Guidance Chronic Pain Management

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					                                                                                                        Chapter 7
                                                                              Chronic pain services, revised 2009

   Guidance on the provision of anaesthesia services for
   Chronic Pain Management
      When considering the provision of anaesthesia, the Royal College of Anaesthetists recommends that
        the following areas should be addressed. The goal is to ensure a comprehensive, quality service
       dedicated to the care of patients and to the education and professional development of staff. The
             provision of adequate funding to provide the services described should be considered.

    ■	 Chronic	pain	is	a	common	and	                              ◆	 appropriate	accommodation,	facilities	
       distressing	condition.	Chronic	pain	                           and	equipment
       services	deal	with	pain	associated	with	                   ◆	 formal	links	between	hospitals	on	
       all	non-cancer	causes	of	pain.		Most	                          a	regional	basis	so	that	appropriate	
       also	treat	cancer-related	pain,	often	in	                      treatments	can	be	offered	to	all	
       partnership	with	palliative	care	services.	                    patients	who	need	them
       Multidisciplinary	management	of	
                                                                  ◆	 provision	for	appropriate	patients	of	
       patients	with	chronic	pain	alleviates	pain	
       and	suffering,	aids	functional	restoration	                    pain	management	programmes	(PMPs)	
       and	reduces	the	socio-economic	burden	                         that	promote	restoration	of	physical	
       of	pain	for	the	individual,	healthcare	                        and	psychological	function,	encourage	
       systems	and	the	community.1–3		                                self	care	and	decrease	inappropriate	
                                                                      use	of	healthcare	resources
    ■	 Effective	and	safe	management	of	
                                                                  ◆	 a	robust	24/7	on-call	system	with	
       chronic	pain	requires:4–8
                                                                      support	from	other	disciplines	(e.g.	
       ◆	 ready	access	to	a	local,	first	class	                       spinal/neurosurgery,	radiology,	
          chronic	pain	service                                        microbiology)	if	neuromodulation	
       ◆	 a	seamless	service	between	primary	                         techniques	are	utilised
          and	secondary	care
                                                                  ◆	 funding	to	enable	the	service	to	
       ◆	 specialist	chronic	pain	management	                         achieve	required	targets	and	quality	
          services	in	each	region	for	patients	                       standards
          with	complex	pain	problems
                                                                  ◆	 continuing	professional	development	
       ◆	 established	links	between	acute	and	
                                                                      of	all	staff
          chronic	pain	management	services	
                                                                  ◆	 equity	of	access	and	service	provision	
          within	each	hospital	to	enable	patients	
          with	acute	pain	that	is	not	resolving	to	                   for	all	patients.
          be	managed	appropriately	as	an	out-                ■	 Consultant	anaesthetists	are	responsible	
          patient                                               for	the	vast	majority	of	chronic	pain	
       ◆	 co-operation	between	chronic	pain	                    clinics	in	the	UK.		Some	are	full-time	
          management	and	palliative	care	services	              pain	medicine	consultants;	many	
          within	hospitals	and	the	community                    have	sessions	in	anaesthesia	or	other	
       ◆	 provision	of	appropriate	time	for	direct	             anaesthesia-related	areas.		The	job	plans	
          clinical	care	for	consultants	in	pain	                of	these	consultants	should	reflect	the	
          medicine,	allied	health	professionals,	               commitments	required	to	run	a	safe	and	
          managers	and	support	staff                            effective	service.	

                             The Royal College of Anaesthetists   ■    Guidelines for the Provision of Anaesthetic Services   ■
Chapter 7
Chronic pain services, revised 2009

         ■	 Specific	arrangements	should	be	made	                     ■	 Activities	of	the	clinic	should	be	
            for	the	treatment	of	the	vulnerable	                         included	within	the	institution’s	clinical	
            (e.g.	children,	physical	or	intellectual	                    governance,	risk	assessment	and	audit	
            impairment,	non-English	speakers).
         ■	 There	should	be	an	active,	ongoing	
                                                                      ■	 There	should	be	a	culture	that	
            programme	of	education	in	the	
            management	and	nature	of	chronic	pain	                       promotes	an	evidence-based	approach	
            for	all	health	professionals	who	care	for	                   to	management	that	is	supportive	to	
            patients	with	chronic	pain.		                                research	and	service	evaluation.	

