2011) patient data pertaining to drugs with USA. In response, Florida’s legislature stated that overall, 16% of people in UK potential for abuse) help mitigate opioid enacted and enforced several laws as drug treatment services present with abuse and misuse trends.5 Indeed, it is part of a comprehensive effort to address problems due to prescription-only or OTC high time we follow the US example and the problem. Law enforcement agencies medications. The report highlights an establish a national prescription monitoring began a crackdown (‘Operation Pill alarming increase in the community system for opioids and other controlled Nation’) on rogue physicians and prescribing of opioid analgesics from drugs in the UK. In the meantime, some pharmacies. The state legislature 228.3 million items in 1991 to 1,384.6 experts have suggested mandatory prohibited physicians dispensing opioids million items in 2009. The report states coding of opioid use in electronic patient and other controlled drugs from their ‘while national treatment data does records, thereby providing data on the use offices. A mandatory prescription drug indicate slight year on year increases in the of opioids nationally, which could also be monitoring program was enforced. The number of individuals in treatment who cross referenced against their other coded result? During 2010-2012, the number of report the problem use of prescription only diagnoses, including alcohol or substance drug overdose deaths in Florida and over the counter opioids, the rapid dependence.6 decreased 16.7%. Death rates for increase in the prescribing of opioids does Moore et al, in an elegant analysis of prescription drugs decreased 23.2% not seem to be fully reflected by the the opioid prescribing problem (BMJ overall, the biggest decline being in increase in treatment demand’3 2013) state: “Pain relief is not normally

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After Tramadol: a closer look at Codeine ?

distributed but usually bimodal, being pain conditions? As Cathy Stannard 3. Addiction to medicine: An investigation into the configuration and commissioning of treatment either very good (above 50%) or poor noted in her 2013 editorial in the BMJ services to support those who develop problems (below 15%). Using averages is unhelpful “As prescribers, we must keep in touch with prescription only or over-the-counter medicine. and misleading, because “average” pain with the current debate, so that we can National Treatment Agency for Substance Misuse. May 2011. www.nta.nhs.uk ( Accessed 3 Aug relief is actually experienced by few (if balance the competing imperatives of 2014) any) patients, and it tells us nothing ensuring a pragmatic and 4. http://www.dailymail.co.uk/femail/article-2424740/ about how many patients will experience compassionate approach to supporting Addicted-counter-opium-Few-realise-codeine- headache-pills-come-source-heroin—evidence- clinically useful pain relief…..We believe patients with pain and avoiding the risk reveals-more-getting-hooked.html#ixzz39Gst0tLa that pain medicine has now reached a of creating problems for individuals and 5. Reifler L. M., Droz D., Bailey J. E., Schnoll S. H., society”8 Fant R., Dart R. C., and Bucher Bartelson B. (2012), degree of maturity where it can confront Do Prescription Monitoring Programs Impact State its failings. We propose a radical Trends in Opioid Abuse/Misuse?. Pain Medicine, References transformation in how we establish 13: 434–442. doi: 1. Decline in drug overdose deaths after state policy 10.1111/j.1526–4637.2012.01327.x analgesic efficacy and harm…..measure changes -Florida, 2010–2012. Centres for Disease 6. Stewart G., and Basler MH. Wanted: national pain in individual patients, expect control and prevention Morbidity and Mortality regulatory monitoring system for long term opioid Weekly Report. July 1, 2014, Vol. 63. http://www. prescription. BMJ 2013;347:f5586 doi: 10.1136/ analgesic drugs to fail to provide a good cdc.gov/mmwr/pdf/wk/mm63e0701a2.pdf bmj.f5586 response in most patients, and prepare (Accessed 3 Aug 2014) 7. Moore A, Derry S, Eccleston C, and Kalso E. for the next step when failure occurs”7 2. Cooper RJ. I can’t be an addict. I am.’ Over-the- Expect analgesic failure; pursue analgesic success. counter medicine abuse: a qualitative study. BMJ BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690 So where does that leave us, as Open 2013;3:e002913. doi:10.1136/ 8. Stannard C. Opioids in the UK: what’s the problem? clinicians treating patients with long-term bmjopen-2013–002913 (Accessed 3 Aug 2014) BMJ 2013;347:f5108 doi: 10.1136/bmj.f5108

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Informing practice

The early days in Seattle and the Pain News 2014, Vol 12(3) 165 –167 birth of the IASP: a history of the © The British Pain Society 2014 pain movement

John Loeser Professor Emeritus, Neurological Surgery and Anesthesia and Pain Medicine, University of Washington

This was an informal session at the 2013 the anaesthetic, and the management of meeting of the philosophy and ethics SIG pain in childbirth remained one of his and included many fascinating portraits lifelong interests. After 15 years of private of and anecdotes about other pioneers practice in Tacoma, John Bonica was of pain medicine, for which there is no appointed as the first Chairman of space in this article. The full text of this, Anesthesiology at the University of and transcripts the rest of the Washington in 1960. proceedings, including the important He immediately set up a pain clinic in discussion, is available as a free booklet cooperation with a neurosurgeon and a from [email protected], and as nurse. I was a resident from 1962 so I a download from the SIG page on the saw the early days of the pain clinic. BPS website Bonica hired a primary care practitioner who saw two new referrals on Monday The pain world started with one person. and decided what consultations were That man was John Bonica. He was needed. During the week they were seen born on the island of Filicudi near Sicily by other consultants in neurosurgery, and brought to the USA by his family orthopedics and psychiatry. If appropriate when he was ten years old. He worked some sort of diagnostic blocks were from the age of ten but managed to get a done, and on Friday the group would scholarship to go to college where he convene and a group formulation of the became a successful college wrestler. He problem was arrived at. Dr Bonica would then went to Marquette medical school make his formulation; he would some- and graduated just before the United times agree with the group; there were States entered World War II. He was two votes, Bonica and everybody else! drafted into the army and had an Then he would explain to the patient what world asked to spend time in the internship in a big army hospital not far the group felt and what treatment options department, learning about pain. from Seattle in Madigan called Fort were available and what should be done. Louis, where they told him he was going To my knowledge the group never again to do anesthesia. He literally self-taught saw the patient. They went off to the The International Association himself what there was of anesthesia at surgeon or the psychiatrist and there was for the Study of Pain the time and spent the entire war at very little feedback. By 1973 Bonica - and I really think it was Madigan. He became concerned there Bonica was also secretary general of just him – decided that it was time to about issues of pain as Madigan received the World Federation of Societies of organise the world to do something a lot of injured soldiers from the Pacific Anesthesiology (WFSA). He used that as about pain. Having raised the necessary theatre, with problems like phantom limb a platform to go all over the world talking money, he used his knowledge of people pain and neuropathic pain. When his first about how he was doing pain all over the world to invite some 300 child was born his wife almost died from management. People from all over the people to a meeting in Issaquah, outside

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Seattle. Bonica was a genius – this place had added his name to the organization because she organised everything so was totally inaccessible; the only way you and we were getting both Melzack and efficiently. She was the mother of the could get there was by a chartered bus Wall. society – seeing to everybody’s needs. or a taxi. So he had 300 people there By the late 70’s there were pain clinics Michael Bond pushed IASP into and they couldn’t leave! We worked a 14 springing up all over the world. From the helping developing programmes all over hour day. This meeting brought together early ones in Oxford, Jerusalem, Sydney, the world was when he was president. people Bonica and his colleagues Los Angeles – about a half-dozen around Each president gets to push the thought would be suitable to start an the world - it just exploded. In the early resources towards the things they feel international pain society. The last event days we said we were going to have a are most important; mine was to on the Friday was an assembly in which governing council with the elected establish chapters all over the world. the question was asked: where do we go officers: president, secretary etc. and The journal Pain is still the best pain from here? We agreed that we should then we will have a council consisting of journal measured by the conventional start an association which should have a six elected councilors and six regional criteria and it’s harder to get something journal, and Pat Wall agreed to be its vice-presidents. But although published in it than any place else. The editor. Pat was a well-known representatives for Europe, Africa and mission of the publishing arm is to neurophysiologist by then and the North and South America were produce cheap books. We distribute seminal Melzack Wall gate theory was acceptable, when you go to Asia (which books and journals in developing already well-known. Bonica realised that includes Australia) none of the major countries on a free basis. one of the problems was that if this countries would accept vice presidents In the 70’s it was like being a pioneer organisation remained a Bonica/Seattle from others so we abolished the VP’s pushing westward in the US to try and organisation it was never going to and just had twelve elected councilors, bring roads, railroads and civilisation into become internationally acceptable. And and we schemed - and still scheme - so the wilderness. What we were trying to so it was agreed that we would form a there would be adequate representation do was new and unheard of. It’s still true society and that the first congress would geographically, discipline-wise, gender- in some countries but by and large the be in Florence two years later. So the wise and we have a good balance. ground has changed. Now the question IASP was launched and took off like a To me the most rewarding thing of the is how do you bring modern knowledge rocket, in no small part because of Pat whole IASP story was going to some be it technical, psychological or Wall and the journal Pain which was a country where they were trying to start whatever, and information about pain to high status journal and at that time the pain clinics and societies and helping people that don’t have it. Pain only journal with the word pain in its title. them to get things going. I was able to management is part of healthcare and The first IASP congress was held in do that in China and the Philippines, we have learnt the hard way that you Florence. Everybody assumed that Bonica Thailand, Bulgaria, Rumania and what is can’t go to someplace where there is no would want to be president and now the Czech Republic. And there was healthcare and try to bring them pain everybody would vote for him, but it was a wonderful group of people in the IASP management. You don’t have the fascinating the way Bonica fixed things. who shared a common purpose and a infrastructure and providers. So the focus He and Mme. Denise Albé-Fessard common goal. We were a family. As it has changed from bringing the issues of decided that she would be president for has evolved and the original family has pain to people who never saw them to three years and past president for three. died or left office it has been sad. getting people to allocate resources to So who would be president-elect? John The numbers have grown from about pain management that are appropriate to Bonica, so he got nine years of basically 500 in Florence to 1100 in Edinburgh their system. You can’t just export running the organization. The first council and straight upward since then. sophisticated pain medicine. The meeting after Florence was held at a town One person in the pain world who was challenge is to fit in your concept of pain near Innsbruck, and I will never forget - not actually a provider but who management into someone else’s culture Denise Albé-Fessard stood up and said orchestrated everything was Louisa and the resources they have. that there were not enough French people Jones. IASP would never have been the Another issue is that young men and holding office in this organisation. And same without her. She progressed from women want to come to the USA for Bonica looked at her and said: “Madame, being John’s secretary to becoming the training. The question I always ask them when the French do something administrative secretary of IASP and ran when they apply is what are you going to worthwhile we’ll get them into offices.” it until she retired about five years ago or do when you’re done with your training, The second IASP conference was in so. She was amazing: first of all IASP’s and only accept them if they are going to 1975 in Montreal because Ron Melzack overhead costs were incredibly low use this for the benefit of their own

