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Peter Reynolds

The life and times of Peter Reynolds

Archive for the ‘Science’ Category

Ignorant Doctors Bring Shame On Their Profession With Foolish Words on Cannabis

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What is it in these British Isles that has resulted in a medical establishment that uses prejudice, scaremongering and specious argument to object to the medical use of cannabis?

The astonishing ignorance that pervades the medical profession on this subject is demonstrated once again by a ridiculous letter in today’s Irish Times.  In a display of hubris, arrogance and plain stupidity, these people who assume they are due our respect, have conflated the issues of medical and recreational use in the most  destructive and confusing way.  These doctors are fundamentally failing in their duty to ‘do no harm’ both in undermining progress towards use of cannabis as medicine and in not providing this medicine to their patients immediately.

The sheer stupidity of the argument advanced by these doctors is breathtaking. They object to progress towards medical availablility by promoting the old chestnut of cannabis in recreational use causing psychosis. Their point is entirely irrelevant, it has nothing to do with medical use. It is no different from denying morphine to patients to control the most severe pain, following an operation, severe injury or at end-of-life, because some people use heroin as a recreational drug. It is a shameful, illogical, irrational and deeply cruel argument that shoud rest heavily on these doctors’ consciences.

And the psychosis argument is nothing but scaremongering anyway.  The evidence clearly shows that the risk of cannabis use correlating with a diagnosis of psychosis is one in 20,000.  As the National Geographic reports, the risk of being struck by lightning in one’s lifetime is merely one in 3,000.

The letter then descends into further evidence-free scaremongering, again totally irrelevant to the use of cannabis as medicine. The risks of cannabis are vastly and dishonestly exaggerated by doctors who clearly have no real idea what they are putting their names to.

It’s a disgrace that this letter has been composed and submitted to the Irish Times and the doctors’ new campaign group, the Cannabis Risk Alliance, is a fraud.

Shame on these quacks who have brought their profession into disrepute and stand in the way of providing proper medical care to their patients.  This must be the final nail in the coffin of unquestioning respect and belief in doctors.  They have shown beyond doubt that they do not deserve to be held in such high regard.

 

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Written by Peter Reynolds

May 21, 2019 at 1:02 pm

The Desperate Rearguard Action the British Medical Establishment is Fighting Against Cannabis

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Professor Finbar O’Callaghan

This Arrogant Man Must Face Tough Questions About his Stance on

Cannabis, his Financial Interests and his Breathtaking Hypocrisy.

Professor Finbar O’Callaghan introduced himself at the recent oral evidence session of the Health and Social Care Committee in these terms:

“My name is Professor Finbar O’Callaghan and I am here as president of the British Paediatric Neurology Association which is the association which represents all paediatric neurologists in the UK. I’m also a consultant paediatric neurologist at Great Ormond Street, an epileptologist and professor of paediatric neuroscience at UCL. I have a particular interest in epidemiology and clinical trials and in particular running clinical trials in childhood epilepsy.”

It’s hardly surprising then that in such a pre-eminent position, his opinion on the use of medical cannabis in paediatric epilepsy is regarded as if it had the force of law amongst doctors.  But I point you to his final sentence and his declared adherence to the doctrine and close involvement in the multi-million pound industry of clinical trials.

Note that Professor O’Callaghan is now becoming the medical establishment’s poster boy in opposing the prescription of cannabis as medicine.  He is now disparaging its use for fibromyalgia in adults, something he is no more qualified about than a junior medical student.

Clinical trials cost tens of millions of pounds (at least) and their primary purpose, at which they do not always succeed, is to ensure the safety of experimental medicines, usually single molecule drugs, synthesised in a laboratory, which may be highly toxic.  All such trials are financed by the pharmaceutical industry with the intention of gaining a licence (known as a marketing authorisation) to enable them to sell their medicines at what are invariably huge prices. The businesses and people involved in the clinical trials process earn vast amounts of money and have a vested interest in ensuring that the regulation of all medicines follows this route.

All clinical trials are conducted under the auspices of the Medicines and Healthcare products Regulatory Agency (MHRA), a government agency which is directed, managed and staffed almost exclusively by people who used to work in the pharmaceutical industry. They all continue to benefit financially from the self-reinforcing, self-regulating and self-serving medical establishment which is built on the pharmaceutical industry and its invention of clinical trials.

Clinical trials are the medical establishment’s ‘kool aid’.  They are a panacea for doctors’ ethical and clinical decision making.  If anything goes wrong, even the most horrendous, catastrophic results, if a doctor has prescribed a medicine which has been through the clinical trials procedure, they can wash their hands, disavow any responsibility and move on to their next ‘doctoring-by-numbers’ appointment.  Increasingly, doctors make very few real decisions. Their actions are all pre-determined by protocols and drugs created and approved by the medical establishment.

So cannabis really doesn’t fit into this system and for Professor O’Callaghan unless any medicine goes through a clinical trial in the specialty which he behaves as if he owns – childhood eplipesy, it will never be good enough to get his endorsement and will therefore be shut out of normal practice and very difficult if not impossible for patients to access.  It is, in fact, a ‘stitch-up’.  A term the Professor will understand as he advocates slicing into a child’s brain in a surgical procedure before trying whole plant cannabis as a medicine.