Introduction: The importance of chronic                               ■	    The	speciality	of	pain	medicine	has	been	at	the	
                                                                            forefront	of	the	rigorous	pursuit	of	evidence	of	
pain management services                                                    effectiveness	of	treatments	by	the	use	of	systematic	
■	    Chronic	pain	is	defined	as	pain	that	persists	beyond	                 reviews2,3,13	and	randomised	controlled	trials.	
      the	expected	time	of	healing	following	injury	or	
                                                                      ■	    Complementary	techniques	(e.g.	acupuncture)	
      disease.		Epidemiological	studies	show	that	up	to	1	
                                                                            should	be	available	when	their	use	is	supported	by	
      in	7	people	in	the	UK	population	have	chronic	pain	
      caused	by	a	wide	range	of	conditions.3,9		The	2008	
      Report	of	the	Chief	Medical	Officer	for	England	                ■	    The	objectives	of	a	chronic	pain	management	
      emphasised	the	importance	of	chronic	pain	                            service	include:
      services.10                                                           ◆	   assessment,	investigation	and	management	of	
■	    Neuropathic	pain	is	common	and	has	a	significant	
      impact	on	quality	of	life.11		As	the	population	                      ◆	   management	of	distress	associated	with	
                                                                                 chronic	pain
      ages,	chronic	pain	becomes	a	more	significant	
      problem	as	pain	prevalence	increases	with	ageing.		                   ◆	   reduction	of	disability	and	restoration	of	
      Unrelieved	chronic	pain	is	a	major	problem	for	                            function
      individual	patients	and	a	massive	socio-economic	                     ◆	   optimisation	of	medication	that	may	include	
      burden	for	the	health	service	and	the	community.12		                       helping	patients	to	withdraw	from	long-term	
                                                                                 medication	when	appropriate	(e.g.	opioids)
■	    Patients	often	have	complex	multidimensional	                         ◆	   reducing	inappropriate	use	of	healthcare	
      problems	that	require	multidisciplinary	                                   resources
      management.		This	usually	involves	doctors	with	                      ◆	   attention	to	social,	family	and	occupational	
      appropriate	training	and	competencies,	specialist	                         issues
      nurses,	clinical	psychologists,	pharmacists,	
                                                                            ◆	   education	and	provision	of	information	about	
      physiotherapists	and	occupational	therapists.	                             chronic	pain	and	its	management	for	patients,	
■	    The	interface	between	primary	care	and	hospital	                           carers	and	the	community
      chronic	pain	services	is	particularly	important	as	                   ◆	   education	about	pain	management	for	non-
      many	patients	are	referred	from	the	community.		                           specialist	nursing,	medical	and	allied	health	
      However,	many	attending	other	hospital	services	                           care	professional	staff,	as	well	as	managers	
                                                                                 and	commissioners
      will	benefit	from	referral	to	the	pain	clinic	
      (e.g.	surgery,	orthopaedics,	general	medicine,	                       ◆	   liaison	with	primary	and	secondary	teams	(e.g.	
      rheumatology,	gastroenterology,	neurology,	elderly	                        primary	care,	palliative	care,	rehabilitation,	
      medicine,	rehabilitation	medicine,	occupational	                           addiction	medicine,	liaison	psychiatry)
      health,	oncology,	palliative	medicine,	psychiatry,	                   ◆	   achieving	national	standards	and	targets
      addiction	medicine,	paediatrics).                                     ◆	   audit	and	evaluation	of	pain	services	and	the	
                                                                                 needs/satisfaction	of	patients
■	    There	is	evidence	that	multidisciplinary	pain	
                                                                            ◆	   research	into	chronic	pain.
      management	is	of	benefit	in	improving	the	quality	
      of	life	of	patients	and	in	lessening	the	socio-                 ■	    Widespread	provision	of	basic	core	pain	
      economic	burden	of	unrelieved	chronic	pain.		                         management	services	and	the	selective	provision	

