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Much has yet to be learned about chronic pain. For instance, doctors used to think that severed nerves could not transmit pain, and nerve cutting was typically prescribed to treat pain. Cut motor nerves cause paralysis, but sensory nerves are quite different. Sometimes damage to these nerves kills them and they stay dead, causing numbness. Sometimes sensory nerves grow back irregularly, or begin firing spontaneously, producing stabbing, shooting, and electrical sensations.The body’s pain system is plastic and is easily molded by pain to cause more pain. A metaphor that is often used to describe this process is that of an alarm continually being reset to be more and more sensitive. At first the alarm is triggered by an animal, then the breeze, and then, for no apparent reason, it begins ringing randomly or continuously. Additionally, pain nerves appear to recruit others in a “chronic pain wind-up,” and the entire central nervous system becomes involved, revving up and undergoing a kind of central sensitization. Research at University of California at San Francisco has shown that with prolonged injury, progressively deeper levels of pain cells are activated in the spinal cord.

The easiest way to think of pain in the nervous system is the idea of pain receptors and nerve cables dedicated to the transmission of pain signals, a hard-wired, line-labelled system. This view has always had obvious flaws. The return of pain after an initially successful cordotomy, and the phenomenon of phantom limb pain are two examples. In a hard-wired line-labelled system the pain should not recur after the cordotomy and patients should not feel pain in a limb as they did before the accident or amputation. Such flaws mean that the simple view of a ‘passive’ nervous system does not explain all that we see.For most acute pain the idea of specific cables whose transmission can be blocked is reinforced by the fact that you can perform herniorrhaphy (painlessly) by using local anaesthetic block or indeed a regional block. The receptors and cables of that region are temporarily disabled by the local anaesthetic, and no pain message gets through to the brain. In some chronic pain syndromes the inadequacy of this simple explanation is exposed. An example is phantom pain, because the painful foot or hand, the receptors and the cables, are no longer there. The concept of ‘pain memory’ in the spinal cord and brain has to be invoked.

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Surgical referrals to pain centres are usually requests to see a patient after surgery because of pain which has resisted conventional treatment and because further surgery is inappropriate. There are few objective signs which the doctor can use to judge the severity of reported pain. Pain is necessarily subjective. Many patients have no obvious (visible) handicap. The most important principle is that the patient and the doctor are best served if the doctor believes the patient’s report. Their problems may be ill-understood, even disbelieved, at work and at home. Chronic pain changes people, affecting their personal and working lives, and ultimately their personalities. Often such changes are reversible with successful treatment. Much time and energy is wasted on procedures designed to ‘catch the patient out’. Labelling patients as malingerers or the pain as psychogenic may be easier than admitting that there is no successful treatment. The differential diagnosis for many pain conditions includes both cancer and non-cancer causes.It is important to enquire specifically about the efficacy of each particular drug class. This information prevents the inept prescription of drugs which have failed previously, and may give important clues as to the kind of pain and its sensitivity to different classes of drug.It is also important to know the dose size, frequency, duration of prescription and the side-effect problems for each drug which has been prescribed. Dose-response relationships apply with analgesics, and therapeutic failure should not be presumed if the dosage was inadequate; a good example is the use of carbamazepine in trigeminal neuralgia. Is the patient taking drugs other than analgesics? Anticoagulation, for instance, is not only an (almost) absolute contraindication to pain management by injection procedures, but also interacts with some anti-inflammatory drugs.It is important to be sure whether nerve-blocks used previously were technically effective, before dismissing them as of no help to this patient. Equally other measures, such as transcutaneous nerve stimulation, may not have been used correctly, and may succeed if the patient receives proper instruction in their use