Note that cannabis is not an experimental medicine, nor a single molecule drug, synthesised in a laboratory, nor is it highly toxic.  It consists of around 500 molecules, is synthesised in a plant and has been in widespread use, we know beyond doubt, for at least 10,000 years.  Currently it is in regular use by 250,000,000 people worldwide as a recreational substance.  In modern times it has been in use as a medicine in Israel since the early 1990s, California since 1996, in Canada and the Netherlands since 2001.  There is no evidence of any significant problems or side effects at a population level, none whatsoever where it is used as a medicine under medical supervision. The only evidence of any significant negative effects is where it is used in extremely potent form as a recreational substance by children and even then the numbers involved are tiny.

This is why in every jurisdiction throughout the world where cannabis for medical use is legally permitted, it is through a special system outside pharmaceutical medicines regulation. Every other government that has recognised the enormous benefit that it offers has come to the same conclusion: cannabis is a special case. It is much, much safer than pharmaceutical products. We need an ‘Office of Medicinal Cannabis’ as there is in the Netherlands, or ‘Access to Cannabis for Medical Purposes Regulations’ as administered by Health Canada. Colorado has its ‘Medical Marijuana Registry Program’ and other US states have similar arrangements. Israel’s Ministry of Health has its ‘Medical Cannabis Unit’. In Australia, its equivalent of the MHRA, the Therapeutic Goods Administration, has established its own set of medical cannabis regulations.

None of this fits into Professor O’Callaghan’s model.  His career and his income is founded on clinical trials and specifically in childhood epilepsy, regardless of the facts of actual experience in thousands of patients, he is going to do everything he can to prevent its use except on his terms.  He has a glaring and outrageous conflict of interest and the failure of any other doctor to point this out simply demonstrates how powerful is the medical establishment and its mafia-like control of our healthcare system.

In his written submission to the Health and Social Care Committee, O’Callaghan had the audacity to attack Professor Mike Barnes, based on a scurrilous article in the tabloid Mail on Sunday, for his “significant financial interests in the cannabis industry”.  He also attacks everyone else who has any knowledge or experience in the area, denigrating them as “experts” (in inverted commas).  O’Callaghan’s hypocrisy is breathtaking and it is time the sycophantic, uncritical reporting of his opinions was highlighted. I have no doubt that he is an “expert” but he is not the only one and there are paediatric neurologists in Canada, the Netherlands and elsewhere whose knowledge and experience of prescribing cannabis vastly exceeds his own.  He needs taking down a peg or two in the interests of children – and now adults – whose care he is interfering with.

Cannabis as medicine has never gone away, despite the best efforts of vested interests and the medical establishment to kill it off. After almost a century of being demonised by governments, the media and every quack on a mission, whether qualified or not, it is here to stay. This doctrine of pharmaceutical drugs, clinical trials and ruthless suppression of empirical knowledge has only been around for that same 100 years.  Modern, reductionist medicine has great deal to offer but so does the wisdom of ages and the plants that have long helped us cure, heal and maintain our health.  They can co-exist and we must put aside arrogance and self-interest in order best to serve the people.

 

Written by Peter Reynolds

April 7, 2019 at 5:11 pm

A CLEAR Response to the Institute of Psychiatry’s Latest Cannabis and Psychosis Scaremongering

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Dr Marta di Forti

The Insititute of Psychiatry is today announcing its latest study on the links between cannabis and psychosis – ‘The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study’.

For many years, its leading lights Professor Sir Robin Murray and Dr Marta di Forti have published study after study attempting to show a causal link between cannabis use and psychosis.  They have never managed to achieve this and despite concerted efforts, the link cannot be described as anything more than extremely tenuous.  The number of people that may be affected is infinitesimally small, while hundreds of millions of people worldwide consume cannabis regularly without any ill effects.

Every year in the early spring Dr di Forti and Professor Murray publish their latest study on the subject. It’s always interesting to see the latest iteration of their work although all the studies are remarkably similar

Cannabis is a psychoactive substance so clearly it can have an effect on mental health.  We know from at least 10,000 years of human experience that for most people this is a beneficial effect.  The number of people that suffer negative effects is difficult to quantify but we can be certain that it is very small. Research published in the journal Addiction shows that in order to prevent just one case of psychosis, more than 20,000 people would have to stop using cannabis. http://onlinelibrary.wiley.com/doi/10.1111/add.13826/full

This level of risk must be compared with other risks to give it any meaning. For instance, if the risk of a diagnosis of psychosis correlating with cannabis use is 1 in 20,000, the risk of being struck by lightning in one’s lifetime is about 1 in 3,000. This puts the risk into a realistic perspective.
https://news.nationalgeographic.com/news/2004/06/0623_040623_lightningfacts.html

It’s also important to understand that this latest study does nothing to show that cannabis actually causes psychosis, only that there is an association or correlation with cannabis use.  There may be other correlations which may or may not be much stronger.  For instance the populations studied may also use tobacco, drink wine, eat spicy food, live in a city centre or exercise regularly or not at all.  Similarly it cannot be shown that any of these factors are the cause of psychosis.