■    The Royal College of Anaesthetists   ■   Guidelines for the Provision of Anaesthetic Services
                                                                                                              Chapter 7
                                                                                    Chronic pain services, revised 2009

     of	more	advanced	specialist	services	are	necessary	                 ■	   Occupational	therapists	can	help	patients	
     to	address	the	problem	of	chronic	pain.		Pain	                           regain	normal	function	and	assist	in	strategies	
     management	services	are	required	to	provide	both	                        for	return	to	work.
     hospital	and	community	care	to	patients	with	a	              1.3		 The	mix	and	number	of	allied	health	professionals	
     wide	range	of	different	conditions.		                               in	a	service	should	reflect	the	caseload,	types	of	
                                                                         patients	and	range	of	treatments	utilised.

Levels of provision of service                                    1.4	 Medical	and	nursing	staff	should	be	available	for	
                                                                         the	management	of	in-patients	with	chronic	pain.		
1 Staffing                                                               In-patients	cared	for	by	a	consultant	from	another	
1.1	 The	delivery	of	high	quality,	multidisciplinary	pain	               specialty	may	receive	a	considerable	amount	of	
     services	requires	the	allocation	of	fixed	sessions	for	             care	and	treatment	from	the	pain	management	
     all	involved	healthcare	personnel	rather	than	an	ad                 team.		This	work	should	be	formally	recorded	and	
     hoc	or	informal	approach.                                           recognised	so	that	appropriate	funding	for	this	
                                                                         activity	can	be	allocated.		Some	pain	medicine	
1.2	 A	chronic	pain	management	service	should	have:                      consultants	give	support	to	other	secondary	care	
                                                                         teams	(e.g.	palliative	medicine,	spinal	surgery,	
     ■	   Specialists	in	pain	medicine	–	every	specialist	               rehabilitation).		There	should	be	appropriate	
          chronic	pain	service	must	include	consultants	                 recognition	for	this	work	within	their	job	plan.
          who	have	been	trained	and	have	appropriate	
          competencies	in	pain	medicine.		The	majority	           1.5		 Pain	management	is	a	consultant-based	service	in	
          of	services	are	led	by	doctors	whose	primary	                  most	hospitals;	individual	job	plans	should	reflect	
          qualification	is	in	anaesthesia;	many	will	                    this	as	it	has	implications	for	the	provision	of	cover	
          be	Fellows	of	the	Faculty	of	Pain	Medicine,	                   and	workload.	
          Royal	College	of	Anaesthetists	(FFPMRCA).		
          Anaesthesia	is	the	only	specialty	that	                 1.6	 Any	pain	service	that	provides	neuromodulation	
          incorporates	advanced	pain	management	                         must	have	a	robust	24/7	on-call	system	with	support	
          within	its	training	programme.	Doctors	play	a	                 from	other	disciplines	(e.g.	spinal/neurosurgery,	
          central	role	in	the	assessment	of	pain	and	the	                radiology,	microbiology).
