A week in my... Pain Clinic: Dr John Browne is a consultant in pain medicine in Cork

I trained in anaesthesia because I originally wanted to do intensive-care medicine. Along the line, I got drawn into pain medicine, which started as a branch of anaesthesia 30 or 40 years ago. Of late, there’s been a push to have pain medicine as a standalone speciality and that’s how it’s seen in Ireland.

In my training in anaesthesia, I had to spend a certain amount of time doing chronic pain management. At the Mater hospital, I first treated a woman who was in cancer pain. For a very small intervention, she got fantastic results. That woman subsequently died, but she was very happy to know that she was going to die pain-free.

Pain medicine is completely results-driven. If someone comes into me in pain, they can be treated with drugs. Most of the patients I see are given injections, from epidurals to nerve blocks to joint injections. We also incorporate other specialities such as physiotherapy, psychology and occupational therapy.

I use a holistic approach in some patients when the drugs and injections don’t work as well as they should.

There’s one group of patients who need major interventions such as spinal cord stimulation and a specialised pump. This intrathecal pump is put under the skin and it pumps drugs into the spine. Personally, I reserve that for severe cancer pain.

It’s also used for the spasticity associated with certain neurological conditions such as MS.

Pain with cancer is relatively common. The majority of cancer patients can be treated with relatively simple analgesia, going up to morphine. Usually, the drug treatment is in association with treatment such as radiotherapy and chemotherapy. But for about 10 per cent of cancer-pain sufferers, interventions such as nerve blocks and morphine pumps are needed.

Wear and tear

The majority of cases I deal with are muscular-skeletal conditions such as back pain and neck pain. Most of these pains are from chronic wear and tear, or acute problems such as acute disc prolapse.

Then there are a certain amount of conditions that are inherently painful, such as damage to a nerve and the pain associated with shingles.

About 25-30 per cent of my work is with cancer patients, and that’s probably the most satisfying work I do. Funnily enough, these patients never express a wish to die although they might be resigned to the fact that they’re going to. You’ll get other patients who say life is not worth living.

Given that you don’t get that with cancer patients, you wonder if these other patients have something that isn’t psychologically right. So you have to look a little bit deeper.

If you can relieve the pain of people who have advanced cancer, there’s a great sense of achievement. It’s highly unusual to have a situation whereby I can’t at least reduce their pain.

There’s a strong overlap between chronic pain and mood. If you have severe pain, your mood won’t be the best. So it’s not surprising that some of my patients become depressed. I’m afraid it also works the other way.

A low mood can precipitate pain. It can be difficult to work out which came first; the pain that’s causing the depression or the depression that’s causing the pain. We’re not very well served in Cork in this regard as we don’t have a dedicated pain psychologist.

It’s something every pain service should have, and we’re hoping the situation will be rectified.

I work at the South Infirmary Victoria University Hospital (SIVUH), Cork University Hospital (CUH) and Marymount University Hospital and Hospice in Cork.

There have been improvements in Cork. We now have a dedicated pain medicine unit in the SIVUH. It’s the first of its kind in Ireland where all pain medicine activity is housed under one roof.

The department includes outpatient facilities and facilities for X-ray-guided and non-X-ray-guided procedures, as well as a large recovery area.

Procedures and techniques

I perform injections in the SIVUH all day Monday: typically between 15 and 20 X-ray-guided procedures and approximately five to 10 non-X-ray-guided procedures. Tuesday mornings begin at CUH with a 7.30am educational meeting directed at anaesthetic trainees. This is followed by an outpatient session in the SIVUH.

In the afternoon, I work in Marymount. We have recently opened a procedure room there with X-ray facilities and a three-bed recovery unit, which allows us to perform interventional techniques onsite for cancer pain. This is the first unit of its kind in a hospice setting in the UK or Ireland.

Wednesday is spent all day at SIVUH with an outpatient clinic at 3pm. After that, I try to catch up on administrative work. Thursday morning is spent carrying out injections in the SIVUH and in the afternoon, I review urgent cases there or teach.

Friday mornings begin at 8am with a multidisciplinary team meeting in the back and neck pain unit at CUH. I attend this with neurosurgeons, orthopaedic back surgeons and radiologists. That’s followed by a multidisciplinary meeting, focusing on difficult cases of cancer pain. Then I do a ward round in CUH reviewing patients who have acute pain and chronic pain.I also run a private clinic in the Elysian building. When that’s over, I return to CUH to review any other patients before the weekend. Friday afternoons are the time that intrathecal pumps are inserted, when required. This is done in association with neurosurgery.

Continuing education

Pain medicine can change rapidly so there’s a legal obligation to keep up my skills by involving myself in continuing education and professional development. I have to attend and give a certain amount of talks every week.

I was in Switzerland recently at a dedicated course for ultrasound-guided techniques for pain management. I have to go to meetings abroad about three times a year.

I trained at UCD. After my intern year, I went straight into anaesthesia and spent a few years in Dublin doing general anaesthesia including intensive-care and pain medicine. I decided to sub-specialise in pain medicine.

I went to King’s College in London, did a fellowship there and was a consultant there for four years before coming to Cork.

I work anything from 50-60 hours a week. My job involves dealing with stressed people. The biggest stress in my job – and it’s possibly true for all consultants – is trying to get the work done. Having enough resources takes away a lot of the stress. Generally speaking, it’s quite rewarding work.

A lot of the patients I see have been to different specialists without getting results. My emphasis is on relieving pain but not necessarily curing a patient. I also do some voluntary work with the Cork City soccer team when they need MRIs or injections.