It is also interesting that the study deems an average of 14% THC to be high potency cannabis.  Throughout the USA and Canada, average THC content now exceeds 20%, sometimes as high as 35% and there is no reported increase in rates of psychosis.

Finally, it has to be said that Dr di Forti is well known for her theoretical projections about cannabis use which can be quite alarmist. Thankfully, they have never been reflected in actual healthcare records and the number of cases of psychosis correlating with the use of natural cannabis in the UK remains very low, no more than a few hundred.  There are many, very much more risky activities to be concerned about.

What is certain is that the way safely to manage the risks of cannabis, even though they are so low, is in a legally regulated environment. In this case products are labelled so that the content is known, quality is maintained to a standard avoiding contamination and impurities and if anyone does experience problems they can seek help without having to confess to a crime. Age limits can also be enforced ensuring that children do not have the easy access to cannabis that they have, for instance, in the UK.

Written by Peter Reynolds

March 20, 2019 at 10:27 am

What Is The Matter With Doctors About The Use Of Cannabis As Medicine?

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In the UK, most doctors, and the medical profession as a whole, are ignorant and bigoted about cannabis.

Their ignorance is not entirely their own fault.  For 50-odd years, since cannabis tincture was last available from UK pharmacies, they have been subject to the same relentless tide of propaganda from the Home Office, successive governments, the tabloid press and rabble-rousing politicians as the rest of society.  Many still regard cannabis as a dangerous drug consumed by degenerates that almost inevitably leads to mental illness.  The idea that it could be a safe and effective medicine which offers real benefits in a wide range of conditions is regarded as laughable.

However, there is no excuse for such laziness amongst a profession that regards itself as scientific.  And this is the charge – indolence, carelessness and laziness – that needs to be laid at those doctors at NHS England, the Royal College of Physicians and the British Paediatric Neurologists Association, that are responsible for the disgraceful ‘guidelines’ published two weeks ago.

Throughout Europe, Israel, Canada and the USA there are thousands of doctors who have made the effort to learn about cannabinoid medicine.  They have had to make extraordinary effort to do because even the most basic science is still rarely taught.  The endocannabinoid system is on the syllabus of very few medical schools, anywhere in the world, despite the fact we now know that it is the largest neurotransmitter network in the body and affects almost every aspect of our health and all medical conditions.  This is a dreadful indictment of the medical establishment but particularly of doctors in the UK, very few of whom have made any effort at all.

So while, to a degree, the ignorance can be forgiven, the bigotry cannot. It is cowardice. These doctors prefer to cover their own backs, protect themselves and prefer an absurd level of caution to doing what is in their patients’ best interests.  The incredibly low risk attached to cannabis in any form, at any age and particularly when under medical supervision, is simply overlooked.

Yes, the medical profession is known to be ‘conservative’ but in the case of cannabis this is an excuse.  Yes, we live in an increasingly litigious society but any truly professional doctor would not be cowed by such fear when the evidence is widely available, if they could be bothered to look. And what is this ‘conservatism’ of?  Modern medicine is barely a century old.  It is new in the history of our species and while the reductionist approach has brought great benefit and made huge advances, it is at the expense of thousands of years of human experience which has been dismissed as valueless.

These doctors may feel that the reforms have been foisted on them with no consultation and little notice but this is not a political game, it affects the lives of millions, from the youngest baby to the oldest, most senior citizens.  These doctors are failing in their professional duty.  For too long they have enjoyed being regarded with ultimate respect, rarely being questioned or challenged by their patients but those days are gone.  Most of the population is now far better informed than ever before, largely because of the internet and although this may cause doctors some problems, they have to learn to live with it.  They have to respect their patients, parents and carers and recognise more than ever before that healthcare is about co-operation, about working together. They have to come down from their ivory towers and start delivering truly patient-centred medicine.

 

Written by Peter Reynolds

November 13, 2018 at 4:57 pm

The Medical Establishment Shows Its True Colours On Cannabis. A Betrayal of Patients.

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NHS England has today published what it describes as prescribing guidance – ‘Cannabis-based products for medicinal use: Guidance to clinicians‘.

The actual guidance is buried within a mountain of bureaucratic doublespeak and requires downloading PDFs from the Royal College of Physicians (download here) and the British Paediatric Neurology Association (download here). In both cases, aside from chemotherapy-induced nausea, the guidance amounts to ‘do not prescribe’. This is a travesty of the intention of these reforms and demonstrates how the medical establishment is more interested in protecting its self-interest than in helping patients gain the benefits of cannabis as medicine. Cowardly and scared are the two words which best sum this up.

It’s no surprise that doctors in the UK are ignorant about the use of cannabis as medicine. They have been subject to the same relentless torrent of reefer madness propaganda from government and media as the rest of society. They have been prevented even from learning about the endocannabinoid system by the authoritarian policy of prohibition and any doctor in the UK who has any experience of cannabis as medicine will have been in breach of professional ethics as well as the law.

