ࡱ> gidefe bjbjJJ \(_b(_b&6 6 6 6 6 $Z Z Z P L Z 1f " "(2"2"2" # # #0000000$n2$506 % # #%%06 6 2"2"07/7/7/%6 2"6 2"07/%07/7/7/2"`l!4z, 7/s00017/5-57/56 7/< #Zg#@7/#4#, # # #00[. # # #1%%%%5 # # # # # # # # #B : John C. Liebeskind History of Pain Collection Oral History Interview with Michael J. Cousins Ms. Coll. no. 127.10 Conducted: 19 October 1997 Interviewer: Marcia L. Meldrum Duration: ca. 3.0 hours Pages: iv, 44 History & Special Collections for the Sciences UCLA Library Special Collections Los Angeles, California 90095-1798 2004, revised 2016 Biographical Sketch Michael J. Cousins, AM MB BS MD (Syd), FANZA, FRCA was born in Sydney, New South Wales, Australia, in 1939. He received an M.D. degree from the University of Sydney in 1968. In 1969 he was awarded a position as Clinical and Research Fellow at the Royal Victoria Hospital and McGill University, Montreal, Canada to work with Professor Philip Bromage in the field of postoperative pain research. From 1970-1974 he was Assistant Professor of Anesthesia at Stanford University, Stanford, California. From 1975-1990 he was Foundation Professor and Chairman of the Department of Anaesthesia and Intensive Care, The Flinders University of South Australia, Adelaide, South Australia. Since 1991 he has been Professor and Head, Department of Anaesthesia and Pain Management, The Royal North Shore Hospital, The University of Sydney, as well as Founder and Director of their Pain Management and Research Centre. Dr. Cousins is well known for his textbook Neural Blockade in Clinical Anesthesia and Management of Pain, which he co-authored with Phillip Bridenbaugh. From 1987-1990 Dr. Cousins served as President of the (IASP). Interview History Dr. Michael Cousins was interviewed in his suite at the Marriott Hotel and Marina in San Diego, California, by Marcia L. Meldrum on October 19, 1997. The interview lasted approximately three hours. The transcript was audit-edited by Cynthia Maya and reviewed by Dr. Cousins prior to its accession by the History of Pain Collection. The tape and transcript are in the public domain, by agreement with the oral author. The original recordings, consisting of two (2) 90-minute audiotapes, are in the Library holdings and are available under the regulations governing the use of permanent noncurrent records. Records relating to the interview are located in the offices of History & Special Collections for the Sciences. Topical Outline (Scope and Content Note) The interview chronicles the development of Dr. Cousins interest in pain beginning with his specialist training in anesthesiology around 1967. This is followed with his training and early career, including his work on postoperative pain management with Philip Bromage at McGill and five years of research at Stanford; his return to Australia and his efforts to establish a multidisciplinary pain center at Flinders; his Chair of Anaesthesia and Pain Management at the University of Sydney; implementation of degrees in pain management ;.the state of anesthesiology and pain management in Australia; IASP finance; IASP Presidential accomplishments; the International Pain Foundation; and recent research in spinal cord injury and injury responses. Access to the Interview This oral history interview, in its audio and transcript forms, is held by History & Special Collections for the Sciences, a division of UCLA Library Special Collections located in the Louise M. Darling Biomedical Library. Those wishing to use the printed transcript or the audiocassette version (which is available by appointment only) should contact: History & Special Collections for the Sciences, UCLA Library Special Collections, Louise M. Darling Biomedical Library, Los Angeles, California 90095-1798. Phone: (310) 825-6940. Terms and Conditions of Use By agreement with the oral author (interviewee), the contents of this interview are placed in the public domain and are made available for use by anyone who seeks to broaden the understanding of pain. However, users must fully and properly cite the source of quotations they excerpt from this interview (see Citation Information). Citation Information The preferred citation for excerpts from this interview is: Oral History Interview with Michael J. Cousins, 19 October 1997 (Ms. Coll. no. 127.10), John C. Liebeskind History of Pain Collection, History & Special Collections for the Sciences, UCLA Library Special Collections. Related Material in the Liebeskind History of Pain Collection Oral history interviews with John Loeser, Michael Bond, and Barry Sessle. Editorial Note The interview transcript has been annotated -- with notes offset in [square brackets] -- to clarify and enhance the readers understanding of the concepts and events described, but as sparsely as possible, so as not to interrupt the flow of the oral authors thoughts. By and large, the transcript is a record of the oral authors ideas and recollections in his own words. Acknowledgments Support for the John C. Liebeskind History of Pain Collection and its Oral History Program came from the American Pain Society and the . . [PHOTO PORTRAIT NEEDED] Michale J. Cousins, MD Professor of Anaesthesia & Pain Management MICHAEL J. COUSINS INTERVIEW TAPE ONE, SIDE ONE PRIVATE  MICHAEL COUSINS: I think really my interest in pain developed during the course of my specialist training for anesthesiology. In fact, I can pinpoint that to somewhere around 1967, when I was managing patients undergoing major vascular surgery. I noticed that the patients with the most severe pain, and often with shivering and other problems in the postoperative period, seemed not to do well in terms of the survival of their vascular grafts. So it was at that time that I started, in fact, to use a continuous infusion of local anesthetic, in those days, just used a local anesthetic, with a very primitive apparatus, I might say, to try to prolong the good effects that were obtained with epidural during this surgery into the postoperative period. And I can remember this caused a bit of consternation among the more senior anesthesiologists in this hospital, but -- MARCIA MELDRUM: Now, which hospital was this? COUSINS: This was the Royal North Shore Hospital. But generally they were supportive, and in fact the vascular surgeons were extremely supportive. And as I look back now, I realize that its thirty years, since I began that interest. But as a result of that, I started to read the literature, and I came across what, at that stage, was very, very early work on postoperative pain relief, by Philip Bromage in Montreal. In fact there was a symposium of the British Journal of Anaesthesia devoted to various aspects of postoperative pain relief; and the article that stood out to me was one by Philip Bromage, which described the management of patients with severely crushed chests after trauma, using a thoracic epidural to relieve their pain and thereby allow them to cough and clear their secretions and recover. For me, that, I suppose, has become a lifelong objective -- to not just relieve the pain, but to restore function. Its turned out of course now to be one of the major aims in both acute and chronic pain management. So thats how it all got started for me, and I was fortunate to be able to gain a traveling fellowship from the University of Sydney, to travel to McGill University and Royal Victoria Hospital in Montreal, to work with Philip Bromage with the objective of pursuing some aspect of research in postoperative pain management. And thats how it all got started. MELDRUM: Wow. Thats quite an interesting story. You know, actually, Dr. Bromage later went to the University of Colorado, I think. COUSINS: Yes, yes, he did. MELDRUM: Because I was working there and I remember him from there. COUSINS: Yes. Although he spent a long, long time at McGill and really was there, I think, in the heyday of medicine at McGill. I was very fortunate when I went there in 1969, it was a superb Department, and I was able to pursue my goal of doing some research in the management of pain after vascular surgery. I collaborated with a young surgeon about my age; his name was Charles Wright. I think we did one of the very early studies of postoperative pain, where we not only documented the pain relief, but also the improvement in vascular graft blood flow that was associated with epidural analgesia. So that really got me going, got me fascinated. At that stage I thought really I didnt want to have anything whatsoever to do with chronic pain; it seemed like a very obscure, difficult, and unappealing area. I saw my future role in anesthesiology in the operating room, in postoperative pain. All of that changed about three or four months after Id arrived in Montreal, when I attended a lecture by one Ronald Melzack. MELDRUM: Oh, my! COUSINS: I can still remember -- it was quite an extraordinary experience -- to hear him expound on the gate control theory and how this had really changed concepts of pain. But I suspect I was equally influenced a few months later, when Pat Wall visited McGill, and in his inimitable style, gave a lecture where he would put up the existing concepts of the neuroanatomy of pain at different levels of the nervous system, and then would proceed to tear it apart unmercifully and show that it was really totally untenable. This included some of the greats of neuroanatomy and neurophysiology of pain in the past, and I sat there quite astounded to hear all of this. MELDRUM: Remarkable stuff. COUSINS: It made me realize that really up until very, very recently, virtually nothing had been known about pain, which was of any use whatsoever in managing patients. I suppose that that was the beginning of an awakening