Pain Service

Dr Catherine James — Consultant

Dr Allister Dow — Consultant

Dr Daniella Tonucci — Consultant

Professor William Fawcett — Consultant in Anaesthesia and Pain Medicine (Inpatient Pain Team)

Dr James Sheehan — Anaesthesia and Critical Care Consultant (Inpatient Pain Team)

Dr Lorraine Nanke — Principal Clinical Psychologist

Despoina Karargyri  — Principal Physiotherapist (Advanced Practitioner)

Victoria Salomonsen — Pain Clinical Specialist Physiotherapist

Flora Hess — Lead Clinical Nurse Specialist

Tanya Carr — Clinical Nurse Specialist 

Grace Ring — Clinical Nurse Specialist

Amy Heptonstall — Clinical Nurse Specialist

Sarah Crossley — Clinical Nurse Specialist

Hannah Youell — Pain Nurse 

Avril Etherington — Medical Secretary

Natalie Brotherton — Medical Secretary

In July 2020, The International Association for the Study of Pain (IASP) revised the definition of Pain as follows:

"An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” which is expanded upon with further description.

• Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

Often the cause of pain is obvious, a broken leg, or a bruise. But there are times when the source of pain is unseen, for example a slipped disc. Occasionally it is very difficult to find the exact cause of a person’s pain.

Acute pain is the body's normal response to tissue damage, it is short term, usually lasting less than 3 months.

Many acute pains are like an alarm telling us something is wrong. For example the pain of a broken leg will make us rest the leg until it heals. Here the pain is helping.

Persistent or Chronic Pain is pain that has continued beyond 3 months, it often serves no physiological purpose and is influenced not only by tissue injury but by a number of emotional, social and cognitive variables.

Persistent pain often serves no useful purpose. The messages from the warning system linked to long-term conditions like arthritis or back pain get confused and the brain cannot understand the signals properly. Over time, it may affect what we can do, our ability to work, our sleep patterns. It can have a strong negative effect on our family and friends too.

Most people with long-term pain find it hard to accept that there is no cure for the pain. Living with long-term pain can involve a journey through denial, anger, resentment and sadness until life finally becomes more manageable and more worthwhile. However, it may well be a life that is different from the one you lived before your pain started.

There are many ways that you can help yourself to live a fulfilling life and managing persistent pain requires a toolkit that you can pick from depending on how your pain is on a particular day. Some of these are described below:

Exercise and being active. For many people with persistent pain, the thought of exercise fills them with dread. Previous experience of movement will often have been painful and associated with the fear of causing damage. With the support of physiotherapist you can learn safe and effective exercises. Becoming less active can lead to stiff joints, increased weight, poor fitness, weak muscles, and shortness of breath, plus in the long term more pain and other health problems. Exercise is vital to help deal with long-term pain and live a meaningful life, if can be difficult to know where to start. It pays to start gently and build up slowly and find an activity that you enjoy so that it seems like less of a chore. Building the exercise into your routine or joining forces with friends or family can make you more likely to maintain the activity. Further advice can be found in our resources section.

TENS Transcutaneous electrical nerve stimulation (TENS) aims to block, or partially block pain signals as they pass through the spinal cord on the way to the brain. It is a similar although more reliable way of reducing pain by “rubbing it better”

Acupuncture may be available in some GP surgeries, NHS pain clinics and physiotherapy departments as well as from private practitioners. The effect is very variable between patients and the benefits are often short term.

Drugs can include standard, stronger, combination and non-standard medications.

Most people expect to be given “pain killers” as their treatment, this however can lead to disappointment if this doesn’t remove the pain either in the short or long term. Although pain medications can have their place in the pain management toolkit, for persistent pain which can arise through different mechanisms, individual medications might not work effectively and only 1 in 3 people with chronic pain respond to pain medicines. Opioids (such as morphine, oxycodone, fentanyl and tramadol) have an important role in treating acute or short-term pain, and pain at the end of life. However, there is little evidence that they help long-term pain. Patients can develop a tolerance to medications which leads to using larger doses to get the same effect. This is particularly true for opioids when used for chronic pain, the correct dose of pain medication is the minimum dose to provide the maximum effect and for the shortest time possible. Which will allow you to stay active and maintain your quality of life. The use of pain medications depends on the balance of benefits versus the draw backs. All pain relief can potentially have side effects, high doses of opioids particularly can cause:

•              Breathing problems. Opioids can slow down your breathing to a dangerous level and possibly lead to death. This is one reason why taking large doses is dangerous.