But it’s deeply disappointing that the authors of these documents have made no effort to understand the excellent work that is being done by medical professionals in other countries.  The Royal College of Physicians and the BPNA will be a laughing stock across the world in the many more enlightened and educated jurisdictions where patients are gaining great benefit. But of course, this isn’t a laughing matter. In fact, these two so-called professional bodies are making it a tragedy.

Clearly, what is in the best interests of patients is that we must bring in expertise from overseas.  There are eminent doctors abroad who will be glad to step in, particularly in private practice, and pick up this baton which the NHS has fumbled and dropped in the most clumsy fashion.

This is a huge opportunity for those in private medicine who can set aside these cowardly excuses and make the most of the new regulations for patients who are fortunate enough to be able to afford it.

For the average Briton with chronic pain, Crohn’s Disease or an epilpetic child this is a kick in the teeth from the profession that is supposed to care for them.

Written by Peter Reynolds

October 31, 2018 at 6:14 pm

Cannabis Advocates Really Need To Stop Accusing Doctors of Being Bribed By Pharmaceutical Companies.

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There may well be some doctors who are corrupt and there are still, despite much improvement, serious questions over the relationship between pharma companies and doctors but the idea that every member of the Faculty of Pain Medicine who signed that letter to the Times is taking bribes is ridiculous.

The real reason is ignorance and that’s not an attack on doctors, it’s a reason.  They have been subject to the same relentless torrent of reefer madness propaganda from government and media as the rest of society.  They have been prevented even from learning about the endocannabinoid system by the authoritarian policy of prohibition and any doctor in the UK who has any experience of cannabis as medicine will have been in breach of professional ethics as well as the law.

CLEAR has been working with some of the very few enlightened doctors since way before the cause of cannabis as medicine became fashionable.  Working with members, their MPs and doctors, we have organised lobbying of ministers and MPs over more than the past 10 years. In several instances we had doctors, both GPs and consultants, contact the Home Office to enquire about obtaining a licence for a specific patient.  In at least three instances these doctors were then contacted by Home Office officials who warned them off using threats and intimidation.  Shocking but completely true.

It is and it always has been government – stupid, prejudiced, bigoted and self-opinionated politicians – who have prevented access to cannabis, even in the face of overwhelming evidence.  This means that there has been no education at all and doctors are as poorly informed as everyone else. They’re also, and understandably, worried, even scared.  They don’t understand cannabis, many will not even have heard of the endocannabinoid system and they are concerned about being sued, professionally disgraced, losing their job and now of being swamped by patients demanding cannabis about which they know nothing.

Of course, it was thoroughly stupid to assert in the letter that “the evidence suggests that the prescribing of cannabis (containing the psychoactive and addictive tetrahydrocannabinol component) will provide little or no long-term benefit in improving pain and may be associated with significant long-term adverse cognitive and mental-health detriment.”

There is no reasonable interpretation of the evidence that supports this. THC can be addictive in a very modest sense but the withdrawal symptoms and negative effects are trivial compared to those from opioids which doctors prescribe readily and frequently.  There is excellent evidence from many sources that cannabis containing THC and CBD benefits pain and while there may be some cognitive and mental health effects, to suggest they are significant or even come remotely close to those from opioids is false and in opposition to the evidence.

I repeat, doctors aren’t saying this because they are bribed by pharmaceutical companies, it’s because they have no idea what they are talking about.

The urgent requirement now is medical education.  It is amazing how radical the new regulations are and many people still don’t seem to realise how far the government has gone.  They go much further than we at CLEAR had even dared to dream and the definition of cannabis-derived medicinal product (CDMP) is very broad.  When we were consulted on it by the Department of Health and MHRA we never thought they would accept all our recommendations.  They enable the prescription of every form of cannabis, including flower, oil and concentrate, provided they meet quality standards.

So the problem with the law is gone. Literally, it is all over. It is absolute and total victory. Now two big problems remain. Education is the first but this is being addressed.  NICE has acted commendably fast to start recruiting a panel to advise on prescribing guidelines and Professor Mike Barnes, CLEAR’s scientific and medical advisor has already developed a series of introductory online training modules. Early in November his Medical Cannabis Clinicians Society launches and this will be an important forum for the future.

The second big problem is supply.  Where are the CDMPs to come from?  Sativex falls into the definition and this was GW Pharma’s big opportunity to act responsibly and imaginatively.  The possibility still exists that it will substantially reduce the absurd, rip-off price that it has been charging for Sativex since 2010.  If it had the imagination it could very easily turn over some of its production to unlicensed CDMPs for which there is now a ready market. I fear that it is wedded to licensed products only, hugely expensive and, in my judgement, unnecessary clinical trials and very high prices for its end products.  If so, then I will be selling my shares.  I admire the company for its courage, innovation and high standards but if it does not seize this opportunity then I believe it is failing in its duty to shareholders and also to Britain, which let’s remember has gifted it a privileged and unique opportunity in the world.  Fail now to provide for the needs of UK patients and that amounts to betrayal.