for me, that mainly this was going to be a major, major field of medicine. So that was the beginning, I suppose, of my preparedness to accept that perhaps I was going to be interested in the management of pain, other than in the surgical milieu. I also witnessed some rather extraordinary events while I was there; I can well remember one of the anesthesiologists working with Ron Melzack to try out what was I suppose a very, very early version of transcutaneous electrical nerve stimulation. In fact, I think the first thing they tried was a rather primitive vibrator, and I mean it was quite a large device about the size of a doughnut, and their idea there was of course to try to activate the large fibers. I think the patient they were working on had some type of neuralgia; I cant remember specifically what. But this really was the beginning of attempts to capitalize on the gate control theory. And it all went from there. That was, of course, still in the era when people were doing lots of nerve blocks, and the concept was still that, if you block the noxious stimulus, that somehow youd help the patient. So Philip Bromage and others in the Department were doing local anesthetic blocks and also neurolytic blocks for patients with cancer. MELDRUM: Forgive me; distinguish between these, for most of our listeners. MELDRUM: Yes. Well, the local anesthetics, of course, were reversible short-acting drugs, and in those days we were only just beginning to have drugs that lasted more than an hour or two. In fact, in that era, lidocaine was around; it was the most commonly used local anesthetic. But a new, long-acting local anesthetic -- and by long-acting I mean several hours rather than one or two -- bupivacaine [Marcaine] became available. In fact, my own wife had a bupivacaine epidural for the birth of our first son, and the epidural was administered by Philip Bromage, and she was one of the numbers in his clinical research series of bupivacaine documentation. MELDRUM: I see. [she laughs] So you were really involved in this research! COUSINS: Thats right. So she played a part in it, too. But that was an era when, I guess rather mistakenly, we had the idea that if you could block the noxious stimulus even temporarily, you might help the patient. But if you could block it much longer-term with a destructive agent, a neurolytic agent, then maybe the whole problem would go away. We really were working of course in a unidimensional model of pain, ignoring completely the inhibitory components of the nervous system and ignoring totally what we now understand is the plasticity of the nervous system. We naively thought we could make holes in the nervous system and get away with it, and in fact we didnt get away with it. The results really were not good. MELDRUM: Im going to stop you for just a second here. [Pause] MELDRUM: Okay. Let me just take you back just a little bit. You told me about the rugby accident -- COUSINS: Oh, yes. MELDRUM: -- and that that stimulated your interest. But you went to the University of Sydney, is that right, for all your training? COUSINS: Yes. MELDRUM: Youd grown up in Sydney; there wasnt any -- thats where you wanted to stay. COUSINS: Yes. I grew up in Sydney, and I really, having decided on medicine, became interested in critical care during my internship and residency years. I suppose I was interested in critical care, because I saw this as being a very dynamic and rapidly developing area; and it was in the course of being involved in critical care that I realized that anesthesiology seemed to be the specialty that, in essence, was pioneering critical care. So initially I went into specialty training in anesthesiology to go into critical care, and I guess in a way that influenced, to some extent, my subsequent path into pain management, because I clearly had an intention of operating as a physician with substantial interaction with patients. I guess, in retrospect, its not too surprising that my practice evolved initially into part operating room-based and part outside of the operating room, and now entirely outside of the operating room. So that probably laid the framework for it. MELDRUM: Yeah. So you were interested in talking to some awake patients. COUSINS: Yes. Well, I think my primary interest was always the patient as a person. I was good at the technological side of things, the technical side, but for me that was only a means to an end. So Im not at all surprised to find that I evolved into, you know, the sort of practice that now is embodied in pain management. MELDRUM: And you had this traveling fellowship that took you to McGill. COUSINS: Yes. Just for a year, of course. MELDRUM: Yeah -- well, you stayed a little bit longer; I mean, you stayed out of Australia a little bit longer than that. COUSINS: I stayed almost five years. While I was at McGill, I would quite gladly have stayed at McGill, because lots of fascinating things were happening there. But I received a call from John Banker, who was the chairman of the Anesthesia Department at Stanford, which in those days was really probably one of the two or three outstanding academic anesthesiology departments, I would say, in the world actually -- had extraordinarily good NIH funding, program project grants, some really brilliant people there. He somehow got to hear of what I was doing in McGill and offered me a job at Stanford. I was very flattered and somewhat -- I think my wife was somewhat bemused about the reversal of the plan to return immediately to Australia after one year. MELDRUM: [she laughs] COUSINS: We drove right across America; I think we traveled about five or six thousand miles in all, way up into the wilds of Canada and back down into America, with a brand-new baby bouncing around in the back of the car. And we eventually arrived at Stanford. I think it was really at Stanford that I received my rigorous training in research. At McGill, Philip Bromage was very supportive; Lloyd MacLean, who was professor of surgery, was very supportive. But in essence I think Charles Wright and I learned on the job. I think we learned quite a lot very fast. But at Stanford I was exposed to a lot of seasoned basic and clinical investigators, and I think I really learned the scientific method there. I was extremely fortunate, shortly after I arrived at Stanford, to become immediately involved in a very, very productive basic research program, but to also have an opportunity to continue to do clinical research. Looking back, I think that was somewhat unusual, because people, then and now, tend to either opt for doing basic research or clinical research. MELDRUM: Yes. One or the other. COUSINS: For me it was an important lesson because I found that the power of having a basic research program related to clinical research and clinical problems was extremely valuable; it really added an enormous amount of pertinence to the basic research and added rigor to the clinical research. This, of course, is a concept that John Bonica really pushed very hard -- MELDRUM: Right. The combining of the two. COUSINS: -- that we really had to get this interchange going between the basic and clinical researchers. So it really continued right throughout my professional life and into the present time. MELDRUM: So you were at Stanford for about four years? COUSINS: Yes. I think about three and a half years in all. MELDRUM: And you had the opportunity -- so you suggested I looked at this article about nephrotoxicity of methoxyflurane? [she laughs] COUSINS: Yes. MELDRUM: One of the things that surprised me in looking through the articles was that there was a lot of discussion about the pharmacokinetics -- particularly the pharmacokinetics, the kinetic action of various drugs -- and I was really surprised that research on this had not been done before, apparently, the 70s and 80s. COUSINS: No, that was quite an interesting era. Methoxyflurane, of course, was a superb analgesic and remains so. I guess if we ever have a global disaster -- and I sincerely hope we dont -- methoxyflurane would have to emerge as a pretty strong contender for an extremely cheap, inexpensive, and easy-to-administer analgesic. Its an anesthetic agent given in full doses, but its an extremely safe drug that can be inhaled from very, very simple little devices -- even a whistle type of device which just has a wick in it that is moistened, and you breathe through the whistle. Its been used in childbirth and is still used in some parts of the world. But our studies really show that it was a dose-related nephrotoxin, and we were able to do some interlocking studies which really pinned down the etiology of the nephrotoxicity. So I learned a lot from that work; it was based upon the Kochs postulates concept, and I think the rigor that went into that work was an important learning experience for me. I suppose it tended also to kindle my interest in pharmacology as a broad subject -- toxicity, recognizing that no agent is useful unless it has a sufficient margin between safe and toxic doses, and that has continued; were still doing work on kidney toxicity [he laughs] as part of our research of analgesics. But it was wonderful. My, the colleague that I worked with there for three and a half years, Dick Mazze, is actually here at this American Society [of Anesthesiologists] meeting; hes coming along to hear my [Emery A.] Rovenstine [Memorial] Lecture tomorrow. Hes no longer involved in clinical medicine, but we were fortunate to click. We had a wonderfully productive -- I dont think Ive ever been as productive as I was in those three and a half years. My research of course has gone well away from the anesthetic agents, although I