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country. Why the US should suck up all come home from the hospital, say a few members of his faculty to go out to his the brightest and best of every other words to his wife and children over house to inject his hip after work. I tried country of the world I don’t understand. dinner and go up to his office and work very hard not to be his neurosurgeon but until 3 or 4 in the morning, and go off shortly before Christmas one year he again after two or three hours of sleep. In acutely herniated a disc and had major Bonica the man 1953 he produced the book entitled The neurologic deficit, so I had to operate on Nobody was too low in status to deny his Management of Pain, which to my him, and for the next twenty years I was attention. He paid attention to anybody knowledge was the first comprehensive his spine doctor! He was not a good who was interested in pain. He’d talk to book on pain. patient! students, nurses – if you were doing John’s wife Emma was a saint. They Bonica retired from clinical activity in anything to do with pain he was had four children and she waited on John 1978 and the pain centre didn’t prosper interested in you. He was a very like no other wife I have ever seen, and the way he wanted it to. In 1982 I multifaceted person. He could be the took care of everything he did other than became director of the pain center. I most arrogant “******” you ever saw. He his profession. She was an example of the was very fortunate because Bill Fordyce did not tolerate snobs at all, and if he adage that behind every great man is a who was without doubt the psychologist thought you were pulling rank or great woman. She raised the children as who did the most to put pain into a whatever he was merciless. There was he was never home. She cooked, she reasonable perspective was looking for one phrase of his that if you heard it you cleaned… He loved her very much in an opportunity to expand his activities. would know it was time to get out of his terms of kindness and respect, but for a He and I got a whole ward in a hospital way. If he ever said “listen friend …” you man whose focus was on something and we constructed an inpatient and knew the trigger was about to be pulled. other than the mundane and the business outpatient service with a group Although he wasn’t very tall his aura was of day-to-day living, you need a wife and treatment programme of some 20 huge. family and the support system that allows patients for three weeks at a time. That When he was an intern and in the army you to do it. As they were growing older served as a model for pain clinics all he wrestled professionally to make money. some of us thought that it would be nice if over the world. When his Commanding Officer decided John died first so Emma could have a little One thing that helped was that Bonica that it was unbecoming conduct for an time to herself, but unfortunately Emma was the secretary-general of the World officer to be a wrestler and told him to died first, only a few months before John’s Federation of Anesthesiologists. And that stop, Bonica became the Masked Marvel! death in 1994 at the age of 77. put him into every developed country in He continued to wrestle with this identity I was one of Bonica’s foot-soldiers. I the world. for several years and won many prizes. was fortunate in that I was not in his He wrote a textbook on obstetric He stopped when he went into practice. department because he could definitely anesthesia and analgesia. He wrote the He paid a price for his wrestling as he had exploit people whose lives he controlled. second edition of the Management of terrible hips, knees, ears and other He worked twenty hours a day and Pain, and I edited the third edition damage that cost him dear in later life. would be angry with you if you didn’t because six months before he died he There are lots of legends about Bonica work as hard or didn’t get a job done as made me promise that I would bring out but the family story is that he would fast as he could. He liked to call junior another edition.

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The challenge of pain in older people Pain News 2014, Vol 12(3) 168 –170 © The British Pain Society 2014 Dr Pamela Ball, Chair of the Pain Alliance of Northern Ireland

Four Seasons Health Care reported on Consequences of pain for the benefits of robust assessment and those with dementia management of pain in residents of their care homes as part of their PEARL Appearing more disabled than they project to improve the lives of residents. really are. Perhaps the most memorable presentation came from a son of a Feeling disempowered, distressed gentleman with dementia. He reported and feelings of not coping. The number of older people in Northern how his father’s distress behaviour was Ireland is steadily and consistently Poor quality of life. alleviated, not by psychotropic drugs but increasing. Between 2011 and 2012 the by simple analgesics, and how relief of Increased pressure and stress on number of adults aged 65 and over his pain allowed his wife to continue to carers. increased by 2.6% to 272,800; the care for him at home. largest year-on-year increase since 1981. Increased likelihood of behavioural Currently we estimate that there are Over the ten year period between 2002 symptoms as a pain response. over 20,000 people in Northern Ireland and 2012 the population of this age who suffer from dementia. Behavioural symptoms not group increased by 20.3%.1 This trend is 64-86% of all older people have recognised as potentially related to expected to continue; the number of CHRONIC pain2, while people with pain. adults aged 65 and over is projected to dementia are EQUALLY at risk of having increase by 12.2%, from 272,800 to Inappropriate treatment becomes painful conditions as the general older 306,000, between 2012 and 2017, and more likely, e.g. anti-psychotics. population3. The more severe the by 63.5% (to 445,900) between 2012 dementia, the more likely the person is to Anti-psychotics are harmful to many and 2032. The median age of the be in pain4. people with dementia increasing population is also projected to increase Pain is devastating to people with likelihood of stroke, fatality, and over the same period, from 37.6 to 42.4.1 dementia who are unable to explain their exacerbating symptoms of dementia. With this in mind, the Pain Alliance of pain5. Pain makes people miserable and Northern Ireland held two events this Increased likelihood of premature it affects what someone can do and year to raise awareness of the problem of admission to higher level of care – makes them appear more impaired than pain assessment and management in nursing/ residential home/ hospital/ they really are. It impacts on functional older people. detention under the mental health and mental capacity, social interaction, order thus increasing the cost of care. quality of life, appetite, sleep, agitation, Pain and dementia depression and anxiety. Changes in Human rights infringements. The first of these events, held by kind behaviour can indicate the presence of invitation of Mr Jim Wells MLA, Deputy pain6. However in the absence of pain Chair of the NI Assembly Health assessment, the response to behavioural successful management of pain in Committee in the Long Gallery, Parliament symptoms in a person with dementia is nursing homes were: Buildings, on 26th March, aimed to raise often the prescription of sedatives and awareness of the burden of pain in those anti-psychotics7. Treating pain can •• Knowledge of pain management who suffer from dementia. reduce the use of anti-psychotic drugs6. (82%) Key note speakers were Prof. Pat One study, done in local nursing •• Getting an accurate report from the Schofield and Prof. Peter Passmore. homes, showed that the main barriers to patient (76%)

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•• Lack of standard approach to Commission) Head of Nursing Home, pain, the need to anticipate pain, even treating pain (71%). Independent Healthcare and Pharmacy when it is not reported, and the use of the Regulation and two Inspectors/Quality Abbey Pain Scale. The introduction of the The meeting called for the following Reviewers to discuss these issues. An Butterfly system to identify and record process to improve the care of those assurance was received that formal pain those with diagnosed dementia and those with dementia who suffer pain: assessment, record keeping and with possible dementia or delirium resulted management form part of the standard in improved patient care which was •• Recognition of pain as a cause of inspection of all nursing and care homes reflected in a high degree of satisfaction on difficult or challenging behaviour in for the past eighteen months and that the part of relatives and carers. those with dementia; this will continue to be monitored and Dr Michael McKenna, GP, West Belfast, •° Training of healthcare and social reported upon in future. presented a case study of an elderly lady care staff – Public Health Agency with polymyalgia rheumatica who (PHA). illustrated all the problems of long term •° Public awareness campaign – Pain management in frail elderly steroid and analgesic use. During repeated PHA. people hospital admissions for complications, •• Pain assessment as a routine upon Following the success of the Pain and including multiple pathological fractures of admission to a healthcare facility or Dementia meeting, the Pain Alliance held dorsal vertebrae, her analgesic medication when behaviour changes; an evening meeting on 26th June at was changed to short-acting drugs •° Training of healthcare and social Mossley Mill Conference Centre to resulting in dose escalation and the need care staff in the use of highlight the challenges of managing pain for regular review in primary care to appropriate tools - PHA. in frail elderly people. restabilise on long-acting preparations. He •° System of recording and tracking Dr Bernadette McGuinness, called for better communication between changes in pain following Consultant in Geriatric Medicine, Belfast hospital teams and GPs. interventions – Northern Ireland Trust, provided a comprehensive Claire Lasini, Senior Physiotherapist in Social Care Council (NISCC), overview of the assessment and an ambulatory care unit, Belfast Trust, Regulation and Quality management of pain including the demonstrated the advantages of Improvement Authority (RQIA). contribution that pain makes to falls, movement for frail elderly patients to their •• Quality assurance of pain exhaustion and feebleness, social pain managements as well as a wide management; isolation and loss of dignity. She reviewed range of other modalities that alleviate •° Pain assessment and the algorithm for assessment of pain and pain. She cautioned against the belief management to be a quality a number of tools appropriate to older that rehabilitation is impossible for frail standard for healthcare facilities people and raised awareness of how elderly people, stressing that given time -NISCC, RQIA. visual and cognitive impairment may and a very gradual increase in the influence choice of tool. Following intensity of movement/exercise in the belief that recognition of pain as a presentation of the evidence for significant benefits accrue. Posture cause of distress and challenging treatment modalities, including drugs, correction can help to reduce stress on behaviour and its appropriate interventional procedures, physiotherapy, joints, improve balance and confidence, management will: psychological therapies and self- and reduce the risk of falls, as does management, she presented a case therapeutic exercise. •• Reduce inappropriate prescription of study of a frail elderly lady with back Dr Pamela Bell, spoke very briefly about psychotropic medication. pain, which demonstrated how the Programme of Care for Older People •• Reduce inappropriate admission to susceptible such patients are to the in the Commissioning Plan for 2014/15. hospitals and care homes. adverse effects of pain and to the Although the plan has been agreed by the •• Permit those with dementia to remain inappropriate use of medication. Public Health Agency and the NI Health at home in their community for Mr Simon Higgs, Lead Nurse for the and Social Care Board, the budget for longer. Acute Pain Service South Eastern Trust, delivery has not yet been agreed. spoke of the difficulties in management of However the Regional Commissioning A further meeting was held with the pain in elderly people with cognitive Priorities for 2014/15 are as follows: Regulation and Quality Improvement impairment in a busy trauma ward and Authority (RQIA – this organisation has a how a change management project had •• Complete consultation process role similar to the Care Quality improved understanding of the impact of regarding statutory residential care