So for now the only possible sources of supply that meet the definition will be Bedrocan in the Netherlands and some of the Canadian licensed producers. US companies cannot export.  Neither can the Israeli companies and they would also face a thoroughly deserved boycott of their products even if Netanyahu was to issue export licences.  Bedrocan can barely meet demand from its existing customers and there is talk of it having difficulties with a ceiling on its export licenses. Only some Canadian producers meet the required GMP quality standards and they too are facing shortages as they also supply the recently legalised recreational market which is seriously short of product.

So the Home Office has to act and start issuing domestic production licences and it has to do so immediately.  Whether it will, remains to be seen.  Its drugs licensing department is a shambles, staffed by officials who do not even understand the law they are supposed to administrate, who regularly give different, contradictory answers on different days and exceed their lawful authority as a matter of course.  If there is a ‘hostile environment’ for immigration in the Home Office, for drugs licensing and cannabis production it has been hostile but also aggressive, paranoid and stupid ever since the Misuse of Drugs Act 1971.

The urgent need is for prospective British cannabis producers to mobilise their MPs and for immediate pressure to be brought on the Home Office at the highest level.  Sajid Javid has shown he can act decisively.  Expanding domestic cannabis production is the inevitable next step in what he has already achieved.  He must act now.

So the future in the UK for those who need cannabis as medicine is brighter than could ever have been imagined.  The next steps are challenging but nowhere near as difficult as the campaign to reform the law that CLEAR has fought for nearly 20 years.  Don’t blame doctors, continue to blame the government and hold their feet to the fire until they act on medical education and cannabis production as they must.

British Doctors Don’t Understand Cannabinoid Medicine. They’ve Been Denied Education In The Basic Science.

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Today’s letter to the Times from a group of pain medicine consultants (reproduced below) is is an astonishing display of evidence-free ignorance from a profession that needs to challenge its own prejudice.

To compare the addiction potential of cannabis with opioids is ridiculous and demonstrates just how detached from the science and evidence are those making this claim.

Doctors will understandably feel challenged by a medicine that upturns many of their conventional habits. They have been prevented from understanding the science of cannabis as medicine by prohibition policy. Most doctors have received no education at all about the endocannabinoid system which we now know is the largest neurotransmitter network in the body and is the mechanism by which cannabis exerts its therapeutic effects.

Understanding cannabis as a medicine requires a new attitude and mindset which looks at the patient’s overall health and physiological stability or homeostasis. Modulating the endocannabinoid system with cannabis can effect many factors which contribute to illness including pain, mood, memory and perception. It’s actually a much more complex model rather than the simplistic, reductionist theories that modern medicine is based on.

‘Holistic’ is a fashionable but much misused word that is truly expressed in cannabinoid medicine. There are a few progressive doctors in the UK, including some pain consultants, who through experience and self-education have learned how this new approach to medicine works.

Outside the UK, in jurisdictions which have taken a more enlightened approach, cannabinoid medicine is much better understood by many more doctors. The profession in UK needs to open its mind and its doors to education and training from overseas. Then they will start to understand this much more rounded and broadly-based approach which can lead to a long-term, preventative approach with fewer side effects and better outcomes for nearly all patients.

 

Letter to The Times, 26th October 2018

CANNABIS PAIN RELIEF

Sir, We, as a group of pain medicine consultants, are concerned that the Home Office and NHS England propose to allow specialist doctors to prescribe cannabis for chronic pain from next month. We know only too well the unmet burden of chronic pain and that pain is cited by our patients as a frequent reason to take cannabis.

While there are clear limitations in studying the effects of past illicit cannabis use, caution is required, as the evidence suggests that the prescribing of cannabis (containing the psychoactive and addictive tetrahydrocannabinol component) will provide little or no long-term benefit in improving pain and may be associated with significant long-term adverse cognitive and mental-health detriment.

We are also concerned that it will be difficult to deny cannabis prescriptions to patients in pain who might be coerced into diverting cannabis into the community where it will remain illegal and have street value.

We have suffered an opioid crisis and foresee history about to repeat itself. Ironically, the likely cost of medical cannabis will be greater than the saving achieved by the inexplicable decision of NHS England to restrict the use of the clinically effective 5 per cent lidocaine plasters.

We support the change in the law to encourage cannabis research. However, we are concerned that in the interests of political expediency, this mandate to allow prescribing of cannabis for pain relief is premature. That cannabis is an effective treatment for chronic pain is not supported by the evidence and may be associated with significant harm.