          formulation	of	management	plans	for	patients.	   	
          Senior	doctors	within	the	team	also	have	               1.7	 Working	in	a	chronic	pain	service	entails	a	
          responsibility	for	the	education	of	student	and	               considerable	amount	of	correspondence,	dictation,	
          postgraduate	medical	practitioners.		Staff	and	                preparation	of	reports,	telephone	calls,	case	
          associate	specialist	doctors	with	appropriate	                 conferences	and	other	clinical	administration.		Due	
          experience	and	competencies	are	well	placed	                   regard	should	be	taken	of	this	workload	within	
          to	provide	excellent	contributions	to	the	pain	                consultant	job	plans.		The	working	arrangements	
          service	in	the	clinical	care	of	patients	and	in	               for	pain	medicine	specialists	should	resemble	
          education	of	staff.                                            those	of	consultant	physicians	in	terms	of	job	
     ■	   Nurse	specialists	and	nurse	consultants	play	a	                plan,	support	services	(especially	secretarial)	and	
          key	role	in	pain	management.		They	may	see	                    accommodation.
          out-patients	independently	for	assessment	              1.8	 Special	problems	exist	for	consultant	anaesthetists	
          or	follow-up,	assess	patients	on	wards,	
                                                                         who	divide	their	time	between	pain	services	
          supervise	medication,	provide	transcutaneous	
                                                                         and	anaesthesia.		Their	job	plans	should	take	
          electrical	nerve	stimulators	(TENS),	deliver	
                                                                         into	account	the	additional	demands	of	this	
          complementary	therapies,	be	involved	in	
                                                                         combination.		The	individual	consultant	and	the	
          PMPs	or	supervise	neuromodulation.
                                                                         clinical	director	should	devise	an	appropriate	
     ■	   Clinical	psychologists	with	special	training	in	               allocation	of	sessions	between	operating	theatre-
          pain	management	are	an	essential	component	                    based	anaesthesia	and	pain	medicine	to	ensure	
          of	all	chronic	pain	management	services.		They	                maintenance	of	competency	in	all	spheres	of	the	
          may	offer	individual	psychological	approaches	                 consultant’s	clinical	activity.		CPD	is	required	in	
          and	participate	in	PMPs.
                                                                         both	clinical	areas.
     ■	   Physiotherapists	make	an	important	
          contribution	to	the	assessment	and	                     1.9	 It	is	recommended	that	there	should	be	no	single-
          management	of	patients	with	chronic	pain.	                     handed	practitioners	providing	a	chronic	pain	
          They	deliver	physical	therapies	(often	                        service.		Where	this	is	unavoidable,	appropriate	
          including	acupuncture)	and	play	an	important	                  arrangements	must	be	made	for	networking,	
          role	in	functional	restoration	programmes.                     external	peer-support	and	review.