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and agreed Trust proposals for •• Access to more options for carers in however elsewhere in the Commissioning service reform. the provision or arrangement of their Plan the Health and Social Care Board •• Undertake review of domiciliary care respite/short breaks. has undertaken to lead on a scoping services and revised contractual •• Increased uptake of direct exercise to define the current provision arrangements payments. and future requirements for pain services •• Development of enhanced •• Working with Integrated Care in NI. safeguarding arrangements. Partnerships to improve the care of Finally, Ms Helen Ferguson, Director, •• Agree service development for the frail elderly. Carers NI, closed the meeting with a dementia services with associated •• Enhancement of dementia plea to all healthcare professionals to performance targets. services. consider the needs of those who care •• Regional implementation of e-NISAT •• Development of a more coordinated for frail elderly friends and relatives; to including the functionality to understanding of and approach to share as much information as possible share information within and across intermediate care provision within the constraints of professional Trusts. underpinned by more effective confidentiality, and involve them monitoring arrangements to improve actively in decisions about care so that and the Local Commissioning Groups discharge arrangements. they can work in partnership to achieve will have responsibility to deliver on •• Continued roll-out of targeted Public the best quality of life for their loved Health Agency preventative health one. •• Improved support for carers through and well-being improvement earlier identification of those not yet programmes. References 1. OFMDFM - Statistical branch 2013 figures recognised as carers; more •• Review emerging reablement 2. Tsai & Chang 2004 accessible information on caring so arrangements and structures to 3. Horgas & Elliott 2001 that carers can take informed ensure adherence to the agreed 4. Achterberg et al 2012 5. Scherder et al 2009 decisions about the value of model and assess the financial and 6. Husebo BS et al 2011 assessment; and greater service impact. 7. Banerjee 2009 personalisation of the assessment 8. Barry HE et al 2012 9. Four Seasons Health Care: Presentation to Pain in process so that it is experiences by Pain is not mentioned specifically in Dementia Meeting, Long Gallery, Parliament carers as supportive. relation to the care of older people, Buildings, 26th March 2014

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How do musculoskeletal Pain News 2014, Vol 12(3) 171 –173 physiotherapists make sense of © The British Pain Society 2014 the language that they use when explaining persistent pain to their patients? An Interpretative Phenomenological Analysis

Michael Stewart Clinical Specialist Physiotherapist East Kent Hospitals University NHS Foundation Trust

Considering the broad, idiosyncratic approaches, IPA’s acknowledgement of nature of biopsychosocial practice and the researcher as an interpreter of the the perceptual definition of pain1 participants interpretations, distinguishes (Moseley, 2003), this article sets out to it as an inclusive method for capturing discuss Interpretative Phenomenological and interpreting meaning (Wagstaff & Analysis (IPA) as a qualitative research Williams, 2014). Smith et al., (2009, p.3) method to explore how clinicians make term this concept the “double sense of their use of language when hermeneutic”. explaining pain to patients. IPA’s capacity to enable researchers to Several key factors for using IPA will be engage within the interpretative reasoning discussed. These include process is considered a fundamental phenomenological and hermeneutical methodological strength (Pringle et al., considerations, IPA’s compatibility to the 2011). However, Radder (2003, p.16) biopsychosocial model (Reid et al., 2005) suggests the double hermeneutic poses and its regard for qualitative validity a multitude of philosophical, Introduction (Yardley, 2000) and rigour (Pringle et al., epistemological and social problems for The clinical landscape for persistent pain 2011). In addition, IPA’s ability to capture research, with the unresolved question management is changing. The prevailing implicit and explicit linguistic nuances will being: “Who is entitled to define the paradigm shift away from a dualistic, be discussed (Snelgrove & Liossi, 2009). nature of human beings: the scientists or biomedical understanding of pain, the people themselves?” towards a more complete With this question in mind, although biopsychosocial model has led to a Phenomenological & the double hermeneutic presents multitude of challenges for Hermeneutical Considerations significant methodological challenges, in musculoskeletal physiotherapists To adequately explore the meanings that order to best explore how clinicians (Sanders et al., 2013). As clinicians clinicians attach to their use of language make sense of their language when adapt their perception of pain, they also when explaining pain, it is important to explaining pain, a dialogical interpretative need to develop communication skills in collect in-depth accounts of their clinical approach as outlined by Smith et al., order to educate sufferers (Warmington, encounters. Compared to more (2009) provides a more rounded 2012). descriptive phenomenological phenomenological stance. When

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comparing IPA to discourse analysis (DA) approach. Whilst acknowledging the role Reid et al., (2005) argue DA is concerned metaphors play within pain education, I with the function of language within must avoid any prior assumptions or restricted, specific contexts. Although DA hypotheses (Pannucci, 2010, Reid et al., might enable linguistic deconstruction to 2005). uncover meanings, IPA’s double hermeneutic, although questionable, Validity & Rigour permits a deeper exploration of To gain a detailed understanding of this phenomena (Biggerstaff & Thompson, particular research question, the chosen 2008). methodology must adhere to sensitivity Pringle et al., (2011, p.21) suggest that to context, commitment and rigour, when compared to other transparency and coherence, impact and phenomenological research methods, importance, as outlined by Yardley “IPA tends to interpret belief and accept (2000). Smith et al., (2009) suggest IPA participants’ stories, albeit in a fulfills these principles, whilst highlighting questioning way.” Whilst this provides a the need for tailored evaluative methods questioning foundation for study, IPA’s for assessing qualitative work. lack of adherence to critical interpretative Larkin et al., (2006) suggest IPA frameworks (Koch, 1999) has been researchers require support as they highlighted by Pringle et al., (2011). within the data. grapple with the dilemma of balancing However, Larkin et al., (2006) suggest Shinebourne & Smith (2010) suggest individual accounts against interpretation that rather than seeing IPA as a definite patient generated metaphors offer a ‘safe and contextualisation. Alongside method, we should view it as a ‘stance’ bridge’ through which they express opportunities for independent audit from which we may approach in-depth emotions that are too distressing to through a reflexive diary (Smith et al., analysis of qualitative data. communicate literally. If so, we must also 2009), IPA’s depth of data production Biggerstaff & Thompson (2008) consider the possibility that whilst also enables opportunities to strengthen suggest the holistic nature of IPA allows clinicians grapple with the complexities of validity and rigour through the use of researchers to explore implicit meanings explaining pain, they might also use peer debriefing (Erlandson et al., 1993) contained within texts through their own metaphors to communicate hidden and triangulation (Biggerstaff & explicit interpretations. IPA acquires obstacles they encounter within practice. Thompson, 2008). However, the use of insight into individual perceptions through IPA provides opportunities to capture ‘bracketing’ (Husserl, 1999) within IPA which we can make sense of the wider covert agendas (Snelgrove & Liossi, has been disputed by Biggerstaff & world (Pringle et al., 2011). This ability for 2009), and permits further interpretations Thompson (2008) who argue that by IPA to offer broader, contextual of their meaning to comprehensively aiming to allow researchers to interpretations makes it an ideal explore this research question. temporarily suspend judgments, the methodology for exploring the Clinicians and patients rely on bracketing of data is in conflict with IPA’s idiographic nature of linguistics when metaphors to make sense of abstract acknowledgement of the researcher’s clinicians explain pain. neuroscientific concepts (Loftus, 2011, role as an interpreter. Moseley, 2007, Stewart, 2014). However, Hale et al., (2007) suggest IPA’s Metaphoric Interpretations whilst metaphoric expressions to explain popularity is, partly, due to the detailed, Pringle et al., (2011) suggest IPA seeks pain are noted throughout the literature, cyclical process of data collection. Scott- to go further than standard thematic a phenomenological knowledge gap Dempster et al., (2009) outline four analysis. This makes IPA an ideal choice exists regarding their use by clinicians. iterative stages of IPA from the initial to explore participant generated IPA will seek to explore the meaning that exploration of text to the formation of metaphors. Snelgrove & Liossi (2009) clinicians attach to their use of emerging thematic clusters from which used IPA to explore the lived experiences metaphors when explaining pain. higher conceptual groupings evolve of chronic pain sufferers. They suggest This poses a methodological dilemma: through the search for superordinate and the method’s dual use of emic and etic the suggestion that metaphors will master themes. This process perceptual questioning enabled richer inevitably form part of the proposed data demonstrates a sensitivity to the data, analysis of implicit nuances contained collection is at odds with IPA’s inductive and enables use of substantial verbatim

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extracts from participants in order to Conclusion Interpretative Phenomenological Analysis in substantiate my interpretations (Smith musculoskeletal care. Musculoskeletal Care. 6 (2) To further understand how clinicians 86-96. et al., 2009). make sense of their use of language to Husserl E. (1999). Ideas 1. In Welton D. (Eds.), The To represent the biopsychosocial explain persistent pain to patients, we essential Husserl: Basic writings in transcendental paradigm, we must modify current phenomenology. Bloomington and Indianapolis, IN: must first acknowledge the cluttered Indiana University Press. research bias towards qualitative data, complexities of biopsychosocial practice Koch T. (1999). An interpretative research process: whilst safegaurding increased rigour in (Loftus, 2011, Moseley, 2007). To Revisiting phenomenological and hermeneutical future studies. Loftus (2011, p.228) approaches. Nurse Researcher. 6 (3) 20-34. adequately explore this research aim, IPA Larkin M, Watts S, and Clifton E. (2006). Giving voice suggests many researchers follow the offers an in-depth approach that’s and making sense in interpretative prevailing metaphoric idea that “evidence capable of capturing a broad spectrum phenomenological analysis. Qualitative Research in is numbers” without considering Psychology. 3: 102-120. of ontological and epistemological Loftus S. (2011). Pain and its metaphors: A dialogical “different purposes require different types beliefs. approach. Journal of Medical Humanities. 32. of description.” To further our Whilst IPA’s acknowledgement of the 213-230. understanding of this research question Moseley G.L. (2003). A pain neuromatrix approach to researcher’s role as an interpreter of patients with chronic pain. Manual Therapy. 8 (3) we must embrace a broad spectrum of meaning offers a dual analysis through 130-140. methodologies, whilst synthesising pain the double hermeneutic, we must remain Moseley L. (2007). Painful Yarns: metaphors & stories to research findings with linguistic analysis. help understand the biology of pain. Canberra. mindful of the plethora of disputes Dancing Giraffe Press. present throughout the literature (Radder, Pannucci C. (2010). Identifying & avoiding bias in 2003). research. Journal of Plastic Reconstructive Compatibility to the Surgery. 126 (2) 619-625. Reid et al., (2005, p.23) suggest IPA is biopsychosocial model Pringle J, Drummond J, McLafferty E, and Hendry C. “particularly suited to researching in (2011). Interpretative Phenomenological Analysis: a Whilst IPA permits in-depth exploration of ‘unexplored territory,’ where a theoretical discussion and critique. Nurse Researcher. 18 (3) experience, it is also noted throughout 20-24. pretext may be lacking.” The present the literature for an affinity to the Radder H. (Ed.). (2003). The philosophy of scientific knowledge gap that exists in our experimentation. Pittsburgh: University of biopsychosocial model. Reid et al., understanding of how clinicians make Pittsburgh Press. (2005, p.21) suggest, “IPA’s increasing Reid K, Flowers P, and Larkin M. (2005). Exploring Lived sense of their use of language when popularity within health psychology may Experience. The Psychologist. 18 (1) 20-23. explaining pain, calls for the use of an Schon D.A. (1983). The reflective practitioner: How well stem from its ability to contribute to in-depth, interpretative exploration of professionals think in action. London. Temple Smith. biopsychosocial perspectives.” Whilst their linguistic choices. Although debate Scott-Dempster C, Toye F, Truman J, and Barker K. this compatibility strengthens the (2013). Physiotherapists’ experiences of activity continues regarding IPA’s methodological argument for IPA’s use to explore this pacing with people with chronic musculoskeletal approach, it provides a valuable method pain: an interpretative phenomenological analysis. particular research question, I must aim of exploration to further our Physiotherapy Theory and Practice, Early Online: to capture the participants’ biomedical 1-10. Doi: 10.3109/09593985.2013.869774 understanding of this critical aspect of voices to gain overall perspective. The Shinebourne P, and Smith J. (2010). The communicative practice. power of metaphors: An analysis and interpretation use of a reflexive diary, triangulation and of metaphors in accounts of the experience of peer debriefing would help identify and addiction. Psychology & Psychotherapy: Theory, Note avoid bias (Pannucci, 2010). Research & Practice. 83, 59-73. 1. “A multiple system output activated by Smith J, Flower P, and Larkin M. (2009). Interpretative Biggerstaff & Thompson (2008) the brain based on perceived threat” Phenomenological Analysis: Theory, Method and suggest IPA promotes a greater (Moseley, 2003). Research. London: Sage. understanding of the intricacies of Snelgrove S, and Liossi C. (2009). An interpretative phenomenological analysis of living with chronic biopsychosocial phenomena within References low back pain. British Journal of Health practice. Similarly, IPA’s depth of analysis Biggerstaff D, and Thompson A. (2008). Interpretative Psychology. 14, 735-749. enables comparative exploration of any Phenomenological Analysis (IPA): A Qualitative Stewart M. (2014). The road to pain reconceptualisation: Methodology of Choice in Healthcare Research. Do metaphors help or hinder the journey? Journal existing epistemological differences Qualitative Research in Psychology. 5: 214-224. of The Physiotherapy Pain Association. 36. 24-31. between the participants. This is vital Erlandson D, Harris E, Skipper B, and Allen S. (1993). Warmington S. (2012). Practicing engagement: Infusing when we consider the influence that Doing Naturalistic Inquiry: A Guide to Methods. communication with empathy and compassion in Newbury Park, CA: Sage. contrasting technical rationale and medical students’ clinical encounters. Health. 16 Fish D, and Twinn S. (1997). Quality clinical supervision (3) 327-342. professional artistry (Fish & Twinn, 1997, in the health care professions: Principled Wagstaff C, and Williams B. (2014). Specific design Schon, 1983) practice beliefs have on approaches to practice. Oxford. Butterworth- features of an interpretative phenomenological Heinemann. our use of language when explaining analysis study. Nurse Researcher. 21 (3) 8-12. Hale E, Treharne G, and Kitas G. (2007). Qualitative Yardley L. (2000). Dilemmas in qualitative health pain. methodologies: A brief guide to applying research. Psychology & Health. 15. 215-228.