do believe that there remains an enormous overlap between anesthesia and pain relief -- not only philosophically, ethically, but also in terms of the emerging pharmacology and our understanding of mechanisms. I suspect that theyre going to come even closer together in the very near future. So I keep an eye on whats going on there; Im still interested in it, but my research really has moved away from the pure anesthetic agents to other areas, which are basically the analgesic agents. MELDRUM: Right. Okay. Let me go back just briefly to the question that I was -- At this time, there were a variety of anesthetic agents in use -- COUSINS: Yes. MELDRUM: But their kinetic action was not well understood? They were being used -- COUSINS: Very little kinetic work had been done in those days, and there are a lot of reasons for that. Firstly, the measurement methods were not really reliable. To measure the anesthetic agents might appear to be simple, but in fact to measure them in the blood was rather tricky. The opiate drugs really hadnt been measured at all with sensitive methods, and my colleague, Laurie [Laurence] Mather, who I recruited back to Australia when I went back there from Seattle, was actually the first person to do kinetic studies of the opiate drug, pethidine. MELDRUM: And he was an American? COUSINS: Australian. He was an Australian; like me, he had come from Australia in 69 to work in Seattle, to sit at the feet of John Bonica. Shortly after I arrived in Stanford, I went up to Seattle to meet John Bonica, because I was interested to see what he thought of my vascular surgery study since hed also -- his group had also studied vascular surgery patients. I suddenly became aware of this powerful figure in the field of pain management; but working at the close-by institution, the Mason Clinic, another Australian, Laurie Mather, was doing kinetic work on the local anesthetics, on the opiates, and I had done some kinetic work with the anesthetic agents. So we immediately entered into a strong dialogue. When I started to get offers to return to Australia, I thought in terms of recruiting him. Weve been working together ever since that time; weve had a partnership that started in 1975 and its still going strong. MELDRUM: Thats excellent. A remarkable collaboration. COUSINS: Im not a pharmacokineticist; anything that I know about pharmacokinetics Ive learned from him. However, I have tended to prompt him to look into various areas that he may not have gone, and as a result of that, weve been able to add some insight into kinetics of various different drugs and also various different methods of administration. I guess thats tended to be our main theme in the last fifteen or so years, looking at different routes of administration, very often of existing agents. Novel routes giving greater advantages to patients with different types of pain, particularly the spinal route, which has really been one, I suppose, thats been the major theme. MELDRUM: Correct me -- let me just state what I think I gleaned from all this -- what you were actually finding was that because you could show that, by using the spinal route, you had the blood concentrations rose more slowly, while the spinal fluid concentrations rose more quickly, showing that the agent was actually getting to the nerves more quickly and more effectively. COUSINS: Yes. Youve just described what was probably the study that really triggered our great interest in the spinal route. That was in 1978 that we did that work, and we became aware of work that had been previously done, in effect, partly by an Australian, Arthur Duggan, at the Australian National University. Arthur, I think, was really the first person in the world with microinjection, with multibarreled, tiny electrodes, to inject little tiny doses of morphine into the dorsal horn of the spinal cord. He showed that it produced an analgesic effect. Then Tony Yaksh, with [T.A.] Rudy, showed behavioral analgesia, and then [J.K.] Wang at the Mayo Clinic showed, in some cancer patients, that intrathecal administration of morphine produced analgesia. Well, right about that time, Tony Yaksh came and visited me in Adelaide, after Id set up the new academic Department of Anesthesiology there, and we were discussing all of this -- and I can remember this very clearly -- I said, Well, you must be able to do this epidurally, because that would be much more valuable. You can place catheters, you can do it over a long period of time. He said, Well, gee, I hadnt thought of that, but Im not sure the opiate drugs would get across the dura. MELDRUM: Ah! COUSINS: But, he said, look, Ill tell you what. Ill give you two months start. You go ahead with it, and I wont do anything for two months. But after that, Im getting into it, too. MELDRUM: [she laughs] COUSINS: So we went straight to the clinical; we decided there was enough evidence of safety, and there was a great deal of evidence to show lack of neurotoxicity. And we gained quite rapid ethical approval from our human ethics committee to study patients with cancer having surgery. AIn fact our very first studies were with intrathecal; we administered intrathecal morphine to a number of patients having thoracotomy for cancer surgery, and we found, to our great interest, that these patients achieved profound analgesia well into the postoperative period. It was very, very exciting, actually. However, we also found that a couple of them developed very, very disconcerting delayed depression -- [Pause] COUSINS: -- and we wrote an immediate letter to The Lancet, which in fact was the first report of delayed respiratory depression associated with spinal administration of morphine. Others quickly reported the same problem, and some of our subsequent research was really focused on trying to delineate why this was occurring, what was the mechanism of it. That led us into the kinetic studies of the spinal fluid concentrations of morphine and the migration of morphine from the spinal area towards the brain. But that was really a sidetrack; our real intent was to study not morphine but the drug pethidine, or meperidine or Demerol, as its known in America, given epidurally. The reason we chose Demerol was it was fairly soluble in the body fat, and according to my pharmacokineticist friend, Laurie Mather, it would cross the dura more readily, more rapidly certainly, and would be a better choice. So our early series of studies were again in cancer patients having surgery, but this time with an epidural catheter placed. We were able to take samples of blood and also samples of spinal fluid, and we did an interesting thing in that study that to my knowledge nobodys ever done since; we took those patients on a separate day and infused pethidine, meperidine, intravenously to find out how, what sort of blood concentration they needed, with infusion intravenously, to get pain relief. Having that information, we could then look at that data we got from the spinal fluid and blood sampling after epidural administration and get some sort of comparators to see whether we were really getting pain relief from the drug in the spinal fluid or whether the blood concentrations that were achieved with that epidural administration were high enough to actually produce pain relief by themselves. In fact, we found that they werent, and we wrote an immediate letter to The Lancet, which was published more rapidly than anything else Ive ever written -- MELDRUM: [she laughs] COUSINS: -- we faxed it over, and twenty-four hours later we received an acceptance. One week after that it was actually published in The Lancet. MELDRUM: Wow! COUSINS: So that was very, very rapid. However, interesting enough, we were pipped at the post for writing the first paper on epidural administration of an opiate drug, by some individuals that had been associated with Pat Wall -- Dr. [M.] Behar and [F.] Magora, who at Pat Walls urging had really just given morphine, in fact, epidurally to a whole series of patients with different problems. Yhey published a series of case reports, and I think their publication hit The Lancet, oh, about two or three weeks before ours. Ours was a different sort of report, of course; we were reporting the early results of a pharmacokinetic and pharmacodynamic study, and the definitive version of that -- it was only a letter that we sent to The Lancet -- was published in the journal Anesthesiology, which was entitled The Pharmacokinetics and Pharmacodynamics of Epidural Administration of Pethidine. That was really the start of the whole series of studies we then did, with firstly looking at how delayed respiratory depression occurred, and we found that morphine diffused rather slowly and migrated rather slowly up the spinal cord to the brain. We found in fact it took about three hours to get there, but then took a little bit more time to actually penetrate deep enough into the brain tissue to affect the breathing center. This was the reason that patients would sometimes get delayed depression of respiratory function about ten or twelve hours after the dose. But we also found, as others did, that it was related to the dose, and when people brought the doses down to sensible levels, the problem really became very, very small, and remains a risk but a very small problem now. But our next focus was really to look at the various drugs, and we found that pethidine, really, if it was going to get to the brain, got there quickly, didnt produce delayed effects, nor did the other opiate fentanyl, which got there extremely quickly. So the advantage of that, of course, was that you could observe those effects while you were with the patients, whereas the