                                   The Royal College of Anaesthetists   ■ Guidelines for the Provision of Anaesthetic Services   ■
Chapter 7
Chronic pain services, revised 2009

2 Equipment, support services and facilities                         2.8	 There	should	be	provision	of	individual	and	
                                                                           group	PMPs	including	cognitive	behavioural	
Equipment                                                                  therapy.12		PMPs	may	vary	in	length	and	intensity	
2.1	 All	pain	services	that	use	nerve	blocks	and/or	                       depending	on	the	patient’s	needs.		Standards	
     neuromodulation	must	have	access	to	fluoroscopy	                      for	physiotherapists	and	occupational	therapists	
     and	the	ability	to	store	and	save	images.	The	                        working	in	PMPs	are	available.14		Accommodation	is	
     management	of	chronic	pain	may	also	involve	the	                      required	for	residential	programmes.
     use	of	specialist	equipment	(e.g.	radiofrequency	
     lesioning,	disc	decompression).		Centres	that	                  2.9	 Some	patients	may	need	overnight	admission	to	a	
     provide	specialist	services	may	require	specialist	                   hospital	under	the	care	of	the	pain	management	
     equipment	(e.g.	neuromodulation,	cordotomy).		                        service,	especially	if	the	patient	has	undergone	
     There	should	be	maintenance	contracts	and	a	                          specialised	procedures.		Access	to	post-anaesthesia	
     rolling	replacement	programme	for	equipment.                          care	units	should	be	available	for	patients	following	
                                                                           interventions.		Appropriate	arrangements	are	
Support services                                                           needed	for	adequate	medical	cover	on	a	24/7	basis	
2.2	 Pharmacy.		Local	guidelines	for	prescribing	and	                      for	any	patients	admitted	to	hospital	under	the	care	
     information	sheets	for	patients	about	medications	                    of	the	pain	management	team.
     and	their	uses	are	helpful.		Centres	that	provide	
     intrathecal	drug	delivery	need	the	support	of	the	              3 Areas of special requirement
     sterile	preparation	unit.		The	cost	of	prescribing	
     for	continuing	care	should	have	prior	agreement	                Pain management services for patients with cancer
     with	commissioners.	Some	drugs	cannot	be	                       3.1	 The	provision	of	pain	management	for	patients	
     prescribed	in	primary	care	(e.g.	ketamine);	special	                  with	cancer	requires	close	collaboration	between	
     arrangements	are	needed	for	this.	                                    palliative	care,	primary	care	and	pain	services	for	
                                                                           both	in-patients	and	out-patients.
2.3	 Information technology.		The	pain	service	should	
     be	provided	with	up-to-date	electronic	systems	                 3.2	 About	10%	of	adults	with	cancer-related	pain	
     for	maintaining	patient	bookings,	medical	records,	                   may	benefit	from	specialised	pain	management;	
     outcome	information	and	other	audit	data.                             the	proportion	of	children	who	may	be	helped	is	
                                                                           not	known.		The	demands	on	pain	management	
Facilities                                                                 services	vary	depending	on	the	size	and	expertise	
2.4	 Chronic	pain	services	are	delivered	in	the	                           of	local	palliative	care	and	oncology	services.
     following	environments:
                                                                     3.3	 Pain	medicine	specialists	use	a	range	of	specialist	
     ■	 out-patient	clinics	in	a	hospital	setting	or	in	a	
        primary	care	facility	(outreach	clinics)                           knowledge	and	skills	for	cancer	pain	management	
                                                                           that	may	include	interventions	(e.g.	neural	
     ■	 in-patient	wards
                                                                           blockade,	neuromodulation).		Modern	palliative	
     ■	 operating	theatres	or	other	treatment	facilities
                                                                           care	means	that	pharmacotherapy	and	simple	
     ■	 PMPs	–	in-patient	or	out-patient                                   physical	therapies	have	often	been	optimised	
     ■	 oncology	and	palliative	care	units	within	the	                     before	referral	for	specialist	pain	management.
        hospital	or	on	external	sites.
                                                                     3.4	 Patients	with	cancer-related	pain	may	be	treated	
2.5	 Appropriate	out-patient	facilities	include	rooms	                     in	the	hospital	as	in-patients	or	out-patients,	in	the	
     for	consultation,	examination	and	treatment	that	                     palliative	care	unit	or	at	home.
     are	provided	on	a	regular	basis	with	access	for	
     wheelchairs	and	disabled	patients.                              3.5	 Consultants	in	pain	medicine	who	provide	
                                                                           specialist	advice	and	services	to	palliative	care	
2.6	 There	should	be	designated	operating	theatre	                         units	require	appropriate	recognition	of	this	
     sessions	supported	by	fluoroscopy/radiographers	                      commitment	in	their	job	plans.
     for	performance	of	diagnostic	and	therapeutic	
     procedures.                                                     Other areas of special requirements
2.7	 Appropriate	office	accommodation	should	                        3.6	 Pain	management	services	should	make	
     be	provided	for	all	staff	in	a	non-clinical	area	                     special	provision	for	vulnerable	and	potentially	
     that	provides	security	for	patient	records	and	                       disadvantaged	groups	(e.g.	children,	elderly,	
     information.		The	service	must	be	compliant	                          learning	difficulties,	physical	impairment,	diverse	
     with	data	protection	legislation	and	patient	                         ethnic	backgrounds,	non-English	speakers).		
     confidentiality.                                                      Particular	difficulties	may	be	encountered	with

