Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non‐specialist opioid prescribers. There is much confusing and conflicting information available to non‐specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi‐faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non‐specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. Significance This position paper provides expert recommendations for primary care physicians and other non‐ specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi‐faceted approach to pain management, in properly selected and supervised patients.

SUMMARY Seventy-one patients presenting with acute herpes zoster ophthalmicus were followed up for six months for a prospective analysis of the natural history of the disease. Acute and chronic ocular complications, nasociliary nerve Standardised assessment forms were completed at presentation and at subsequent visits. Pain was assessed by visual analogue scale (VAS). The patient was asked to look at a 100 mm horizontal line with a zero at one end and three pluses at the other, with the instruction that the latter represented the worst pain he could possibly imagine. He was then asked to indicate with a mark along the line the severity of any pain being experienced at the time of the interview, and a measurement was taken in millimeters. At subsequent interviews a fresh line was presented. Ocular involvement, nasociliary nerve (NCN) involvement at presentation, rash severity, and duration were also assessed.Assessment of pain by a VAS has been shown to be reproducible for the same individual and a method that allows reliable statistical analysis.6 Like all pain assessment it is subjective, and hence direct comparisons between patients cannot be made. However, 353

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Seven consecutive patients with multiple sclerosis and trigeminal neuralgia were investigated with MRI to determine the occurrence of a lesion which would account for the patients' pain. Two patients had bilateral symptoms. In the patients with unilateral trigeminal neuralgia vascular compression of the nerve by an artery at the root entry zone on the symptomatic side was confirmed in three patients and an epidermoid tumour distorting the nerve on the symptomatic side was identified in one patient. A demyelinating plaque was identified in only one patient, affecting the trigeminal nerve at the root entry zone at the pons. In those with bilateral symptoms neurovascular compression was identified on both sides in one patient and on one side only in the remanng patient. Microvascular decompression cured the pain in two patients with neurovascular compression. The variable aetiology of trigeminal neuralgia is stressed even in patients with coexistent neurological conditions such as multiple sclerosis, which can cause trigeminal neuralgia independent of other causes. (7 Neurol Neurosurg Psychiatry 1995;59:253-259)

A study of the extent of sympathetic blockade after stellate ganglion block was assessed using liquid crystal thermography. Two volumes (10 and 20 ml) of bupivacaine 0.5% plain were used. Irrespective of the volume used cranial sympathetic block always occurred and thoracic sympathetic block never occurred. While upper cervical block was present in all patients, lower cervical sympathetic block was present only in the 20-ml group (P less than 0.05). The larger volume was associated with a significant incidence of hoarseness due to spread of local anaesthetic onto adjacent laryngeal nerves.

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Forty-Jive patients undergoing Caesarean section under epidural anaesthesia with bupivacaine were randomly allocated to three groups. Group I received 4 mg of epidural morphine immediately postoperatively and 2 mg naloxone by intravenous infusion for 12 hourspostoperatively; group 2 was treated as group I but without naloxone infusion: group 3 received I0 mg morphine intramuscularly and 20 ml epidural saline after delivery of the baby. Epidural morphine 4 mg produced better postoperative analgesia than 10 mg of morphine intramuscularly (p < 0.001) and the intravenous infusion ofnaloxone didnot ablate the analgesic eflects of epidural morphine. The incidence of itching and vomiting was higher in the epidural opioid groups @<0.05) and intravenous naloxone, although it reduced the severity of the itching, did not reduce its overall incidence. Respiratory depression was not detected in any of the three groups.