other one, with morphine, might occur while the patient was back in the ward with little surveillance. More recently, we studied the drug Dilaudid, hydromorphone. I did that, in fact, while I was on sabbatical, back at Stanford again, in 1987. And we found that Dilaudid was really very, very similar in fact to morphine -- same potential for delayed depression, but in fact the drug had a more rapid onset and was perhaps a bit more rapidly cleared out of the brain, which makes it perhaps a little bit safer. But that interest in epidural administration of drugs has really continued with the whole host of new agents thats now emerging; theres really a new pharmacology, a new spinal cord pharmacology. MELDRUM: Oh, I have so many questions! [she laughs] Okay. Just touching on that, then, again, I associate John Bonica with introducing epidural anesthesia for obstetrics. Is this incorrect? COUSINS: Well, John didnt really introduce epidural for obstetrics; he certainly championed it, theres no doubt about that. There are various people who contributed to epidural for obstetrics. One was a man who was actually in Montreal; his name was [John G.P.] Cleland. MELDRUM: Charles Cleeland? COUSINS: Yes. Now -- no, not Charlie Cleeland; no, no, no. A different Cleland, much older than Charlie. He was really the first to clearly describe what could be called segmental epidural -- in other words, an epidural block only affecting the segments of the spinal cord that were absolutely essential for the relief of childbirth pain. In early labor, that turns out to be only two or three segments of the spinal cord. MELDRUM: Oh, I see! COUSINS: And the value of that, of course, was that only small doses of a local anesthetic needed to be given. So in my mind, Cleeland is the person who gave us the information about the real advantage of lumbar epidural, whereas up until that time the technique of caudal had been used, which was really popularized by Hinkson. But John, I think, really championed the use of good pain relief for childbirth pain in general, which included caudal, epidural, and other methods. And part of that, as you may have heard from others, related to a rather horrendous experience he had with his own wife, who received quite appalling anesthesia for one of her births. MELDRUM: Angela. The birth of their first daughter. COUSINS: Yes, thats right. But Johns little book for the WHO -- no, it was not the WHO; I think it was for the WFSA [World Federation of Societies of Anesthesiologists], on pain relief in childbirth, was one of the very early books on analgesia for childbirth which was widely available. And then, of course, his own textbook on pain relief in childbirth made an important contribution. MELDRUM: Now, clearly, at least as I understand it, what youre doing it is marrying basic research and clinical research -- COUSINS: Yes. Yes. Very much so. MELDRUM: -- marrying the pharmacological studies with the observations of the patients. COUSINS: Yes. We tend to, in fact, go both ways. Very often well identify a clinical problem and well then design some basic research studies to attack that problem, and then with the insight gained from the basic research, well go back into the clinical studies again. Weve done that many, many times over. For example, the studies with spinal administration of opiate and non-opiate drugs very much exemplify that. I should say that, in our very first study that we did with pethidine, I used the term selective spinal analgesia. Initially that was sort of embraced as being a very exciting new concept, but a lot of people who read the eventual article in Anesthesiology, I think, misunderstood what we were saying. What we were saying was that the analgesia one could obtain with spinal administration of pethidine was different to the analgesia one would obtain with a local anesthetic, in that local anesthetics clearly would block potentially sensory and motor and sympathetic fibers. Whereas the opiate drugs tended -- well, they didnt do that. We now know that pethidine can, in fact, if you increase the concentration, produce some degree of neural blockade; morphine doesnt. But some people misinterpreted that to say that we were implying that there were no effects on the brain. We knew very well that there were effects on the brain, because we measured blood concentrations that clearly, in some patients, actually were high enough to produce analgesia at a brain level. Well, thats all become a bit academic now, because were now aware of the fact that the opiate drugs in fact act, if theyre given into the systemic circulation or they get into there from any route, they will act at the periphery, if theres tissue damage at the periphery, at the spinal cord, and also at the brain. But the original concept, I think, of selective spinal analgesia is a very, very important one, because that now has become the target for our new drugs. We now really are trying to develop drugs that purely act on the spinal cord, or predominantly act there, and most importantly of all, leave other functions, sensory, motor, and sympathetic function untouched, and were getting very close to that now. MELDRUM: Well, thats exciting. COUSINS: Many, many of the drugs that are actually now being used clinically do achieve that already. MELDRUM: Is that coming from the pharmaceutical companies, working on this proposition? COUSINS: Some of them are; some of them are coming from research workers who have reevaluated old drugs. Clonidine is a very good example of that; clonidine is an alpha-2 agonist drug which was originally used for the treatment of high blood pressure. We may want to turn off for a minute; somebodys trying to come through, I think. [Pause] MELDRUM: Okay. Can I ask you just a little bit, because this is a particular interest of mine, on the one hand you were rating the patients pain relief -- I think in one article, an early article, you were using a numeric score, zero, one, two -- COUSINS: Yes. That was very early on. MELDRUM: -- then later you went to visual analog. And I just wondered if youd comment about which method seemed to be preferable, or which -- ? COUSINS: Well, in the very early days, we were working with postoperative patients, and often in the early postoperative period. And we found that they would sometimes find it difficult to work with the visual analog scale. MELDRUM: Yes, I can see that. COUSINS: So we tried to simplify matters almost down to the level of, Have you got pain or have you not got pain? MELDRUM: [she laughs] [Henry K.] Beecher used that. COUSINS: Thats right. Thats a fairly fundamental question, really. But later on our work tended to move much further into the postoperative period, to the second and third day, and of course with cancer patients and patients with intractable, chronic pain. In those settings we found the visual analog scale was really a -- it gave us more information. But that of course alone was insufficient; like others, we found that we needed other dimensions of pain, and nowadays we use the McGill-Melzack Pain Questionnaire and others to give that wider dimension of not only the pain, but also the dysfunction associated with the pain, both mental and physical. MELDRUM: Okay. And I think in one of the last papers you were talking about variability between patients and how that has to be taken into account. COUSINS: Yes. That was one of the big themes that Laurie Mather developed. One of our Ph.D. students, Kevin Austin -- he was our first Ph.D., in fact, when I went to Adelaide to take up the new chair there -- he studied blood concentration in analgesia, after intramuscular administration in patients with postoperative pain. I suppose this was one of the very early studies measuring blood concentration in opiates. Not surprisingly, in retrospect, he found an enormous variation in the blood concentrations that were required to produce pain relief among patients. I think this is a very important paper, because it pointed out that one really had to carefully titrate the dose in individual patients and observe the response. Of course, in the past, people would just give the standard dose, and if it didnt work, the comment would be, This patient has a low pain threshold, and that of course is either very patronizing and, in fact, a very inaccurate statement. We know that there are many mechanisms, both physical, psychological, and environmental, and indeed also pharmacokinetic and pharmacodynamic mechanisms, that contribute to this variability among patients, and we expect it now. So I think that was a very important step, and unfortunately failure to appreciate this variability among patients still leads to poor treatment of pain -- both undertreatment and also overtreatment. MELDRUM: Thats very interesting, because its standard to think, yes, that there are physical and emotional and experiential differences among patients, but theres actually differences in the blood concentration levels which -- I mean, that must be biochemical, genetic -- COUSINS: There are many factors involved in it; we dont know them all yet. Interesting enough, one of the few mistakes that Henry Beecher made -- I think Beecher made some enormous contributions to the understanding of pain; probably amongst the greatest was his description of subjective responses in humans, the design of clinical trials -- but he did make a mistake with his publication, I think in the New England Journal of Medicine, of a paper that described the dose of morphine. MELDRUM: Ah, yes, I remember that. COUSINS: The paper really put the message very clearly that 10 mg was the dose, and to go any higher than that was really a very bad