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Where is your pain? Pain News 2014, Vol 12(3) 174 –175 © The British Pain Society 2014 Richmond Stace Specialist Pain Physiotherapist

Richmond Each patient has a story to tell. Their an immune response to name but a few. originally narrative emerges as they attempt to Pain will then be present for as long as trained as a describe something that they feel without there is a perceived threat of harm to the Registered necessarily being able to find the words whole person. Whether or not there is an General that convey the essence of their actual threat matters not, for pain is not Nurse, and suffering. The clinician listens and an accurate yardstick for determining developed observes to gain an insight, but of tissue damage. an interest course without ever truly ‘knowing’ the The discussion of pain and from where in pain person’s pain, as pain is personal, unique it emerges is one with a great history. whilst and owned by the individual. The Science and philosophy are increasingly observing common way to indicate pain is to point merging when it comes to pain, the varying and say that it ‘hurts here’, the verbal and rightly so, for we have to continue to responses in recovery after operations. expression of pain being accompanied change our thinking about this universal Richmond continued to train as a by body postures, facial expressions and experience. There is no better example physiotherapist and has a further degree utterances. The language of pain tells us than when we are faced with a patient in Sport Rehabilitation and a Masters about the way in which the painful part, who comes to learn about their problem, Degree in Pain Science. His passion is e.g. the back, is being experienced right what they can do about it, and how long providing the latest in treatment for now, even though the back itself is not it will take. This is a huge responsibility chronic and complex pain and seeing ‘pain’. The language of pain conveys a for the clinician and the reason why we people relieved of symptoms, develop public warning for the observer to behold are obliged to be able to answer the healthy habits and change so that they as much as the person communicating questions: why is this person in pain? may lead normal and fulfilling lives once the private suffering. What is the impact of this pain? What more. Pain is about protection with the can I do to help this person? Much of the purpose of defending a part of the body information resides within the narrative, Every day clinicians ask this question, but also the self. In the case of phantom the remainder to be elucidated by simple guiding the patient to indicate where limb pain, this can occur even if the body clinical tests and investigations – tests to they hurt. For many years we have part is no longer in existence, or never be used wisely. One only needs read known that despite being able to point existed. We can argue the mechanisms Oliver Sacks’ great books to understand to a body part or region, this is not the of pain are an essential and a this notion. He urges us to consider the full story. Thankfully for patients, the phenomenal survival device, particularly person as much as the condition; wise day when a knee pain or a back pain is when we have an acute injury. The words and pertinent in the light of the considered simply a knee or a back individual has to know that something more recent thinking on first-person problem has gone. Researchers, dangerous has happened or may neuroscience. First-person thinking scientists, philosophers, writers happen, and be motivated to think in the considers the subjective experience, the and sufferers have shown that we must right way and then to take appropriate meaning and impact of the pain, and not think more widely about the problem of action. On determining that a threat over-valuing third person data. After all, pain if we are to have success in exists, there is a compulsion to protect the result of an MRI scan is clearly not changing for the better what is often oneself due to the unpleasant attention- pain and does not adequately explain the described as a sensory and emotional drawing experience that is pain. This is subjective experience of pain. experience. Fortunately, this is starting accompanied by a concurrent change in So, where does pain come to happen in the healthcare setting. the way we move, a stress response and from? Surely if we can answer this

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reality, no body system works in isolation, individual simply not knowing how to go and certainly not in isolation to the self, about living their life. The fear and anxiety which consists of all systems as a whole. that develop drive over-protective The research focus upon the nervous behaviours and the vision of the future system (peripheral and central) narrows. As Henry Ford stated, ‘Whether helped immeasurably to enhance our you think you can, or you think you can’t, understanding of the role of the brain in you’re right’, and I believe that this is true pain. However this paradigm has been for patients, so many of which have superseded by the knowledge that a received negative messages from large part of the brain is made up of themselves and others that hinder their immune cells and their significant role at sense of self and self-worth, funnelling the synapse. The immune system is their beliefs into limited choices. The responsive to how we feel and hence reality is that all patients can improve and how we think, relating this to the sense move forward with the right of self, our purpose and beliefs about understanding, an appropriate and ourselves and the world around. Dr flexible set of strategies and a clear vision Mick Thacker has plausibly that is meaningful for them. hypothesised that perception of threat A priority within the pain community evokes multi-system responses that are must be to continue to answer the inter-reliant and manifest via the whole question, ‘Where is your pain?’, and question, we will be able to reduce person, including the experience of communicate this to patients and suffering immeasurably. It will always be pain. Pain, he contends, emerges from society. The costs of persisting pain important to have pain in response to an the whole person on this basis, a view continue to rise financially, socially and injury or pathology, but what about to which I wholly subscribe (personal personally, and only by changing our persisting pain beyond the normal communication). This framework is allied thinking will we be able to deal healing time that disrupts living and the with the belief that pain can and does effectively with the problem. This can sense of self? change when the right conditions are start by considering the whole person, Our attempts to discover the origins of created for the whole. and continuing to draw upon science pain have taken scientists on a journey The contemporary approach to the and philosophical thought for the benefit into the brain, the immune system, the problem of pain is one that of society at large and the individuals endocrine system, the recognises the person as well as and the who come to us for a meaning for their gastroenterological system, the condition. The pain emerges from the pain and a way to move forward and autonomic nervous system, genetics, individual (Thacker & Moseley, 2013), re-engage with their lives. memory and into what we know about within the context of their life to date yet consciousness. Surely then, we are in the present moment, and not any one ** I dedicate this article to Dr Mick delving into the nature of pain that lies part, but that of the whole. The shift in Thacker, Dr Lorimer Moseley and Louis within the essence of who we are as sense of self that defines suffering is Gifford who have profoundly influenced human beings – and can we ever created by the impact of the pain: the my thinking and work. I thank them discover the absolute truth behind who inability to work, play and socialise. In whole-heartedly for opening my eyes. we are when it is us doing the looking? In some cases the impact is due to the

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Teams in Pain Management Pain News 2014, Vol 12(3) 176 –179 © The British Pain Society 2014 Bronwyn Lennox Thompson Senior Lecturer, Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch

When chronic pain management History of interdisciplinary pain programmes were introduced, and management teamwork especially during the heady days of the Beliefs and models of pain have been 1980’s and early 1990’s, teamwork was part of human history as long as humans the best way to manage the complex have experienced pain. Possibly the needs of people who had experienced most remarkable change in beliefs about chronic pain for many years. Sadly, as pain arrived with the introduction of the commentators have pointed out, this is gate control theory (Melzack and Wall no longer the case in many countries 1965), paving the way for innovators with (Loeser 2006, Gatchel, McGeary et al. a psychology background to introduce 2014), and increasingly people with behavioural pain management (Fordyce chronic pain are seen by a single 1976), shifting the prevailing model from “comprehensively address the professional working independently a biomedical one, to the inclusive biopsychosocial model of pain” (2014), (Manchikanti, Pampati et al. 2010). biopsychosocial model. During the and stated that centres should include: Moreover, in the situations where a team 1970s, awareness of the impact of does exist, the mode of working may be chronic disease on the individual living Health care providers capable of far from an interprofessional (inter- with illness supported the move towards assessing and treating physical, disciplinary1) approach, and instead be addressing not only pain intensity but psychosocial, medical, vocational and what is called a multi-modal one – where also distress and disability associated social aspects of chronic pain. These the style of interactions between team with pain. Notions of suffering as distinct can include physicians, nurses, members represents what I have heard from pain have emerged more recently psychologists, physical therapists, called serial monotherapy. In this (Cassell 2011), but chronic pain occupational therapists, vocational approach, each discipline or profession management programmes of the 1980s counsellors, social workers and any provides their preferred intervention can be credited with turning the focus other type of health care professional drawing from a model that may not be towards helping individuals reduce who can make a contribution to shared by any other team member, with suffering as they restored their sense of patient diagnosis or treatment (2014). differing goals that may not take into self-identity by re-engaging with valued account another team member’s occupations2 and relationships in their IASP emphasised the need to address contributions. world. both physical and psychosocial aspects While not wanting to hark back to the During the late 1980s, when these of pain. golden olden days, it might be useful to programmes were possibly at their Over time and even during the 1980s, review the rationale for interprofessional height, the International Association for challenges were faced by teams working teams, and what contributes to making a the Study of Pain drew a taskforce in this way. Funding was, as always, a team effective. This could help generate together to generate guidelines defining major limitation. Time dedicated to arguments for retaining an pain management centres. This taskforce training and fostering an interdisciplinary interprofessional approach for people recommended that interdisciplinary team was difficult to find. Finally there who have chronic pain. teams should be involved to was the lack of a clear model to guide