Dr Rajesh Munglani, consultant in pain medicine London; Dr Andrew Baranowski, consultant in pain medicine, University College London Hospitals NHS Trust; Dr Stephen Ward, consultant in pain medicine Brighton and Sussex Hospital Trust; Dr Arun Bhaskar, consultant in pain medicine Imperial College NHS Trust; Dr Cathy Price, consultant in pain medicine St Mary’s Portsmouth Solent NHS Trust; Dr Jonathan Bannister, consultant in pain medicine NHS Tayside Scotland; Dr Ilan Lieberman, consultant in pain medicine University Hospital of South Manchester; Dr Dalvina E Hanu-Cernat, consultant in pain medicine Queen Elizabeth Hospital Birmingham; Dr Pravin Dandegaonkar, consultant in anaesthesia and pain medicine; Calderdale and Huddersfield NHS Foundation Trust; Dr Sarang Puranik, consultant in pain management and anaesthesia Kingston Hospital, Surrey; Dr Mike W Platt, consultant in pain medicine Imperial College Healthcare NHS Trust; Dr Jon Valentine, consultant in pain medicine Norwich; Dr Teodor Goroszeniuk, consultant in pain medicine, London W1, UK; Dr Michael Coupe consultant in anaesthesia, pain medicine and intensive care Royal United Hospitals NHS FT; Dr Hadi Bedran, consultant in pain medicine St Georges University Hospitals NHS Trust; Dr Karen H Simpson, consultant in pain medicine Leeds; Dr Aditi Ghei, consultant in pain medicine, West Herts NHS Trust; Dr Kiran Koneti, consultant in pain management City Hospitals Sunderland NHS Trust; Dr Tim McCormick, consultant in pain medicine Oxford pain Management Centre; Dr Sadiq Bhayani, consultant in pain medicine University Hospitals Leicester NHS Trust; Dr Nicholas M Hacking, consultant anaesthetist, Lancashire Teaching Hospitals NHS Trust; Dr Joshua Adedokun, consultant in pain medicine, The Pennine Acute NHS Trust; Dr Neil Collighan, consultant in pain medicine East Kent Hospital NHS Trust; Dr Bela Vadodaria, consultant in anaesthesia and pain management The Hillingdon Hospital; Dr Fraser Duncan, consultant anaesthetist and pain specialist Birmingham; Dr Hoo Kee Tsang, consultant in anaesthesia and pain medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust; Dr Richard Gordon-Williams, APT, University College London Hospitals NHS Trust; Dr A Tameem, consultant in anaesthesia and pain management Dudley group of hospitals; Dr Marcia Schofield, pain sPecialist West Suffolk NHS Trust Bury St Edmunds; Dr Giancarlo Camilleri, consultant Ashford & St Peter’s Foundation NHS Trust Chertsey; Dr Joseph Azzopardi, consultant in pain medicine London; Dr Dick Atkinson, retired consultant in pain medicine Central Sheffield University Hospitals; Dr Basil Almahdi, consultant in pain medicine London; Dr Katharine Howells, consultant in pain medicine, RUH Bath NHS Foundation Trust; Dr G Baranidharan, consultant in pain medicine, Leeds Teaching Hospitals NHS Trust; Dr Philippa Armstrong, consultant in anaesthesia and pain medicine, York Teaching Hospitals NHS Trust; Dr Lourdes Gaspar, consultant in pain medicine Orthopaedic Hospital Oswestry; Dr Carolyne Timberlake, consultant in pain medicine Kings College Hospital NHS Trust; Dr Intazar Bashir, consultant in pain medicine Worthing; Dr Mark Sanders,consultant in pain medicine at Norfolk and Norwich University Hospital; Dr Andrzej Krol, consultant in pain medicine St George’s Hospital London; Dr Peter Hall, consultant in pain Management York Hospitals NHS Trust; Dr Susmita Oomman, consultant in pain and Anaesthetic Withybush General Hospital Hywel Dda NHS Trust; Dr Sue Jeffs, consultant in anaesthesia and pain Management Abergavenny Wales; Dr Murali-Krishnan, consultant in pain medicine Northampton; Dr Sabina Bachtold, ST7 pain medicine (APT)/anaesthesia London; Dr A Ravenscroft, consultant in pain Management Nottingham University Hospitals; Dr Sanjay Kuravinakop , consultant in pain medicine Dartford and Gravesham NHS Trust; Dr Nicolas Varela, consultant in pain medicine Royal National Orthopaedic Hospital NHS Trust; Dr Michael Atayi, consultant in pain medicine George Eliot Hospital; Dr Carl TJ Broadbridge, consultant in pain medicine and anaesthesia Salisbury District Hospital; Dr Ramy Mottaleb, Kingston NHS Foundation Trust; Dr Richard Sawyer, consultant in anaesthesia and pain management, Oxford University Hospitals NHS foundation Trust; Dr Rajesh Menon, consultant in pain medicine Calderdale and Huddersfield NHS Trust; Dr Jeremy Weinbren, consultant in Anaesthetics and pain medicine Hillingdon Hospital; Dr Paul Rolfe,consultant in pain medicine Cambridge; Dr Brian Culbert, consultant in pain medicine East Yorkshire Hospitals NHS Trust; Dr Rokas Tamosauskas, consultant in pain medicine Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust; Dr David Gore