•              Opioid-induced hyperalgesia. This is when high doses of opioids might make your pain worse instead of better. Something minor, like a pinch, could feel much worse and affect a wider area than it would if you were not on opioids.

•              Tolerance. This is when you need higher and higher doses to get the same effect. It might explain why opioids are often not effective in the long term.

•              Dependence. You might rely on opioids within 1 to 3 months of starting to use them. This might be a physical reliance or a psychological reliance.

•              Immune suppression. Taking opioids can make it harder for your body to fight infections and heal wounds.

•              Impaired hormone function. Taking opioids can affect your sex hormones. This can cause sexual problems, reduced sex drive, and infertility.

•              Osteoporosis. Taking opioids can make your bones thinner over time, and increase the risk of breaks in the bones.

•              Depression and anxiety.

•              Increased risk of heart disease and an abnormal heart rhythm.

•              Blood sugar (glucose) problems. Taking opioids can cause glucose intolerance (when you have high blood glucose levels) and increase your risk of diabetes.

•              Changes in the brain. If you use high-dose opioids in the long term, there might be changes in the brain. This can affect your memory and concentration.

•              Headaches or migraines.

For more information regarding opioid awareness please click here for the Faculty of Pain Medicine resources 

Interventions such as Injections can be provided if suitable to reduce symptoms and improve activity levels.

Non-pharmacological and self-management strategies can include:

Pain diaries to help track how you are feeling plus the effects of any medications.

Setting goals and managing activity; it can be important to pace yourself and prioritise activities. 

Managing sleep is important as sleep and pain can impact each other, more details can be found in our resources section.

Relaxation and mindfulness techniques, practising these techniques regularly can help to reduce tension, stress and, in some cases, the pain too. It is a useful skill to have, but takes time to develop. Learning to relax can help you sleep, get good quality rest and cope well with stressful and difficult situations

Keeping active, Socialising, and Hobbies- Getting involved in activities or hobbies that take the focus of attention away from your pain can be helpful.

 

As a team, we pride ourselves on offering patient centred care to help people live a fulfilling life despite their pain.

It may not be possible to get rid of your pain so we offer a holistic approach to help you manage your persistent pain.

We aim to help you reduce your symptoms, if possible, and improve your quality of life. Our treatment focuses on your physical and mental health.

Our ultimate goal is to support you to live a fulfilling life despite your pain.

The inpatient pain service is made up of Clinical Nurse Specialists and Consultant Anaesthetists, many of whom work across the outpatient clinics as well.

We aim to provide a high standard of patient care throughout your inpatient stay.

We cover acute and post-operative pain, as well as supporting patients who have acute pain in addition to ongoing persistent pain problems.

As part of the wider multi-disciplinary team, we are involved in the care of all patients who receive PCA (Patient Controlled Analgesia) or epidurals.

We are also able to provide non-pharmacological interventions such as TENS (Transcutaneous Electrical Nerve Stimulation) in the ward area.

We understand that travelling with pain can be difficult that's why we offer telephone appointments as standard; however, face-to-face appointments can be facilitated at your request, or if felt clinically indicated.

You are welcome to bring someone with you to your appointment if you wish. 

Initial Appointment

This will be held with one of the pain consultants / advanced physiotherapist practitioner / clinical nurse specialist. They will complete a full holistic pain assessment-discussing your pain and pain medical history. They will then be able to offer advice on a variety of treatment options available. The clinician will aim to provide;

• Education and support 
• Optimisation of pain medications
• Consideration of investigations and injections
• Advice for self management strategies
• Advice for non-pharmacological pain management techniques, such as TENs therapy

Following this appointment you may be referred to a different member of the team for ongoing care. A letter will be sent to yourself and GP with the suggested management plan.