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healthcare management to implementing just a matter of electing a team leader processes that develop and maintain an who can tell others “what to do”, effective interprofessional team. The because this reverts back to a research on interprofessional teams has hierarchical model. Interdisciplinary grown extensively over the past 15 – 20 teams work because they hold common years, but while the literature may have goals, take the time to reach alignment, grown, implementing these findings in and respect one another’s contributions the real world of busy healthcare to the whole. O’Neill and Allen (2014) practitioners may not have progressed define task conflict resolution as “the nearly as quickly. extent to which different opinions, Impediments to effective viewpoints, and perspectives [are] interdisciplinary teamwork include turf resolved (p. 160)”, and found that wars over role boundaries, for example, resolving task conflict is significantly where both the occupational therapist related to team task performance as a and the psychologist believe they have whole, mediating between the negative the required skills to provide activity personality trait of secondary management (pacing), or where no-one psychopathology (Paulhus and Williams chooses to address self-identity or self- 2002) and team task performance. This concept issues because “they’re not my finding suggests that teams need to role” (Brown, Crossley et al. 2014). develop ways to resolve task conflicts, when it is time to stop attempting to Housing teams in separate buildings or and “team members holding strong reduce pain and turn to helping an facilities contribute to less coherence in a views about their discipline’s perspective individual accept the “new normal”. team. It is corridor conversations, and may impede this, particularly if those Over time, in many parts of the world, the tea room discussions that cement team members tend towards using interprofessional teams have given way relationships, bridge between different strategies that arouse negative emotions to an upsurge in biomedical perspectives, and provide a sense of in others” (O’Neill and Allen 2014). interventions, sometimes provided within belonging that are necessary to effective a multidisciplinary team but seldom teamwork. integrated within an interprofessional Limited attention to induction can Strategies to improve teamwork approach. The reasons for this increase create undercurrents within teams as Youngwerth and Twaddle (2011) are unclear, although Manchikanti, new members settle in. Induction is conclude that effective teamwork Pampati et al. (2010) speculate that a particularly important for ensuring new requires attention to communication, combination of greater numbers of team members understand the treatment interpersonal relations, team composition providers, better physician judgement, model, the contributions made by and structure, and organisational factors. convenient locations and short waiting clinicians from different disciplines, and They point out that leadership is often times all contribute. Whatever the for some, reconceptualising their task-dependent, defined by each underlying reasons, the rationale for an understanding of chronic pain. The situation, with the team collaborating to interprofessional team approach to problems arising from inadequate develop innovative solutions to unique chronic pain management in the 1980s induction to the pain management problems. Naming a single person as was that no single discipline possesses approach is compounded when each leader with responsibility for directing the all the answers for reducing both discipline has a separate line manager team is unlikely to work as teams disability and distress for an individual and professional department and little navigate rapidly changing situations. with chronic pain. This has not changed. understanding within these departments Communication refers to both formal of the unique interprofessional approach and informal opportunities to share adopted in chronic pain management unique information, with studies showing Teamwork challenges teams. that “sharing of patient and family I suspect that along with the three major Teams can implode when members fail information as psychosocial stories, as challenges of funding, time and models, to agree on goals or approaches. When opposed to biomedical data, has been a fourth problem has contributed to the teams do not have effective, transparent shown to help build positive relationships decline of interprofessional teamwork. and fair processes for resolving between team members” (Youngwerth This is the relative lack of attention within differences, teams can splinter. It is not and Twaddle 2011, p. 651). In a recent

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study Howarth, Warne et al. (2012) process because the team will inevitably of resolving team task conflict are identified that collective efficacy, or the judge the credibility of a newcomer. developed without resorting to a belief a team will achieve their intended Finally, being located within the same hierarchical decision-making structure, goals, influences a partnership between building appears to provide necessary that each professional is confident in people attending a chronic pain opportunities for team members to every other team member’s ability to management team, and the team itself. access one another and to develop contribute effectively, that members like The level of confidence each team social relationships. Howarth, Warne et and trust one another, and that ways to member holds for their own skills and the al. (2012) call this negotiated space, or a meet both formally and informally are skills of other team members strongly place where team members could learn encouraged. This finding is echoed in influences the sense of collective efficacy, about one another, readily exchange interprofessional chronic care teams so that team members know the ideas, and develop a relaxed atmosphere (Fouche, Kenealy et al. 2014). contributions they can expect from other where team members feel comfortable to Finally there is the need to establish team members, know when to include ask questions, or challenge one another. agreement between team members one another, and how to support one about when it is time to shift from another. This in turn contributes towards focusing on pain reduction to pain establishing team credibility as a whole. Who belongs in a chronic pain management. This is possibly the This finding suggests that team members management team? thorniest issue of all, but for the people need time together to appreciate what While many publications suggest that a who look to interprofessional teams to one another brings to the team. Mesmer- core team of medical, psychology and help them solve their problems with Magnus and DeChurch (2009) possibly physiotherapy professionals chronic pain, it is critical. Knowing that completed a meta-analysis of information should work together, there is equally “returning to normal” is not possible is a sharing and teamwork and found that considerable literature showing that other vital part of the transition from seeking groups mainly discuss information health professionals such as nurses, pain reduction to accepting chronic pain already shared, but groups that share occupational therapists, and social and working towards developing a new unique information make better workers can all be involved in delivering sense of self-identity (Asbring 2001, decisions. Paradoxically, groups that talk an effective interdisciplinary chronic pain Gullacksen and Lidbeck 2004). This is more tend to share less unique management approach (Shannon 2002, difficult to achieve while there is a information. Teams are more able to Wells-Federman, Arnstein et al. 2002, promise of pain abolition. This issue is share unique information when using a Colon and Otis-Green 2008, Moon, also one of the most divisive amongst highly structured, focused method of McDonald et al. 2012). What matters is clinicians involved in chronic pain discussion, and finally and particularly not so much the professional discipline, management. It challenges clinicians to relevant in pain management, groups as that team members hold a common acknowledge the limitations of our have more trouble achieving consensus model of chronic pain and its knowledge of pain, and it forces the less than solving a problem with a specific management. This notion has been glamorous contributions of allied health answer (Mesmer-Magnus and DeChurch recently supported in the book Pain- professionals such as occupational 2009). related fear: exposure-based treatment therapists and physiotherapists into the A second finding from Youngwerth and for chronic pain (Vlaeyen, Morley et al. spotlight. Twaddle’s study identified team maturity 2012), where rather than indicate specific as a key factor (Youngwerth and Twaddle professions, the authors have identified 2011). This refers not only to the length the skills required to conduct this A personal thought of time team members have worked approach. I originally trained in occupational therapy, together (on average three years or There is little agreement as to what graduating in 1983. Since then I have more), but also to the maturity of the constitutes an effective pain been mentored by clinical psychologists, individuals themselves. An important management programme, and the “black physiotherapists, nurses, social workers aspect of this factor is that the credibility box” of a cognitive behavioural approach and medical doctors. I have a Master of of each individual as a professional and a remains fairly opaque. This means that it Science degree in psychology, and I have person with life experience contributes to is not possible to argue for, or against, just completed my PhD looking at the the overall sense of confidence within the any individual discipline being involved. It ways of coping used by people living well team. This suggests that when recruiting seems far more important to ensure that with chronic pain. My original clinical for professionals to join the team, the a biopsychosocial model of pain is held orientation remains focused on helping team should be involved in the selection by every member of the team, that ways people do what is important in their lives,