■   The Royal College of Anaesthetists   ■   Guidelines for the Provision of Anaesthetic Services
                                                                                                            Chapter 7
                                                                                  Chronic pain services, revised 2009

	    those	who	habitually	use	drugs,	are	prisoners	or	                  under	the	leadership	of	doctors	who	have	achieved	
     are	survivors	of	torture.                                          the	competencies	and	experience	in	advanced	pain	
                                                                        medicine	as	defined	by	the	FPMRCA.15
3.7	 There	is	a	need	for	specialised	multidisciplinary	
     clinics	for	certain	conditions	or	patient	groups	(e.g.	     6.3	 Chronic	pain	services	should	have	designated	
     sickle	cell	disease,	chronic	pelvic	pain).                         management	support;	managers,	administrative,	
                                                                        secretarial,	clerical	and	IT	support	staff	should	be	
4 Training and education                                                available	to	underpin	in-patient	and	out-patient	
4.1	 All	those	involved	in	chronic	pain	management	                     work	in	the	same	proportion	that	they	are	available	
     should	be	trained	adequately	to	ensure	that	they	                  for	other	medically-based	specialties.		A	pain	
     achieve	the	competencies	needed	for	the	delivery	                  management	service	more	closely	resembles	a	
     of	a	safe	and	effective	service.			                                traditional	medical	service	rather	than	a	surgically-
                                                                        based	model	in	terms	of	volumes	and	complexity	of	
4.2	 There	should	be	an	ongoing	programme	                              case	mix.
     of	continuing	education	and	professional	
     development	for	all	staff	within	the	pain	                  6.4	 The	organisation	of	the	service	should	encourage	
     management	services.		Time	and	funding	should	be	                  close	co-operation	with	related	specialties	
     provided	for	these	activities.		                                   including,	if	appropriate,	joint	clinics	with	other	
                                                                        doctors	who	have	a	special	interest	in	specific	
4.3	 Training	in	the	management	of	pain	forms	an	                       patients	(e.g.	oncology,	palliative	care,	paediatrics,	
     integral	part	of	the	training	programme	for	                       psychiatry,	addiction	medicine,	gynaecology,	
     anaesthetists;	this	includes	provision	for	up	to	12	               rheumatology,	rehabilitation,	neurosurgery,	
     months	of	advanced	training	in	pain	medicine.		                    orthopaedics,	plastics,	spinal	surgery).		Useful	
     Rigorous	assessments	of	competency	in	pain	                        links	may	be	established	with	occupational	health	
     medicine	have	been	developed	by	the	FPMRCA.		
                                                                        specialists	and	employment	advisors.
     Regional	advisers	in	pain	medicine	have	been	
     appointed	by	the	FPMRCA	who	supervise	                      6.5	 The	organisation	of	clinics	should	take	account	of	
     the	provision	of	pain	medicine	training	and	                       the	fact	that	patients	with	complex	chronic	pain	
     assessment.		Anaesthetists	who	have	achieved	                      problems	require	thorough	assessment.		Therefore,	
     the	advanced	pain	medicine	competencies	can	                       the	initial	consultation	may	be	prolonged	and	clinic	
     apply	for	the	Fellowship	of	the	FPMRCA.		These	                    schedules	should	recognise	this.	In	this	regard,	
     competencies	are	essential	in	all	other	routes	to	the	             comparison	should	be	made	with	specialties	such	
     Fellowship	for	specialists	in	pain	medicine.                       as	psychiatry.