thing, because it wouldnt be any more helpful, and it would be dangerous. That was one hundred percent wrong. I guess we all, all of us, publish papers that are wrong [he laughs], and that one was certainly -- it held back, I think, in a very powerful way -- MELDRUM: Right. It was very influential. COUSINS: -- this attention to individual response. That concept still is ingrained in the teaching of quite a number of health professionals, I have to say. MELDRUM: Wow. Ten milligrams. COUSINS: Thats it. Any more than that and youre an addict. MELDRUM: Oh, yes. Well -- ! Okay, so we sort of lost track of you. You were at Stanford -- COUSINS: Yes. Yes. MELDRUM: -- and you were happy and doing well, but then you received an offer to come back to Australia. COUSINS: Well, yes, I received -- MELDRUM: Or were you looking for an offer? COUSINS: I actually received an offer to stay at Stanford, and this precipitated everything. I was extremely tempted to stay there. I might say that, at this stage, I had well and truly started my practice in pain management, and I suppose in a way it started a dual interest that continued for the next ten years or so, where I continued to pursue anesthetic pharmacology, but also became increasingly involved in the clinical treatment of pain and to some extent in pain research, both clinical and basic. But the offer to stay at Stanford precipitated us to look fairly closely at whether we were going to finish up living in America or Australia, and I suppose in the end there our choice to go back to Australia was heavily influenced by the presence of our families there, and probably also, a rather conscious decision that we chose that our children would grow up in Australia. Otherwise, the balance was overwhelmingly in favor of staying at Stanford. The opportunities for academic endeavor in anesthesia in Australia were virtually nil at that point, although I became aware of a new, a very exciting new university being developed in the south of Australia called the Flinders University of South Australia, and I can remember looking at an aerial view of the campus there; it was set out of town amongst the hills, and I remember a shiver ran up my spine and I said, My goodness; that looks a bit like Stanford. At that stage I had no inkling that Id finish up there; I purely went back to Sydney, to my old hospital, to a not terribly receptive environment, Id have to say, but I managed to start a pain management center. I borrowed some space in an outpatient department; I inveigled a physiotherapist to work with me, who was superb; I managed to borrow some nursing staff; borrowed some operating time; and I remember I had to do nerve blocks in a side theater, while I was supervising a resident doing anesthesia in an adjacent theater. So -- and Id take calls from patients over the telephone, while I was working in the operating room. MELDRUM: So you were really sort of scrounging in your research. COUSINS: This was pretty tough stuff. But I also managed to get quite an extensive clinical research program going, with three or four Fellows, and I even managed to get some animal toxicology work going. However, it was tough, and not many people were terribly interested in academic endeavor. So, after about nine months, I became aware that the chair of, new chair of anesthesia and intensive care had been advertised at the Flinders University in South Australia; I didnt apply for it, and I thought I was too junior, not ready. But I received a telephone call one day to say that various people had suggested that I should apply; and they noted that I had not applied, and would I consider doing so? MELDRUM: [she laughs] Thats very flattering. COUSINS: So I did, and to my great surprise I was successful. And in 1975 I went down there, there was nothing there, the hospital wasnt finished. There was nobody in the Department; there was no research laboratory, whatever. So I had an opportunity to plan the whole thing from the ground up. MELDRUM: Thats exciting. COUSINS: It was exciting. It was an enormous challenge for a very young person. However, it was probably one of the more rewarding things Ive done. I decided at the outset that pain research and a pain management clinic would be a very high priority, and I remember writing a submission for the then university and hospital administrators, and Id have to say they werent the slightest bit impressed by the submission; they saw my brief as being developing a good service in the operating room and a good intensive care unit, end of story. MELDRUM: Okay. Were almost at the end of the tape, so Im going to END OF TAPE MICHAEL J. COUSINS INTERVIEW TAPE ONE, SIDE TWO MARCIA MELDRUM: Okay. Were starting the second side of the tape, and this is Tape One of my interview with Michael Cousins on October 19, 1997. We were talking about your setting up your own Department and pain management center at Flinders. MICHAEL COUSINS: Thats right. That was in 1975. Despite considerable lack of enthusiasm on the part of authorities there [sounds of cleaning crew] I think theyre going to be going upstairs [Pause] COUSINS: So, as I was saying, I think probably rather, in a rather similar manner to the experience of people even today, my proposal to establish a multidisciplinary pain center in Adelaide was not received with great enthusiasm. I had to battle extremely hard to obtain the space and the resources to do this. Indeed, we started without any significant space. We had a little borrowed space in the Outpatients Department; we were able to allocate some -- I had some reasonably generous research space allocation, so we immediately allocated a substantial part of that to basic pain research, and I quite deliberately attracted some basic pain research workers. But it wasnt until about 1983 that I was able to obtain funding from the state government, by going around the hospital authorities, basically. MELDRUM: Im sorry -- thats the state of -- COUSINS: The state of South Australia. In fact, in the end, I obtained that funding by weighing into the heroin debate, which became a political debate in Australia. Our Labour Party decided to espouse the use of heroin, and they consulted me shortly after Id had an operation, as a matter of fact; I remember I was at home, I wasnt feeling very well. My initial intention was to tell them to go and jump in the lake. MELDRUM: [she laughs] COUSINS: Because the evidence, of course, at that stage was quite clear that heroin offered nothing special to patients for pain relief. But they asked me if I would do a study. So I said, Well, yes, I think its a very interesting question, and we should really meet and talk about it in detail. I invited the Minister for Health out to my Department, and I arranged for two patients, one with cancer pain, one with chronic pain, to be there to describe to him their experience before they had effective treatment and after that, and neither of course had been treated with heroin. After that we gave him a very brief overview of some of the options that were then available for the assessment and treatment of pain, and after that was finished, he said, Look, Im getting the feeling that this heroin business is a bit of a distraction, and that the real issue is that were not applying what we know about the treatment of pain. He then, about a week after that, his wife was referred to me for treatment, and fortunately we were able to diagnose her problem very quickly and to help her; and very much, I suppose, after that, we entered a series of discussions that resulted in quite substantial funding for us to build a purpose-designed pain management facility with its own consulting rooms, operating theater, treatment rooms -- MELDRUM: So this was all from externally obtained funding. COUSINS: Yes, this is all from the government, directly from the government. I also obtained a substantial ongoing funding award to recruit a whole bunch of new staff, both research and clinical staff. So we then established quite a big multidisciplinary pain management and research group there, which continues today to operate quite successfully. When I returned to New South Wales, to Sydney, the same, again, it was very difficult. It was in the middle of a depression; despite the hospital having promised various things, they then found out their financial situation was too difficult. On this occasion, although the government made lots of very supportive noises and so did the university, they actually came up with very, very little. So on that occasion, I formed a group of people from the community, and in fact its now become a tax-exempt foundation in its own right. But they raised, over the course of the last five years, about six millions dollars in toto. With that money, we again built a purpose-designed pain management center; we put a large amount of that money into basic and clinical research facilities and equipment, and now were putting money into attracting really high-quality basic and clinical research workers from [elsewhere], some of them, including Arthur Duggan, incidentally, whos now coming back from Edinburgh to join us, and a number of other people of similar caliber. But in this situation it really has been down to the general public to identify this as being a priority area. Sadly, the government is not yet seeing the necessity to really address this massive medical problem. MELDRUM: Yes. Well, its no different in the States, as you know. COUSINS: Well, Im actually proposing in my lecture tomorrow that this is going to be the disease of the next century, the major disease of the next century. So for the government not to put resources into this is, I think, very