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but I use a wide range of tools to help greater depth of collaboration between Howarth M, Warne T, and Haigh C. (2012). ““Let’s stick them achieve this. individuals Stone, J. (2014). “AIPPEN - together” - A grounded theory exploration of interprofessional working used to provide person When I am part of a team, I hope the Australasian Interprofessional Practice centered chronic back pain services.” Journal of three years I spent training in & Education Network.” Retrieved 03 Interprofessional Care 26(6): 491–496. occupational therapy all those years ago July 2014, 2014, from http://www. Loeser JD. (2006). “Comprehensive Pain Programs aippen.net/what-is-ipe-ipl-ipp. Versus Other Treatments for Chronic Pain.” The has left a mark on what I offer to a team. 2. Occupations are “the everyday activities Journal of Pain 7(11): 800–801. At the same time, I think I may have Manchikanti L, Pampati V, Singh V, Boswell MV, that people do as individuals, in families learned a great deal in the intervening Smith HS, and Hirsch JA. (2010). “Explosive and with communities to occupy time growth of facet joint interventions in the Medicare years. This knowledge and experience and bring meaning and purpose to life. population in the United States: a comparative influences what I can contribute to an Occupations include things people evaluation of 1997, 2002, and 2006 data.” BMC interprofessional team. I’m not alone in Health Serv Res 10: 84. need to, want to and are expected to Melzack R, and Wall PD. (1965). “Pain mechanisms: a this: clinicians working in chronic pain do” WFOT. (2010, 2011). “Definition new theory.” Science 150(3699): 971–979. management have often worked “occupation”.” Retrieved 05/09/2013, Mesmer-Magnus JR, and DeChurch LA. (2009). elsewhere, and been influenced by life 2013, from http://www.wfot.org/ “Information sharing and team performance: a aboutus/about occupationaltherapy/ meta-analysis.” Journal of Applied Psychology events, other professionals, and 94(2): 535. literature. Even within a discipline, definition ofoccupationaltherapy.aspx. Moon M, McDonald R, and Van dDJ. (2012). individuals develop specialised interests “Occupational therapy for pain management in the compensation setting: Context and principles.” and skills that make their individual References Occupational Therapy Now 14(5): 16–18. contribution different from another within (2014). “Pain Clinic Guidelines - IASP.” Retrieved 03 July O’Neill TA, and Allen NJ. (2014). “Team task conflict 2014, 2014, from http://www.iasp-pain.org/ the same profession. This means a resolution: An examination of its linkages to team Education/Content.aspx?ItemNumber=1471. personality composition and team effectiveness simplistic representation of whatever Asbring P. (2001). “Chronic illness – a disruption in life: outcomes.” Group Dynamics: Theory, Research, original profession he or she trained in identity-transformation among women with chronic and Practice 18(2): 159–173. fatigue syndrome and fibromyalgia.” Journal of probably does not hold true. My hope is Paulhus DL, and Williams KM. (2002). “The Dark Triad Advanced Nursing 34(3): 312–319. of personality: Narcissism, Machiavellianism, and that interprofessionalism in chronic pain Brown G, Crossley C, and Robinson SL. (2014). psychopathy.” Journal of Research in Personality management will recognise, celebrate “Psychological ownership, territorial behavior, and 36(6): 556–563. being perceived as a team contributor: The critical and support contributions from Shannon E. (2002). “Reflections on clinical practice by role of trust in the work environment.” Personnel occupational therapists working in multidisciplinary individuals who choose to work in this Psychology 67(2): 463–485. pain management programmes in the UK and the field. I also hope that by holding a Cassell EJ. (2011). Suffering, whole person care, and USA.” Australian Occupational Therapy Journal the goals of medicine. Whole person care: A new common model of pain, interprofessional 49(1): 48–52. paradigm for the 21st century. T. A. E. Hutchinson. Stone J. (2014). “AIPPEN - Australasian teams can develop ways of working New York, NY, Springer: 9–22. Interprofessional Practice & Education Network.” together to meet the rising tide of people Colon Y, and Otis-Green S. (2008). “Roles of social Retrieved 03 July 2014, 2014, from http://www. workers in interdisciplinary pain management.” J who need our help. Finally, I hope aippen.net/what-is-ipe-ipl-ipp. Pain Palliat Care Pharmacother 22(4): 303–305. Vlaeyen J, Morley S, Linton SJ, Boersma K, and de organisational development and Fordyce WE. (1976). Behavioral methods for chronic Jong J. (2012). “Pain-related fear: exposure based teamwork research can help pain and illness. St. Louis, Mosby treatment for chronic pain.” Fouche C, Kenealy T, Mace J, and Shaw J. (2014). interprofessional teams become even Wells-Federman C, Arnstein P, and Caudill M. (2002). “Practitioner perspectives from seven health “Nurse-Led Pain Management Program: Effect on more successful and perhaps supported professional groups on core competencies in the Self-Efficacy, Pain Intensity, Pain-Related Disability, by health funding authorities. context of chronic care.” Journal of and Depressive Symptoms in Chronic Pain Interprofessional Care 0(0): 1–7. Patients.” Pain Management Nursing 3(4): 131–140. Gatchel RJ, McGeary DD, McGeary CA, and Lippe B. WFOT. (2010, 2011). “Definition “occupation”.” Notes (2014). “Interdisciplinary chronic pain management: Retrieved 05/09/2013, 2013, from http://www. 1. I will use these term interchangeably, Past, present, and future.” American Psychologist wfot.org/aboutus/aboutoccupationaltherapy/ although the Australasian 69(2): 119–130. definitionofoccupationaltherapy.aspx. Gullacksen AC, and Lidbeck J. (2004). “The life Interprofessional Practice and Youngwerth J, and Twaddle M. (2011). “Cultures of adjustment process in chronic pain: psychosocial interdisciplinary teams: How to foster good Education Network argues that the assessment and clinical implications.” Pain dynamics.” Journal of Palliative Medicine 14(5): term interprofessional denotes a Research & Management 9(3): 145–153. 650–654.

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A Nation in Pain: Healing Our living with chronic pain; the difficulties in Biggest Health Problem by Judy its diagnosis, the unpredictability of pain Foreman (ISBN 9780199837205) intensity and the increasing levels of limiting scope it causes. What is Published by Oxford University apparent is the author’s choice of only Press including descriptions by physicians who have themselves developed persistent Reviewed by Muna Adan, PH.D., pain to perhaps point out that School of Pharmacy, Nottingham frustrations, disappointments and the University, UK insidious experiences of chronic pain is only fully comprehended by someone A Nation in Pain is a masterful chronicle who has the symptoms. As a of chronic pain and its devastating dermatologist-turned-patient explains: the UK as elsewhere. impact on individuals and society alike. “there is a divide between the sufferer The most intriguing and heartfelt This well researched book, co-published and the outside observer, pain brings section in the book is the chapter on by the International Association for the these boundaries between people into paediatric pain and its management, Study of Pain (IASP), aims to provide an such acute focus.” which is examined in detail due to the account of reasons behind the chronic The author within the same chapter author’s concerns of deficient attention pain crises in the 21st century and takes gives an analytical perspective on the to the subject. Foreman initially highlights a critical look at some of the wide range current extent of pain education covered past debates questioning the existence of treatments currently available in by medical schools compared with pain of pain in infants and children and takes controlling long-term pain. Judy Foreman curriculum topics recommended by a glance at past preposterous paediatric states that the failure to better manage working groups from the International pain management. Examples of pivotal chronic pain worldwide may be Association for the Study of Pain. research on neurological reports, for described as tantamount to torture. Although there has been relatively little example the fact that infants may even The 464-page book is organised into research focusing on pain education in feel more pain than adults due to the 14 chapters, which include a focus on the medical schools, a review of most recent shorter travel distance of their nerve enormity and complexity of the chronic literature on the topic is initially presented impulses from the periphery to the brain pain problem, genetic and immunological and a solid argument is made on the even though some nerve fibres may not influences, gender differences and need for stronger support for pain yet be myelinated, are described. pharmacological as well as non- education to endure the incorporation of The chapter on the therapeutic uses of pharmacological management of painful new knowledge into the curricula. opioids, their safety, efficacy and misuse is chronic conditions. The chapters provided However, the author gives a somewhat most thought-provoking and useful. The are highly referenced and the information limited reflection on possible factors author highlights the less clear risk/benefit included is based on recent research, explaining some of the existing pain ratio of opioids in chronic pain of non- which is presented in a style that does not educational barriers mentioned. malignant nature. However, despite this overburden the reader with in-depth Moreover, invariably, as in a lot of the there is a sense of advocacy of such scientific details, yet allows for a level of chronic pain areas covered in the book, treatment that comes through in the objective appreciation of the findings. This an American context is mostly evaluated. writing, which spans two chapters. In makes it ideal for a wider readership. Nevertheless, given the prevalence of contrast several crucial therapeutic The initial chapter of the book is a chronic pain worldwide, the subjects advances such as serotonin and narrative insight into the experiences of raised are as relevant to the situation in norepinephrine reuptake inhibitors e.g.

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duloxetine, venlaflaxine as well as few be commended. The result of years of book as mentioned earlier is that most of promising emerging pharmacological research into what is known and not the topics covered are largely looked at agents such as Resolvins and AC1, which known about chronic pain from the from a US healthcare system standpoint. are still in clinical trials, are discussed. author’s perspectives both as an Having said this A Nation in Pain is a Overall, this is an ambitious and far- investigator and an observer makes it thoroughly insightful publication and a ranging book, for which the author is to interesting. The only downside of this delight to read. I highly recommend it.

Book review

Mindfulness for health: a their difficult symptoms, and that this can practical guide to relieving pain, lead to more significant improvements in reducing stress and restoring quality of life than can be achieved by wellbeing Vidyamala relying solely on health professionals’ Burch and Danny Penman advice. It is a step-by-step guide through the basics of learning a method of (ISBN 978-0-7499-5924-1) meditation using breathing and progressive muscle relaxation Published by Piatkus, part of Little, techniques. Using well-established Brown Book Group. cognitive behaviour therapy principles, the authors invite the reader on a course Review 1 by: Dr Austin Leach of self-discovery and introspection which Consultant in Pain Medicine, is designed to encourage commitment, Liverpool; British Pain Society alter potentially unhelpful behaviour, Council member improve flexibility and most importantly, to recognise negative emotions such as Through their association with the anger and fear and use the simple Breathworks enterprise the authors of this physical skills on offer to reduce the book have previously produced a impact of unpleasant symptoms. substantial body of work relating to The authors have a deep understanding mindfulness, and its use as a vehicle for of pain and its impact on the human self-improvement and self-management of psyche. This reviewer did not particularly difficult pain symptoms. Vidyamala Burch like the reinterpretation of the IASP has been a Buddhist and practitioner of definition of pain as the painful sensation However, this is still a useful, methodical meditation for decades after ‘discovering’ itself being described as ‘Primary Pain’ and practical book that makes its points the method for herself following several and the unpleasant emotional component gently and logically. I had a sense of being significant back injuries. Danny Penman is of pain perception that accompanies it as led by the hand through the mindfulness a medical journalist, currently working as a ‘Secondary Suffering’. While Patrick Wall process, with no particular sense of feature writer for the Daily Mail, who has a has endorsed the word ‘suffering’ in urgency, and the text uses the ‘three R’s’ PhD in biochemistry. relation to pain, I feel that it has been (Remind, Reinforce, Repeat) method of Mindfulness for health has been rather over-used more recently, and as a education to ensure that important details written for a lay audience who have result the word’s impact has been of technique are not missed. taken on board the idea that individuals lessened; it may encourage a victim Key to the whole process, and this can assume responsibility for managing mentality in the mind of the ‘sufferer’. idea underpins the text, is the allocation

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of set periods each day for some kind of physical deconditioning, low self-esteem simple phone apps available for people mindfulness activity, with a gradual and tiredness. very new to the topic. The book gives a progression in complexity as the weeks Rating: 4 stars out of 5 lot of additional support and information go by. Those who succeed in of more use once simple relaxation and incorporating regular sessions of a few focus is achieved. Usefully there is Review 2 by: Geraldine minutes’ duration into their daily downloadable audio and suggestions for Granath, a patient schedule are, by definition, imposing a “mindfulness toolkit” that may be useful self-control on a situation which might Interest in mindfulness is growing, there as a starter for 10 or a reminder, and an otherwise encourage chaotic thinking. don’t seem to be many areas where it online presence for those who would find By following the guidance and relaxation isn’t being recommended; be a better this helpful. Advice on gentle movement regime the ‘sufferer’ will be leader, reduce stress, become more and comfortable positioning is also strengthening his or her own locus of productive and improve your health. helpful. control. This book explores the use of The ubiquity of mindfulness at present For those who don’t really understand mindfulness in pain management by may cause professionals to view it as a what mindfulness is, I rather liked this outlining an initial eight-week programme fad with a trajectory of unbridled quote: which will help you to establish a lifetime enthusiasm, uncritical acceptance and practice. The book and the programme eventual disillusion. I would like to see “Virtually everyone’s mind wanders is based on the work of Jon Kabat- Zinn acknowledgement that some patients will while meditating. This is entirely of the University of Massachusetts find this approach less helpful and normal… Becoming aware of your Medical Center, used by Vidyamala appealing so there becomes less of a wandering mind is a sign that Burch to develop a Mindfulness-based view that this is an approach for the self mindfulness is beginning to take root.” Pain Management programme. selecting few. The book is wide ranging and reflects My own experience of mindfulness is The book is accompanied by a CD a considerable body of work but I think it largely positive, having practised on and with the eight weeks’ exercises narrated could be daunting for the reader who is off since the late 80’s I find it gives me by a gentle female voice. new to the topic. Access to mindfulness the ability to relax muscle tightening and The main criticism of the book is that it training is variable across the UK and avoid painful spasm. The body scan is one among many similar offerings by personally I would find it very difficult to technique helps to focus on areas of pain the same and other authors. But it does only use the book without some ongoing and “turn down” intensity; recognising do ‘exactly what it says on the tin’ and face to face support. The case studies my own response to pain helps me to the reader/student should, if the that run through the book are a mixed face flare-ups with more equanimity. programme is adhered to, be able to bag, overall I didn’t find them particularly Please do try mindfulness, but look develop useful skills that can be helpful or illuminating. outward as well as inward and press for the deployed against troublesome issues As a practical introduction my own best care, treatment, education and such as joint and muscle pains, anxiety, preference would be for one of the research possible in all areas of pain as well.