ST6 Advanced pain Trainee, Oxford University Hospitals; Dr Manohar Sharma, consultant in pain medicine The Walton Centre NHS Foundation Trust, Liverpool; Dr Jayne Gallagher, consultant in pain medicine Barts Health Trust London; Dr Raju Bhadresha, consultant in pain medicine and anaesthesia East Kent Hospitals University Foundation Trust; Dr Owen Bodycombe, consultant anaesthesia and pain medicine Gloucestershire Hospital’s NHSFT; Dr Ramy Mottaleb,consultant in pain medicine Kingston NHS Foundation Trust; Dr Christian Egeler, consultant in anaesthesia and pain medicine, Swansea ABMU HB; Dr Deepak Malik, consultant in pain Management University Hospitals Birmimgham NHS Foundation Trust; Dr Mohjir Baloch, consultant in pain Management Frimley Park Hospital; Dr Martyna Berwertz, consultant in pain medicine Sheffield Teaching Hospital NHS Foundation Trust; Dr Ron Cooper, consultant pain medicine & anaesthesia Causeway Hospital, Coleraine, N Ireland; Dr Ashish Shetty, consultant in pain medicine, University College London Hospitals; Dr S J Law, consultant in pain medicine West Suffolk Hospital; Dr M Mali, consultant in pain medicine Darent Valley Hospital; Dr S James consultant and Lead Clinician Chronic pain Services NHS Lanarkshire; Dr Sarah Aturia,consultant pain and Anaesthetics Milton Keynes University Hospital NHS Foundation Trust; Dr Henriette van Schalkwyk, consultant in pain medicine North Hampshire hospital Basingstoke; Dr Shamim Haider, consultant in pain medicine East Suffolk & North Essex NHS Foundation Trust Colchester & Ipswich; Dr Simon Thomson, consultant in pain medicine and Neuromodulation, Basildon; Dr Danielle Reddi, Locum consultant in pain medicine University College London Hospitals NHS Trust; Dr Thomas Samuel, consultant in pain medicine East and North Herts NHS Trust; Dr Arindam De, pain Management consultant University Hospitals of Morecambe Bay (UHMB); Dr Evan Weeks, consultant in anaesthesia & pain medicine Addenbrooke’s Hospital, CUHFT; Dr Ravi M Kare, consultant in pain Management and anaesthesia Norfolk & Norwich University Hospitals; Dr Niranjan Chogle, consultant in pain medicine Ulster Hospital, Northern Ireland; Dr William Campbell, consultant Emeritus and Past President British pain Society, Ulster Hospital Dundonald; Dr Subramanian Ramani, consultant in pain medicine Northampton General Hospital; Dr Adrian Searle, consultant in anaesthesia and pain medicine, Derby; Dr Sameer Gupta, consultant in anaesthesia and pain Management DRG Health Clinic Doncaster; Dr Diana Dickson, Retired consultant in pain medicine, Leeds; Dr Attam Singh, consultant in pain medicine West Hertfordshire NHS Trust; Dr James Wilson, consultant in anaesthesia & pain medicine Maidstone & Tunbridge Wells NHS Trust; Dr Sharmila Edekar, pain Specialist Glangwili Hospital Hywel Dda HB; Dr Bernard Nawarski, consultant in pain medicine Frimley Health; Dr Sridevi Ramachandran, consultant in pain medicine, Anglian Community Enterprise; Dr John Wiles, consultant in pain medicine The Walton Centre NHS Foundation Trust; Dr A T Arasu Rayen, consultant in pain Management, Sandwell and West Birmingham NHS Trust; Dr John Titterington, consultant pain Management, Leeds Teaching Hospitals; Dr Deepak Subramani, consultant in anaesthesia and pain Management George Eliot Hospital; Dr Ian D Goodall, consultant in pain medicine, Chelsea and Westminster Hospital NHS Trust; Dr Seshu Babu Tatikola, consultant In pain medicine & Anaesthesia, Hull and East Yorkshire Hospitals NHS trust; Dr Kevin Markham, consultant in pain medicine Surrey Heath Community pain Clinic; Dr Husham Al-Shather ,consultant in pain medicine Royal Berkshire NHS Foundation Trust; Dr K.Dhandapani, York Hospitals NHS foundation Trust York; Dr Chris Naylor, consultant in pain medicine, Southend University Hospital NHS Trust; Dr Sally Ghazaleh, Locum pain consultant Royal Berkshire hospital; Dr Bala Veemarajan ,Sherwood Forest Hosp NHS trust; Dr GR Towlerton, consultant in pain medicine, Chelsea & Westmister Hospital; Dr Mandar Joshi, consultant in anaesthesia and pain medicine, Aneurin Bevan University Health Board; Dr Ashish Wagle,consultant Anaesthetist and pain specialist Cwm Taf University Health Board Wales; Dr A Doger, consultant University Hospitals Birmingham & Associate Medical Director John Taylor Hospice; Dr Salmin Aseri, consultant in pain medicine & Anaesthesia; St Helens & Knowsley Teaching Hospitals NHS Trust; Dr George Harrison, consultant in pain medicine, Birmingham Queen Elizabeth Hospital; Dr Rashmi Poddar, pain consultant Kettering General Hospital; Dr Ashish Gulve; consultant in pain Management The James Cook University Hospital Middlesbrough; Dr Yaser Mehrez,consultant