short sighted -- very short sighted and, I think, sadly illustrates the fiscal rather than humanitarian approach to medicine that has characterized the end of this particular century. So again, Im hopeful that the next millennium will start with a more humanitarian approach because we certainly have lost that with managed care and various other approaches at the end of this century. Very sadly. MELDRUM: Yes. In the last, really, thirty years. COUSINS: Yes. It has not been a humanitarian era, I think, in the development of the human race. MELDRUM: [she laughs] COUSINS: Weve tended to focus on very materialistic and fiscal sorts of issues. MELDRUM: Cost-benefit. Yeah. COUSINS: I think so. MELDRUM: It is -- pain management is a hard thing sometimes to measure fiscally, although theres a lot of work lost. COUSINS: Its becoming better; its becoming better. We have data now -- all of our patients going through our center are followed up, and we accumulate data on every patient. We now have quite clear-cut information from one of the major programs, that the return-to-work rates are extremely high. The analgesic consumption, days-off work, consumption of medical and surgical treatments dramatically falls. I think those are the sort of data that will help the government to focus more on this sort of problem. MELDRUM: Yes, I would think so. But you were successful at putting together this new pain center at Flinders, and then what kinds of projects did you develop? Or did you recruit the staff and let them develop the projects? COUSINS: It was a rather interesting time. One of my early recruits to Adelaide was a man who had worked with Tony Yaksh, who was then at the Mayo Clinic; his name was Peter Wilson. I recruited him really specifically to set up animal models of spinal drug administration -- rabbit models -- because we wanted to be able to investigate the whole variety of drugs that could be useful spinally. He in fact pursued that for some time and then decided to return to the Mayo Clinic, and hes there to this day. Hes an Australian. But he, I guess, was very attracted by the milieu at the Mayo. MELDRUM: Yes. Its an exciting place. COUSINS: But we did, in fact, pursue animal studies of spinal drug administration; we were able to look at drugs of different lipid solubility, such as morphine compared to meperidine and even novel agents, in fact, develop some quite good models for examining whether drugs given spinally together just had additive effects, or whether one was able to obtain synergism. One of the very good scientists I recruited was a man called Plummer, John Plummer, and our paper of the combined effects of clonidine and morphine created quite a controversy because it challenged the existing method of looking for synergism, which was the so-called isobologram method. I still believe that the method we described was much more rigorous, and I was supported in that belief by quite a torrid series of letters in the medical literature -- MELDRUM: [she laughs] COUSINS: -- one of the people prominent in that debate on our side was Jon Levine, from the University of California, San Francisco, who had pursued a rather similar approach to the one that we pursued. But it has become an important issue, because we are indeed looking for drugs that are able to combine when given spinally, hopefully to add to each others effects. But the icing on the cake, I think Id describe it now, is to actually be able to get synergism, so theres a potentiation of effect; instead of getting one plus one, you get one plus one equals a little bit more than that. But its a somewhat semantic argument, because, quite frankly, if were able to add a second drug and get any improvement on the first drug, its still an advantage, provided we dont see some added toxicity. Thats where our continuing interest in looking at toxicity still comes to the fore. Its interesting how these themes seem to run through ones areas of interest. So we started that work, but we also started some very, very rigorous work on pharmacokinetics, and my colleague, Laurie Mather, set up a rather extraordinary sheep preparation with catheters across every organ in the body, so that we could actually measure very directly how the body handled drugs in each of the organs -- the heart, the lungs, the liver, the kidneys, the brain. Also, what effects those drugs had on the function of those organs. And that model we continue to pursue to this very day. I think it is a unique model, extremely difficult to maintain -- MELDRUM: I would think it would be very difficult, yeah. COUSINS: Its like an intensive care unit type of management; the animals have to be seen several times seven days a week. But weve been able to gain an enormous amount of information from that model. So that was, it took about five years to develop that fully. Another person I recruited was a young man who came to us initially from Oxford -- his name is Christopher Glynn -- he spent about three or four years with us and was really quite a key player in many of the early studies we did of spinal drug administration. He eventually returned to Oxford. We do have a significant brain drain from Australia, not surprisingly, and hes now one of the senior clinicians in the Oxford pain relief unit. But I think he carried with him some of the experience and approaches that had been developed while he was with us in Adelaide, particularly his interest in pharmacokinetics, which I think my colleague Laurie Mather was responsible for kindling in him. So there were a couple of early key people, and of course Laurie Mather himself was an enormously influential person in our early pharmacokinetic research. MELDRUM: He came with you from the States to Sydney? COUSINS: No, he joined me in Flinders, and in fact hed worked partly with John Bonica, but also partly with Dan Moore. His first work with local anesthetics was with Dan Moore, and Geoff Tucker was the other person who worked jointly with Laurie and Dan Moore. Laurie joined me as a lecturer initially, and over the years in Adelaide he rose to senior lecturer, associate professor, and finally to a personal chair, which is the position he holds in Sydney at the moment. But we continued with quite a lot of toxicity work in Adelaide, and we had animal models both of the kidney and also of liver toxicity. In fact, we developed quite a large group there that focused mainly on liver toxicity, with a pathologist, a biochemist, pharmacologist, and a very, very productive group, in fact. We published a large number of papers around that area, I suppose strayed a little bit from my eventual theme of pain relief, but in fact the methodology that we developed there, were still using for some of our studies now of analgesic-related organ toxicity. But we had a lot of clinical studies going, and in addition to the spinal drug administration, we really tried to optimize the use of opiates by whatever route -- by the oral route, intravenous, and even rectal administration. One of the studies, I think, that was potentially a useful one was our early study of the kinetics and dynamics of the oral administration of morphine and methadone, physeptone [injectable methadone]. I think it was one of the first papers we published in the journal Pain. MELDRUM: Yeah. Pain. I have that. COUSINS: Really what that showed I think was, again, the big variability in the bioavailability of the drug morphine given by mouth, and again the need to titrate, to make sure that -- MELDRUM: On each individual patient. COUSINS: -- in this particular patient, you were achieving an effective blood concentration. But also importantly in that study, we confirmed, in a prospective study, what had been documented by people like Robert Twycross, retrospectively, that if you actually got good control of the patients pain, that the dose stayed stable, until a new event occurred. We were able to document in that study that in virtually every case where the dose suddenly took a steep increase, that the patient had a fresh metastasis or some new -- MELDRUM: Wow! Thats fantastic. COUSINS: -- and thats been pretty much, I think, confirmed by other groups. Methadone we found to be a very intriguing drug; we invested a lot of effort in trying to optimize the use of methadone, and we found, in fact, that if you did study its kinetics carefully, you would use it safely. Unfortunately, I think its time has gone by; its proven that its too difficult for most people to use successfully, because there is an enormous variability in the half-life of methadone; it varies from about -- by half-life, I mean the time it takes to take the blood concentration down a half level -- it can vary from as low as four hours to as high as fifty hours. Obviously, if you get the timing interval wrong for a particular patient, the drug accumulates very quickly. So -- but we did quite a lot of work further to characterize what factors have an influence on the clearance of the drug methadone, and we came up in one of their publications with a very workable little regimen to be able to characterize the kinetics of methadone, just on an outpatient basis by having the patient come back on two successive days. And do blood concentrations and then plan a sensible regimen. It is certainly useable; I dont think many people are using it now because of the advent of MS [Morphine Sulfate] Contin and other sustained-release opiates, which, incidentally, later became a subject of the Departments research. Weve played, I think, the key part in developing the Australian version of sustained-release opiates, the drug Kapanol [Morphine Sulfate]. That was, that work was really done entirely by