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In this issue of Pain News we chat to the Chair of the Patient Liaison Committee – a vital committee that provides patient representation at all levels within the BPS, from Council level right down to SIG committees and attendance at BPS events. We would like to thank Antony for the time he has taken to answer our questions.

Q What first Committee (PLC) and I love being mainstream and in the community, brought you able to make a difference to people reaching out to more people and in contact who live with pain. The role I see is allowing the public to self-refer. Pain with the looking after the other members of management courses would be BPS? the PLC and making sure they are available to anyone living with pain and I was Chair supported and happy. We then have people would be able to get ongoing of the to focus on the work which comes up support, so that no one would feel Patient for the PLC from the work of the alone with their pain. Older people Partnership BPS. I like looking after people and I would be especially targeted to meet really like making a difference for the huge amount of unseen and Antony Chuter Group at the people living with pain. under-reported pain in older people. Haywards Heath RCGP and I There would also be a public West Sussex was able to Q What do you feel is the role of the awareness campaign on how people Chair – Patient put forward PLC within the BPS? living with pain want to live normal lives Liaison Committee ideas for the but need support and understanding. Clinical I feel that the PLC offers a number of Champion Programme which the College patient perspectives to the work of Q What are you known for runs. Council members are also able to the British Pain Society. I think we professionally? put areas forward for consideration, but I have a unique chance to help make was not that hopeful for pain as there are things just a bit better for people living I am not sure that I am a professional usually lots of ideas each year. I was also with pain. in any particular area as I didn’t work on the committee which selects the for a long time due to my long term champion area and pain is so personal to Q If you were President of the BPS for pain and the effects of living with me. So I did encourage pain being one of a day, what would you do? pain. I think I am good at facilitating a champions just a little bit! I was delighted I don’t think I could do a better job group of people, which is what I do when Martin was made the Pain than William. But if I were in charge of with the PLC, but I have no Champion for the RCGP and was invited the NHS for a day I would setup up a professional qualifications in that or in to join the stakeholder group which met task force to revolutionise how pain is anything really. Work wise, I with Martin a couple of times a year treated in the UK throughout the accidentally landed on my feet in population. Pain would be measured healthcare research a couple of years Q What is your role in the BPS? What at every opportunity where someone ago. I kept saying that if research was excites you about this role? could be in pain and then treated to be patient centered, it needed I am the Chair of the Patient Liaison quickly. Pain clinics would be patients as lay members on the

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Spotlight

project themselves. I am now a Talk - now it depends on if you ask RNLI. I would have to say, I have co-applicant on five research me or Andy. I would say I talk about deep gratitude towards the men and projects. I really love my work. I don’t politics and fairness. Inequality women of the RNLI. just work in isolation but find other bothers me as does a lack of people from the community to work generosity and kindness in the world Q What would be impossible for you to with me. It’s a bit like looking after a around us. Andy would say I just talk give up? PLC on each project. I like looking too much and that he switches off…. I have lived with pain for 22 years, so after people, happy people work Pah! that would have to be my pain better! medication. I have handled the most Q Where can we find you in your spare extraordinary amount of pain but Q What are you most passionate about time? What is your favourite way to knowing I have the means to control professionally? spend a weekend or a Sunday it is key to my sanity. I enjoy and get a great deal of afternoon? How do you want to be remembered? satisfaction from knowing that a When I get home from a day working Q group of patients and members of the away, I love nothing more than I would like to be remembered for public have made a piece of research spending time with my chickens. I having made a difference for people better, perhaps more relevant for have 6 girls and they are so funny. It living with pain, improving patient patients. I love listening to peoples’ is a lovely way to unwind at the end safety (one of my research interests) experiences and find focus groups of the day. At weekends, my partner and for having a happy life with my fascinating. I enjoy recruiting people and I are often found on a preserved partner Andy. for them and looking after them on railway, the Blue Bell Line. It is only a the day. Most of all I like to then use couple of miles away and there is no Q Any life achievements you are their experiences to help make mobile signal, so I have to switch off - particularly proud of? changes, this happened recently with plus the tea and muffins are a treat! I could easily say the day I married a ‘Quality Measure’ for use in General Andy. In my teens and 20s, I never Practice. Q Any other volunteer activities apart thought that we would be able to do from the BPS that you’re passionate that. Or I could say it was when I was Q What do you have a knack for? about? given Hon. Fellowship of the RCGP. Recruiting people for research, be it It has to be Pain UK, I am the Chair of That was a deeply special day too. to join me on a project team or for a the charity and it means a lot to me But I think my proudest life focus group. I enjoy the challenge of that I do the best I can in that role. achievement is surviving what’s been filling a day. Recently I needed to find thrown at me and how I have gone 10 women for a focus group but they Q Any favourite non-profit organisations through the mill and survived. Getting had to be between 18 - 45 and living that you support and why? ill, losing everything including my with Bi-Polar or Schizophrenia. It was hopes and dreams, deep depression I used to sail a lot when I was a challenge but I did it! and hopelessness for 12 years and younger and I loved the sea (I lived then the slow rebuild over the last 10 What are you passionate about my whole life next to it until 5 years Q years - I am proud of me! personally? What do you really enjoy? ago). When I was 22 I was on a yacht What can’t you stop talking about? which sank in the English Channel on Q Anything else you’d like to tell Three questions in one!!! Ok here a stormy afternoon. We were only 3 people about yourself? goes; miles out but it was far enough to be really scary and the skipper had no I am half man, half labrador - I am Passion - making a difference for the radio or flares. We did have life very food driven! Sausages, steak, time I am on this earth, we are only jackets on. By chance, someone in a good burgers and bacon and egg here one time! block of flats had been watching up sandwiches. Never be between me Enjoy - FOOD, I love food, eating it with binoculars, they saw what and the buffet! and cooking it for other people. happened. My life was saved by the Thank you for your time Antony!

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Pain News addendum

Obituary on Dr Andrew Lawson in June 2014 issue page 77 had contributions from Simon Barton and Glyn Towlerton.

Karin Cannons Author of the article published in June 2014, page 94, works at Frimley Park Hospital, not John Radcliff Hospital

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Allegories of Change; the poetry of Pain News 2014, Vol 12(3) 186 –188 Ted Hughes and Images of the © The British Pain Society 2014 natural world

Ian Stevens

“Go Fishing understanding the human condition and Join water, wade in underbeing aspects that conspire to either enhance or Let brain mist into moist earth suppress the instinctive healing capacity Ghost loosen away downstream of an individual may prove fruitful. Gulp river and gravity …. Pain science suggests that activation … Lose words of nociceptors is not ‘pain’ – and that Cease pain is largely a threat response Be assumed into glistenings of lymph dependent on meaning and context. As if creation were a wound Many years ago, I was asked by an As if this flow were all plasm healing orthopaedic surgeon to see a young man Try to speak and nearly succeed who couldn’t walk. He was a prisoner Heal into time and other people from Barlinnie, prison near Glasgow where all the hard men are sent. He was In a simple experiment with patients By Ted Hughes, River* thrown from an upstairs gantry and had with complex regional pain were told to bilateral os calcis fractures. His heels look at their painful and oedematous limb Ted Hughes poetry - the natural raw were too painful to put any weight on though the binoculars the ‘wrong way elemental landscapes, animal themes and because he couldn’t walk the prison round’ As the perceived threat ‘shrank’, and in some cases such as the officer took off his handcuffs. While the a patient’s physiology changed: allegorical journey described in writer officer was engrossed in his paper he inflammation, oedema and reported pain have influenced me greatly. Ted Hughes had crawled under the bed, got out by all decreased, showing that ‘pain’ and uses the allegorical river journey using the fire escape, climbed over the wall, perception are ‘neuroplastic’ phenomena Celtic symbolism of water, turmoil and a summoned a taxi and escaped! So the and potentially malleable. process akin to a shamanic ritual of power of context in pain cannot be immersion and renewal. I have used the overlooked! I have often reflected on how poem as a vehicle to reflect on aspects the environmental context (in terms of Movement and change of change and stasis typically setting/interactive process and empathy) “From a whisper in the forest, to the encountered in many aspects of chronic may often be the source of the alleviation felling of a mighty tree, ‘tis all pain. or amplification of suffering in many movement’.” *The full text of this poem is printed in the chronic pain problems. We have heard William James (brother of transcript booklet of the proceedings of about patients on Jumbulance holidays the novelist Henry) the 2013 meeting of the Philosophy and normally dependent on medication for Ethics SIG, available from pwgorman@ severe pain who were enjoying My greatest interest in life is movement in btinternet.com themselves so much they didn’t miss it at nature. More and more of us live out of all when inadvertently separated from it. contact with nature and often-prolonged Context and pain It seems that a window view, friends, pain and suffering seem to encourage In many cases of chronic pain and kindness and care are as powerful as isolation, immobilisation and stasis. unexplained somatic distress opiate medication in some instances. People often lose or have limited