Follow-Up Appointment

You may be offered a follow-up appointment with any member of our multi-disciplinary team, depending on your individual needs. You may also be offered an appointment within our specialist physiotherapist services (including acupuncture and fibromyalgia group), joint psychology and physiotherapy clinic, or recommended to attend one of our pain management programmes.

Injection Appointment

Evidence based injection interventions could be offered, which can reduce severity of pain and support physiotherapy rehabilitation. You will have a follow up appointment in a nurse led post injection clinic.

When attending you appointment please make sure you are accompanied by a responsible adult to ensure you reach home safely afterwards.

If you are taking medications to prevent blood clotting such as Warfarin or Clopidigrel  please make your team aware. National guidance recommend holding these medications prior to some higher risk injections, below is a table with some of the common anti-coagulants and the injections which require them to be held. They can usually be restarted the next day. If you are unsure please contact us.

Length of time to hold anticoagulation prior to injections under pain management

Drug	Acceptable time to hold drug for prior to injection	Examples of injections
Aspirin	No additional precautions	Nerve root block Facet joint injections Sciatic nerve block Coeliac plexus block Lumbar plexus block Deep cervical plexus Single shot epidural
Clopidogrel	7 days
Warfarin	5-7 days
Apixaban	24-48 hours

Please find further information about injections here: Faculty of Pain Management Patient Info

Please let us know if you are unable to attend your appointment, it allows us to offer this slot to another patient.

We currently offer three pain management programmes in the Pain Management Service. We would encourage you to talk to a member of the team if you are interested in attending one of these programmes.

Explain Pain

This workshop offers an introduction to understanding pain, the typical responses to pain in our mind and body, and suggests different resources to help support you with pain management. The workshop is currently in an online format that contains a presentation from staff, and also includes time for questions and answers at the end. 

Introduction to Mindfulness for Pain using Acceptance and Commitment Therapy (IMPACT)

This 7-week pain management programme aims to help you live a fulfilling life with pain (2 hours per week). The course focuses on strategies which include:

• Finding flexible and creative ways of living well with your pain
• Letting go of old habits which no longer work for you
• Enhancing mindful awareness of your body
• Gently building the five core aspects of physical fitness

This group is helpful for people who would like to consider what works well for them and are curious to explore ways of changing what doesn’t.

Mindfulness Based Stress Reduction for Pain (MBSR course)

This course offers an 8-week structured, educational teaching of mindfulness meditation in a group setting. Mindfulness is a method for managing stress and long term pain. To support your learning, home practice is required for one hour per day throughout the duration of the course.

Typically, groups are run virtually on Friday afternoons between 14.30-16.30.

How do I get referred to the outpatient pain team?

The usual route for referral is via your GP if your pain management requires more specialist input.

 

How long are the wait times for appointments?

Unfortunately the waiting list for all appointments have increased and you can expect to wait 6 months or more to be seen. If you are concerned that you haven't heard anything about an appointment then please get in touch. If you are struggling with your pain then see our useful resources page for helpful links that can provide you with support and advice.

 

I have been referred to the pain team but haven’t heard anything yet?

Our waiting lists are currently very long for appointments but if you are expecting to have been referred to the pain team and haven't heard anything after several months then please contact us and we can check for you.

 

Where is my appointment held?

The majority of our appointments are held via telephone, but if you prefer you can request a face to face appointment. This will mostly be located in Castle Outpatients at the Royal Surrey Hospital, however the location of your appointment will be detailed on your letter. For injection appointments, these will generally be in the Day Surgery Unit.

 

How often can I have injections?

You will have a follow up appointment to assess how successful your treatment has been and if further intervention is suitable. Repeat injections will be at a minimum 6 months later. The aim of injections is to improve symptoms and enable improved engagement in physiotherapy and exercise.

 

I’m struggling between my appointments, what can I do?

You can contact us to see if there is anything else we can offer. For additional help our useful resources page has links to provide support for self management techniques. You can also contact your GP for additional advice