5 Research and audit                                             6.6	 There	should	be	agreed	referral	and	discharge	
                                                                        policies	with	established	lines	of	communication	
5.1	 There	should	be	regular	evaluation	and	audit	
                                                                        between	pain,	primary	care	and	relevant	secondary	
     of	outcomes	and	complications	of	treatment.		
                                                                        care	services.
     Whenever	appropriate,	audit	activities	should	be	
     integrated	with	those	of	related	departments	(e.g.	         6.7	 The	chronic	pain	service	should	be	responsive	
     anaesthesia,	orthopaedics,	palliative	medicine).                   to	the	needs	of	patients	and	primary	care	
                                                                        professionals.		Input	should	be	sought	from	
5.2	 There	should	be	a	culture	that	is	supportive	
                                                                        patients	and	patient	support	groups.
     of	research	into	chronic	pain,	especially	the	
     conduct	of	well	designed	clinical	trials,	including	
     multicentre	studies.	                                       7 Patient information
                                                                 7.1	 The	culture	and	practice	of	the	service	should	
6 Organisation and administration                                       embrace	the	fact	that	patients	must	be	able	to	
6.1	 Every	pain	management	service	should	be	clinically	                make	informed	decisions	about	their	management,	
     led	by	a	healthcare	professional	with	expertise	                   supported	by	verbal	and	written	information.		This	
     in	pain	management	who	is	responsible	for	co-                      should	cater	for	those	whose	native	language	is	
     ordinating	the	provision	of	a	safe	and	effective	                  not	English	or	those	who	have	communication	
     service	in	consultation	with	colleagues.                           difficulties.		

6.2	 Some	specialist	chronic	pain	management	can	take	           7.2	 Patients	should	be	made	aware	of	sources	of	
     place	in	primary	care;	it	is	important	that	this	work	             support	(e.g.	Expert	Patients	Programme,16	British	
     is	carried	out	by	appropriately	trained	staff.		Those	             Pain	Society	patient	resources,	condition-related	
     working	in	this	role	in	primary	care	should	be	                    self-help	groups).

                                  The Royal College of Anaesthetists   ■ Guidelines for the Provision of Anaesthetic Services   ■
Chapter 7
Chronic pain services, revised 2009

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   on	daily	life,	and	treatment.		Eur J Pain	2006;10(4):287–333.
2	 Guzmán	J	et	al.		Multidisciplinary	bio-psycho-social	rehabilitation	
   for	chronic	low	back	pain.		Cochrane Database Syst Rev	
   2002;(1):CD000963;	and	Database Syst Rev	2006;(2):CD000963.
3	 Morley	S,	Eccleston	C,	Williams	AC.		Systematic	review	and	meta-
   analysis	of	randomized	controlled	trials	of	cognitive	behavioural	
   therapy	for	chronic	pain	in	adults,	excluding	headache.		Pain	
4	 Services	for	patients	with	pain.		Clinical	Standards	Advisory	Group	
   (CSAG).		DH,	London	2000	(
5	 Pain	Management	Services:	Good	Practice.		RCoA and Pain Soc,	
   London	2003		(
6	 Desirable	criteria	for	pain	treatment	facilities.		International
   Association for the Study of Pain,	2006	(
7	 A	practical	guide	to	the	provision	of	chronic	pain	services	for	adults	
   in	primary	care.		British Pain Society,	2004	(www.britishpainsociety.
8	 Royal	College	of	Paediatrics	and	Child	Health.		Prevention	and	
   Control	of	Pain	in	Children:	A	Manual	for	Health	Care	Professionals.		
   BMJ Publishing Group,	London	1997.
9	 Maniadakis	N,	Gray	A.		The	economic	burden	of	back	pain	in	the	UK.	
   Pain	2000;84:95–103.
10	150	years	of	the	Annual	Report	of	the	Chief	Medical	Officer:	On	
   the	state	of	public	health.		DH,	London	2008	(
11	Jensen	MP,	Chodroff	MJ,	Dworkin	RH.		The	impact	of	neuropathic	
   pain	on	health-related	quality	of	life:	review	and	implications.		
   Neurology	2007;68(15):1178–1182.
12	Reyes-Gibby	CC	et	al.		Pain,	depression,	and	fatigue	in	community-
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   adults.		British Pain Society,	London	2007	(www.britishpainsociety.
15	Guidance	and	competencies	for	the	provision	of	services	using	
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   British Pain Society,	2008	(
16	Expert	Patients	Programme	Community	Interest	Company	(EPP	CIC)		

■   The Royal College of Anaesthetists          ■   Guidelines for the Provision of Anaesthetic Services