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Allegories of Change; the poetry of Ted Hughes and Images of the natural world

proprioceptive balance, exteroception poem literally, the less likely we are to and interoception and sensory make sense of it or gain any value from experiences. Many non mainstream it. Similarly, in some aspects of health approaches that involve mindful care and illness, approaching a problem movement such as tai chi, ‘feldenkrais’, head on or attempting to find solutions forms of yoga, dance or even deliberate solely through logical algorithms often walking practice may modulate and alter reduces our possibility of finding fresh or ‘defensive’ motor activity. novel solutions to a problem. We have increasingly come to forget In her books The Balance Within and that our minds are shaped by the bodily Healing Spaces Rheumatologist Esther experience of being in the world; Sternberg describes the temples of textures, sounds, smells and habits as Change therefore often requires a spirit healing in Greece and suggests that we well as the genetic traits we inherit and of experimentation, a change of heart, as often worship the wrong gods. The two the ideologies we absorb all affect the well as risk and in some cases reflection. gods of healing are Aesculapius, the god brain neuromatrix. Approaching a complex multifactorial of intervention whom we tend to over- We are losing touch and becoming problem such as chronic pain and worship and Hygeia who is more disembodied to a greater extent than in suffering with linear reasoning and concerned with self-care. Perhaps in the any previous historical period. Nan solution (either as a patient or clinician) is modern era we need to value Hygeia a Shepherd wrote, “one should use the probably akin to the schizophrenic world little more and understand in many cases whole of one’s body to instruct the spirit. described by Iain McGilchrist in The that the certainties promised by ‘techno This is the innocence we have lost: living Master and his Emissary. Linear thinking, medicine’ are often illusory. in one sense at a time to live all the way stereotypical motor activity, an inability to Patients who face a window often through.” Sensory experiences changes understand allegory and metaphor or to require less medication and natural people. see the value of poetry and fiction, or scenes are beneficial and promote calm. The poem by Ted Hughes reveals that respond to rhythm in music, are Pain clinics I have worked in are often the loss of words and immersion in a synonymous with excessive left brain airless and windowless and more like dangerous unpredictable environment lateralisation and are extremely common Barlinnie than a healing temple of Hygeia! leads to transformation. It has been my in chronic stress. The way out of this rare experience that some individuals situation is not more of the same or a seem to have replicated this allegorical repetition of the metaphor of the balloon Water as a metaphor narrative. In some instances it has been on its lower branches. Clinically this is In dealing with chronic pain, insight from necessary to cease believing in the akin to the repetition of procedures and the humanities, poetic allegories and medical process, inadvertently nocebo as approaches which have failed previously. lessons from nature may lead to this may sometimes prove, and to seek This scenario is all too common where experiences being experienced afresh. fresh challenge and commit to activity. As the dominant ethos is ‘doing’ rather than This contrasts with the prevailing a physiotherapist I have seen patients understanding and interacting with mechanistic approach to interpreting and embark on this process and thrive. patients in chronic pain. The ‘way out’ of adjusting bodily dysfunction. The metaphor for change suggested complex defensive strategies such as We can use the picture of a river in by the evolutionary psychologist Nick chronic pain often needs a ‘whole brain’ spate as an image of biomedicine. When Humphrey of a balloon caught in a tree approach. McGilchrist suggests narrow you have to hand over yourself in trauma hitting the same branch until the wind focused attention - the effects of or acute disease, (as you can’t do changes and it floated higher. This seems excitement, fear and stress actually anything to stop that huge flow of water) to be a good one for chronic pain; you inhibit the neuronal spread of information biomedicine is appropriate and works can bounce on the bottom branch over into the right hemisphere. The danger in well. But another picture, that of smooth and over again, but to experience big the modern world is that the prolonged water running over a weir, is a metaphor change you need a different stimulus. As activation of this response without respite for chronic pain. If you are a canoeist in Humphreys suggests: “we too need to prevents the scene being experienced danger of getting caught up in the middle have a whirlwind blow through our lives afresh or for new information to be of the turmoil the only escape is to get to before we will start over again and give processed or healing/recovery to occur. the side to find natural respite. Man ourselves the chance to move on to a In terms of poetry and metaphor the made weirs often offer no such respite new level.” harder a person tries to understand a and are more like a washing machine

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Allegories of Change; the poetry of Ted Hughes and Images of the natural world

from the known into the unknown and it is always different and always the subsume the forces that you can’t same.” control. My own experience with body Heraclitus therapies and meditation is that when words cease senses change; that can be In this too our bodies are like rivers. Sta- metaphysical and complex or very sis, which is the allegory of chronic pain simple. and the opposite of flux, is incompatible with life and leads only to separation and disintegration. “The nature of things is intrinsically So be optimistic; neurogenesis is hard to seek out using the tools with possible with the right mix of ingredients be stuck on a perpetual spin cycle. In some which we normally equip ourselves it watching images or Tai Chi. But sitting situations of chronic pain, medicalisation for the task. Our natural assumptions still ruminating about our problems doesn’t and iatrogenic disability, people often get and our common ways of thinking will achieve very much. So get out there and caught up in the middle of this ‘weir’. The lead us astray and we need to be do something different - give it a go! way out of this common scenario is to both wary and indefatigable in our embark on a journey using different path, seeking of the truth. All things flow; This presentation done at Philosophy sometimes with a guide or helper who stability in the experiential world is and Ethics SIG meeting, concluded with follows a different narrative. always stability provided by a form a slide-show of photographic images of Ted Hughes’ poetic imagery suggests through which things continue to flow. nature, many of exquisite beauty, to be that when words cease and forces As they step into the same rivers found by following this link : http://www. overwhelm you, you are the allegory of other still waters flow upon them. One flickr.com/photos/ianstevens/ the shamanic journey when you move cannot step twice into the same river; sets/72157638243787946/

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2. Story competition: There It is what it says – Snap and Chat. If are a couple of any of you have any photos or photographs, again taken at artwork, which reminds you of BPS, ASM. Let your imagination pain or its treatment, please send it run wilder, become more to us with your comments. The creative and write a short comments should convince us that story. The story should not the ‘Snap’ you send is ‘Chattable’. exceed 500 words. The Go on. Look in to your old most creative and photograph collections or snap while entertaining story will win a you are out and about. You will win a prize. Come on. Why are prize if your snap and chat really you still reading this? You excites the editorial team. Every should have started writing month there will be one prize to win! the story already. Send your snaps to newsletter 1. Caption competition: Let’s see how The entries should be sent to newsletter@ To start the ball rolling here we have creative you can be. Please send us britishpainsociety.org It should reach us some photographs taken from ASM. We your caption on this photograph. The by midnight, October 10th 2014. Editorial have two competitions. best one wins a prize! board decision is final.

1. Caption Competition Image

2. Story Competition Image

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Ratified at the February and July 2014 Council Meetings

Name Position Institution Mrs Hanan G. Ali El.Tumi Research Student - Pain Physiology Leeds Met University Miss Claudia Poynton 3rd Year Biomedical Scientist Leeds Met University Ms Andrea Louise Cain Highly Specialist Physiotherapist in Chronic Pain Management Salford Royal Hospital Dr William Rea Consultant Anaesthesia Royal Orthopaedic Hospital Miss Sophie John Physiotherapist Pain Rehab Nuffield Orthopaedic Hospital Mrs Helen Marie Firth Highly Specialist Physiotherapist - Pain CTR Salford Royal Hospital Dr Udaya Kumar Chakka ST6 Anaesthetics, Advanced Pain Trainee Royal Victoria Infirmary, Newcastle upon Tyne Miss Esther Sieff Clinical Specialist Nurse in Chronic Pain Stepping Hill Hospital Mrs Harriet Barker Lead Nurse - Pain Services St Peter's Hospital, Chertsey Mrs Cindy Thomas Specialist Nurse Practitioner - In-patient Pain Services Nuffield Orthopaedic Hospital Dr Sailakshmi Murugesan ST5 Anaesthetics Royal Preston Hospital Mrs Rachael Barton Staff Nurse, Day case Neurology & Neurosurgery The Walton Centre Dr Navtej Sathi Consultant Rheumatologist & Acute Physician Wrighton Hospital, Wigan Dr Ruth Cowen Pain Fellow Chelsea and Westminster Hospital Mrs Maureen Booth Clinical Nurse Specialist - Acute Pain Torbay General Hospital Kristina Zhivkova Grancharska Assistant Prof. Physiology; Kinestherap Faculty of Public Health and Sports, South - West University ''Neofit Rilski'', Bulgaria Dr Andrew Levy GeneralDentist (also research assistant at Birkbeck college) Align & Smile, London Dr Lucy Ann Miller Anaesthetic SPR/ Pain Fellow Bristol Royal Infirmary Dr Margaret Lorang Surgical Assistant Private Hospital, Sydney Dr Jennifer Thomas Consultant in Rehab University hospital of Wales Dr Shaun Clarke VMO/Consultant in Anaesthetics Coffs Harbour Health campus, Australia Dr Hari Sankar Ankireddy Registrar (ST6) Anaesthetics Royal Gwent Hospital Dr Anand Natarajan Pain Fellow Arrowe Park Hospital Dr David Waluube Retired Associate specialist - Anaesthetist William Harvey Hospital Dr Sachin Rastogi Consultant Anaesthetist & Pain Physician Royal Victoria Infirmary, Newcastle Mrs Omimah Said PhD Student Centre for Psychological Research, University of Derby Dr Azfer Usmani Consultant Pain Forth Valley Royal Hospital Miss Katheline Jolly PhD Student Centre for Neuroimaging Sciences, Kings College London Dr Duncan Hodkinson Postdoctoral Researcher Centre for Neuroimaging Sciences, Kings College London Dr Matthew Allsop Research Fellow in Applied Health University of Leeds Miss Kathryn Anderson Lead Nurse Royal Free Hospital Dr Hugh Antrobus Consultant Anaesthetist & Pain Management Warwick Hospital Dr Robert Atkinson Consultant Anaesthetist Pontefract General Hospital Dr Gaurav Chhabra Specialist Registrar Anaesthetics Royal Victoria Hospital Miss Rachael Docking Research Fellow Acute and Continuing Care University of Greenwich Mr Rory John Todd McMillen Director The Maymask Healthcare Group Ltd Mrs Madeleine Anne Nicholson Clinical Specialist Physiotherapist Abergale Hospital Mrs Janet Norton Chronic Pain Nurse Specialist Medway Maritime Hospital Dr Kavita Poply Clinical Lecturer in Pain The Royal London Hospital Mrs Shivaun Rackham Chronic Pain Specialist Physiotherapist Waters Green Medical Centre (linked to Macclesfield Hospital) Mrs Gillian Simon Clinical Nurse Specialist up to 2013 Addenbrookes (last place of work) Mrs Kate Wyatt Specialist Nurse Norfolk & Norwich Hospital Dr Ben Huntley Consultant in Pain Medicine and Anaesthesia Queen's Hospital, Romford Dr Sarah Ciechanowicz Specialist Registrar Anaesthetics The Lister, Stevenage Dr Melanie Smith Clinical Psychologist Salford Royal Hospital Dr Hannah Twiddy Specialist Clinical Psychologist Walton Centre Mrs Roseanna Brady Psychologist Milton Keynes Hospital Dr Michael Downton Croft GP Care UK, HMP Isle of White Dr Joanna Renee Advanced Pain Fellow Western General Hospital Mr Marcus John Beasley Research Assistant University of Aberdeen Dr Roy Miller Consultant in Anaesthesia and Pain Medicine Colchester General Hospital Dr S Caroline Cochrane Consultant Clinical Psychologist Astley Ainslie Hospital Mr William J Cottam Research Assistant/Radiological Sciences University of Nottingham

190 Pain News l September 2014 Vol 12 No 3

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