two people that I recruited to the Department: Geoff Gourlay, who was a biochemical pharmacologist, an excellent basic and clinical researcher, and David Cherry, who was a young registrar when I first went to Adelaide, and became very interested in pain management and involved in our clinical research program. Those two men, with input from John Plummer, really helped the Forling Company in Australia [Ed. Note: This company is now part of GlaxoSmithKline] to develop a sustained-release formulation of morphine, which I suspect is going to very strongly challenge the other formulations now available. So we now have at least two very good, long-acting oral morphine preparations available in the world. MELDRUM: Thats quite an achievement. COUSINS: Well, I personally played very little part in that latter study, apart from encouraging the other members to pursue that. In fact, I was close to leaving for Sydney, but they pursued it very well and, in fact, I think to some extent pushed the Forling Company to go on with this work and to bring it to fruition. MELDRUM: And you went to Sydney in 1991? COUSINS: 1990. Now that was a different Chair, in that I insisted on this occasion that it be called a Chair of Anaesthesia and Pain Management. MELDRUM: Yes. I saw that. COUSINS: I was the first Chair of Pain Management in Australia and I think really one of the very early Chairs of Pain Management anywhere in the world. At that stage there was no Chair of Pain Management in North America; the Bonica Chair was still being advertised, and it was advertised as a Chair of Pain Research. So I think this was a very early naming of a medical chair as pain management. Its interesting to see that many other medical centers in America, and some in Canada and some in Europe, have now decided to link anesthesia and pain management, which I think is very logical. Obviously, pain management could be applied to other specialties, too, and I suspect it will be. But that has, I suppose, enabled us to make it quite clear that our major focus is on those two areas, and probably about fifty percent of our research resources, both clinical and basic, are now focused on pain management. MELDRUM: Now, in your departments, where youre using anesthesiologists, obviously some pharmacologists as well, and combining clinical and basic research, are any physiologists participating? COUSINS: Yes, we have a number of subgroupings; with Arthur Duggan joining our group, we have, in fact, four neurophysiologists in the group now; we have a number of biochemical pharmacologists; we have quite a large number of clinical psychologists. In fact, I think at last count about five of them. Several psychiatrists, some of these of course involved in research at the clinical level, some of them in clinical care. We have other individuals, such as physical therapists, who are involved in research also. So it is very much a multidisciplinary group. We have a Ph.D. rheumatologist who is obviously interested in rheumatological pain and rheumatological pain research. So we have in fact developed very much along the Bonica concept of a multidisciplinary group, both at a clinical and a basic level. One of the more unusual things that weve been involved in recently has been starting a university diploma, a university masters degree in pain management, which again is run on a multidisciplinary basis. So the teachers are multidisciplinary, and the students are drawn from medicine, many disciplines, nursing, physical therapy, and even clinical psychology. That started in 1996; the first group graduates at the end of 1997. I think thats one of the early, if not the first, university-based specialists -- not specialists, a university degree course in pain management. MELDRUM: Yeah. I certainly dont know of too many in this country [the US]. [noise of cleaners in background] COUSINS: Do you want to move upstairs? Its getting a bit -- MELDRUM: Yes, it is getting a little -- [Pause] COUSINS: A year of research as well as doing the coursework for the diploma. MELDRUM: So these are like doctors, physicians already? COUSINS: Yes, theyre all postgraduates. Its a postgraduate course, but they can be postgraduates from any of the health sciences. So they have to have a tertiary degree of some description. MELDRUM: You probably have nurses as well? COUSINS: We do. We have a substantial number of nurses. But they would be predominantly anesthesiologists, nurses who have tended to focus their activity in pain management, a significant number of physical therapists, and in the new intake, which were just starting to receive applications for now, there will also be clinical psychologists, which was a bit underrepresented in the first intake, because, I think, of their perceived difficulties with the physiology and pharmacology side of it. But weve addressed that; its taught very much in an interactive manner, and the students interact much in the same way that they would in a multidisciplinary pain center. MELDRUM: So they sort of learn that from the beginning. COUSINS: Yes. So its, of course, very much in keeping with the current trends to teach medical students in an interactive problem-oriented sort of approach. MELDRUM: Is there any funding from the government for this program? COUSINS: None whatsoever. MELDRUM: People have to pay their own way? COUSINS: Weve had to seed this from the foundation which supports our work, and we aim, however, to become self supporting in two years time, based upon student fees. Well be starting a distance education program about the middle of next year, which will help to support it, of course, but will also open it up to the Asia-Pacific region, where there really is not a high level of activity in pain management, although in some countries there have been pain clinics for quite a long time. A lot of them are not multidisciplinary, however, and they tend to sort of still focus on the old concept of the nerve block clinic. So for them, it may be quite useful to have access to this sort of university-based course; we certainly hope so anyway. MELDRUM: Okay. We could go in two directions at this point. We could talk a little more about anesthesiology and pain management in Australia in general; why dont we talk about that for a little bit? COUSINS: All right. Sure. MELDRUM: I have the impression that when you came to Flinders and set this up, that this was kind of revolutionary in your country. COUSINS: Fairly much so, but not unique. There were some early pain pioneers, I guess would be the best way to describe them, in Australia, one of them being a man called Brian Dewire, who pulled together a group of specialists in Sydney, to Methodist Hospital in Sydney, mainly focusing on cancer pain, but also on other sorts of severe pain. And he went across and saw the Seattle clinic and decided that he would do something similar. The clinic really, however, didnt fully encompass, I suppose, the involvement of clinical psychologists and the assessment of psychological factors in patients with pain; it tended more to use psychiatrists and in those days, of course, we were still pretty much in the medical model. And it wasnt until more recent times that we realized that one needed to assess in every patient the physical, psychological, and environmental factors. But I think that was a forerunner; sadly, that sort of grouping in that institution is really not present any more, and I think the focus there has tended to shift to other venues and other approaches. But he was an early pioneer, theres no doubt about that. The support for this sort of thing was virtually nonexistent in his day. MELDRUM: That was the 60s? COUSINS: This was the 60s, yes. This had to be done really by voluntary contributions of time from the people that he managed to convince to do this. So I -- he was one of the people that I consulted when I first came back to Australia, and he was enormously helpful to me. In fact, he was one of the leaders in those days, called a dean; they were the so-called Faculty of Anaesthetists then; its now The College of Anaesthetists. But Ive got no doubt that he was one of the figures in Australia who tried to interest anesthesiologists in this as a field; very few took it up, sadly, very few. And still not a large number of anesthesiologists are being attracted to the field of pain management, so we still have some work to do. About eighteen months ago, I took on a task, for our College of Anaesthetists, of leading a committee which is now called the Pain Management Committee of the Australia and New Zealand College of Anaesthetists; and we started at the beginning of 1996 a Certificate in Pain Management, which really is rather similar to the American Society of Anesthesiologists certificate, with some differences in that we have to approve the facilities and the program for training; we actually approve posts for training, and our assessment is continuous rather than being an exit exam, although we do require people to write a mini-thesis at the end of the year. In 1999, well be moving to an actual diploma. As you know, we tend to have diplomas rather than boards in Australia, so the ANZCA -- Australia and New Zealand College of Anaesthesists will offer a training program and an exit examination in 1999, which will actually result in a qualification, a diploma, in pain management. And thats my responsibility to develop that; I have a committee helping me, and were pretty well, pretty much on target to get that all started. Incidentally, the English College will be -- the Royal College of Anaesthetists -- will be starting a diploma at around about the same time as the Australian College; Im