in pain medicine and anaesthesia Milton Keynes University Hospital NHS Trust; Dr Victoria Tidman, consultant in pain medicine University College London Hospitals NHS Trust; Dr Tacson Fernandez,consultant in pain medicine Royal National Orthopaedic Hospital; Dr Kim Carter, consultant Anaesthetist & pain Northampton General Hospital; Dr Anand Natarajan, consultant in pain Management Wirral University Teaching Hospitals; Dr Dominic Aldington consultant in pain medicine Royal Hampshire County Hospital; Dr Emma Chojnowska, consultant in pain medicine and anaesthesia Chichester; Dr Liza Tharakan, consultant in pain medicine and Anaesthesia; Royal Orthopaedic Hospital; Dr Moein Tavakkoli, consultant in pain medicine University College London Hopsital (NHNN); Dr Manojit Sinha ,consultant pain medicine King’s College Hospital NHS Foundation Trust; Dr Sanjay Varma,consultant in pain Management Sunderland Royal Hosptal Sunderland; Dr Shravan Tirunagari, consultant anaesthesia and pain Management, East and North NHS Trust Hospitals; Dr Monica Chogle, consultant in Anaesthetics and pain Northern Health and Social Care Trust Northern Ireland; Dr Subhash Kandikattu, consultant in pain Management, Peterborough City Hospital North West Anglia NHS FT; Dr Jan Rudiger, consultant in Anaesthetics and pain medicine, Redhill; Dr Arun Sehgal, consultant in pain medicine and Anaesthesia,Peterborough and Stamford Hospitals; Dr Matthew LLoyd Hamilton, consultant in anaesthesia and pain medicine, Homerton University Hospital NHS Foundation Trust, London Dr Athmaja Thottungal, consultant and Trust Clinical lead for pain management, East Kent Hospitals NHS Trust; Dr Rubina Ahmad, Title: Locum consultant, work place; Brighton and Sussex University Hospital NHS Trust: Dr Sean White, consultant in pain medicine, London pain Service; Dr Anup Bagade, consultant in pain medicine East and North Herts NHS Trust; Dr Tom Smith, consultant in pain medicine London; Dr Jason Brooks, consultant pain medicine Belfast Health and Social Care Trust; Dr Vinay Anjana Reddy, consultant in pain and anaesthesia University Hospital Lewisham; Dr S Murugesan, consultant in anaesthesia and pain management, Wrightington Wigan and Leigh NHS Foundation Trust; Dr Nancy Cox, APT, University Hospital Coventry and Warwick NHS Trust; Dr Ashwin Mallya, Northern Lincolnshire and Goole Hospital NHS Trust; Dr M Serpell, consultant & Senior Lecturer in pain medicine & anaesthesia Greater Glasgow & Clyde NHS; Dr Srinivas Bathula, consultant in pain Management Heart of England NHS Trust University Hospital, Birmingham; Dr Ann-Katrin Fritz, consultant Alain Management Norfolk & Norwich University Hospital; Dr Ashok Puttappa, consultant in anaesthesia and Chronic pain University Hospital North Midlands Stoke on Trent; Dr Tom Bendinger, consultant in anaesthesia and pain medicine Sheffield Teaching Hospitals; Dr Sumit Gulati,consultant in pain medicine and anaesthesia Walton Centre NHS FT, Liverpool UK;Dr Arun Natarajan, consultant in pain medicine Hillingdon Hospital; Dr Katrina Dick, consultant in anaesthesia and pain medicine Ayrshire and Arran; Dr Shefali Kadambande , consultant in anaesthesia and pain management University Hospital of Wales; Dr Nick Roberts, consultant in pain Management Kettering General Hospital; Dr Somnath Bagchi, consultant in pain medicine University Hospitals Plymouth UK; Dr Lakshman Radhakrishnan, consultant in pain management Royal Lancaster Infirmary; Dr Stephan Weber, consultant in pain Management BMI Goring Hall Hospital; Dr Kiran Sachane consultant in pain medicine NHS Lothian pain Service, Edinburgh Scotland; Dr James Blackburn, consultant in pain medicine, St George’s Healthcare NHS Trust; Dr Srinivas Bathula, consultant in pain medicine, University Hospitals Birmingham NHS FT; Dr Ravi Srinivasagopalan, consultant in pain Management and anaesthesia The Hillingdon Hospitals NHS FT; Dr John Goddard, consultant in Paediatric pain medicine Sheffield Children’s Hospital; Dr Chad Taylor, pain medicine consultant, Jersey (Channel Islands UK); Dr Udaya Kumar Chakka, consultant in pain medicine, Coventry; Dr Pallav Desai, Neuromodulation Fellow, James Cook University Hospital; Dr Azfer Usmani, Dartford and Gravesham NHS Trust; Dr Neal Evans, consultant in pain medicine Bucks Hosps NHS Trust; Dr Kanar Al-Quragooli, Associate Specialist in anaesthesia and pain medicine , Manchester FT; Dr Valentina Jansen, consultant in pain and anaesthetics Glangwili General Hospital Hywel Dda NHS Trust; Professor Emeritus Sam H Ahmedzai, University of Sheffield; Dr Mike Hudspith, consultant in pain medicine Norfolk & Norwich University Hospital;

Written by Peter Reynolds

October 26, 2018 at 9:46 am