very much in contact and collaboration, very open collaboration with Douglas Justins, whos an expatriate Australian, who has the role on the English College council of doing the same sort of exercise. So, by about the year 2000, we should be starting to see emerging, people who actually have professional college diplomas in pain management, and of course in the USA, as in Australia at the moment, there are individuals whove gained certification. I think a very important step, because to recognize pain management as a specialty in its own right has been a very, very important move. I should say that, of course, in America theres also the American Academy of Pain Medicine, which of course is a multidisciplinary group. MELDRUM: Right. Thats trying to set standards -- COUSINS: Yes. Well, not only that; it conducts examinations for individuals from a whole range of specialties, not just anesthesiology. And, again, I think thats been an important contribution. In Australia, we aim to join forces with our College of Physicians and Surgeons and rehabilitationists and psychiatrists, to actually run a joint examination. So the degree will be awarded in the specialty that represents the individuals activity, but were hoping to conduct a jointly supervised training in the examination program. And, again, thats part of my brief, to help do that. So I sincerely hope we can achieve it, because we work together, when they can work together, to do things successfully, and it seems rather logical, to do it that way. MELDRUM: Actually, yeah. Thats very far sighted of you. You said that there were sort of two people who pioneered, and you talked about one of them -- COUSINS: Yes. Well, I think the others tend to sort of fall into a -- a whole host of people who largely were doing nerve blocks. Some of them were able to pull together some degree of multidisciplinary approach, but they werent anesthetists, by and large. The person who I think really did set out in a very concerted way to develop a multidisciplinary approach was Issy Pilowsky, who is, of course, a psychiatrist. He was working at the other institution in Adelaide [the University of Adelaide], and we used to talk about the Adelaide School. So Sydney Sunderland, who did a great deal to help me to start the Australian Pain Society, used to, in his after-dinner speeches, refer to the Adelaide School, since there were really two groups in three different universities. Issy Pilowsky has, ever since that time, been a close friend of mine. Sadly, we never worked together in the same institution. It would have been a lot of fun to do so. But he pulled together a group of individuals at the University of Adelaide, based around the Department of Psychiatry. In the early days there was an anesthetist, a social worker, of course a number of psychiatrists, and some clinical psychologists working under his supervision. yhey were running a good multidisciplinary pain center. MELDRUM: But very few, I mean, in Perth and Melbourne and Canberra? COUSINS: Theres nothing in Melbourne, nothing much -- there was a man in Melbourne doing nerve blocks; there was a man in Perth doing nerve blocks, and also working in collaboration with a neurosurgeon and a number of other people. But the emphasis there was on procedures for pain management, and in fact they achieved, I think, some very good results with some of the procedures they were doing. The man in Melbourne was concentrating pretty much on cancer pain. His name was Russell Cole, and he did nerve blocks for many, many years for pain management. The person in Perth was a man called Keith Giles, who died recently. His interest was pretty heavily oriented toward nerve stimulation and spinal cord stimulation. But he also did a large number of nerve block procedures for diverse pain problems. Perth has now evolved to a multidisciplinary pain center; Melbourne has not yet done that, but I hope will do it soon. Were working very, very, hard at the moment, actually, to pressure the Victorian government, and weve been able to obtain some federal government support in fact for Melbourne to establish a center, but they still need a little support from their local government to get it going. But it will get going very soon, and we just finished training a very good man who will be able to go back to Melbourne, and next year well be training a clinician-basic scientist, who will definitely go back to Melbourne. So Melbourne, I think, will very soon emerge as a pretty major center. In Queensland, the focus is on palliative care, at the moment; there have been two attempts to get a major multidisciplinary center started. They failed largely because of a lack of government support, and at the moment that seems to be somewhat in abeyance, but hopefully well -- I think this exemplifies the fact that there still really isnt a high level of government interest in addressing this problem. MELDRUM: See, this is one of the things -- I mean, this is true in the United States as well -- theres sort of a government lack of interest, and obviously there are people with chronic pain, but its sometimes hard to mobilize them. I mean, you look at the American Cancer Association, for instance, going out and beating the bushes. COUSINS: Well, I think the problem is just the scarce resources for medical care in general. John Bonica found, and found very successfully, you have to be a strong champion for this area to get the resources. In some of these centers, there hasnt been an individual with enough political clout, I suppose is the best way to put it, in the local system, to be able to get the resources. I should say in Brisbane, a former professor of anesthesiology, Professor Tess Cramond, has done a very good job for many, many years in developing cancer pain management and really, more recently, palliative care, broadly speaking. In association with that, she is currently developing chronic pain management resources with some success now. So I think things are on the way; its a real struggle; its an enormous struggle for all of those centers. Theyre all under-resourced, they have inadequate staff, and the people doing it, I think, continually feel beleaguered and as though theyre working on, you know, about a half-empty tank, and sometimes an empty tank. So its still a pioneering field, extraordinarily, at this late stage. I sense very much that thats not just so in Australia; when I talk to my colleagues here in the USA and in Canada, theyre in exactly the same situation, except for a very small number of well-resourced units, and some of those are wavering a bit. Even the University of Washington, I think, is experiencing difficulties at the moment. We are still at the very, very early stage of this field, quite extraordinarily, when one looks at the magnitude of this problem. This is why I intend to push this concept of pain relief as a basic human right, because once society picks up on this, it will become very, very difficult for politicians not to provide the appropriate resources to do the job. And it should be a basic human right. MELDRUM: And so is this a matter of writing and speaking in the popular fora to try and spread the word? COUSINS: Yes. Obviously, starting to speak in the scientific and medical fora, because the more people that acknowledge that this is a valid concept, the more this will appear to be a unanimous opinion from the people who were meant to know what they were talking about. But then I think the crucial step will be to get prominent members of the community in philosophy, in arts, in as many different arms of the community as possible -- the lawmakers, the legislators, wed like to get some prominent figures in all of those areas to pick us up. MELDRUM: You had a sort of prototype model when you put together a group to fund your Sydney hospital. COUSINS: Yes, weve been very fortunate. Weve had some very prominent individuals from the business community who have put their weight behind us, and theyve done it in a big way. Im fairly encouraged that it can be done, but it wont be easy; it wont be easy at all. The Wisconsin Initiative, of course, for Cancer Pain [Wisconsin Cancer Pain Initiative, SCPI] is a good example of what one can do. Cancer pain tends to be a little bit easier than non-cancer pain. MELDRUM: Right. Well, theres an establishment in place, which is working on cancer, and you can sort of tap into that. COUSINS: There is indeed, and it tends to be a more emotive and readily understood area. Whereas chronic pain, Im afraid, is much misunderstood and to some extent has had a rather cruel and unfortunate label. People with lower back pain are sometimes characterized in a very condescending manner, and this goes back a long way, even to some of the cartoons in former eras. I think it will not be an easy endeavor, but the crucial thing will be some very good communicators in the lay community who decide to pick this up, and so far there havent been many of those, actually. I think Margaret Somerville in Montreal [Acting Director of the McGill Centre for Medicine, Ethics and Law], who has taken this cause up from a lawyers point of view, has been very helpful. I think the way she puts her concepts is very persuasive. So thats, thats a good start, and there are others who have done the same. MELDRUM: Okay. Well, this seems -- were running at the end of the tape again, but this seems like a good place to start talking about the IASP []. COUSINS: Yes. Yes. Sure. MELDRUM: When the IASP was formed, you were at Stanford -- COUSINS: Yes, I was at Stanford. MELDRUM: -- and you visited Seattle; you were aware of this -- COUSINS: I visited Seattle a number of times, actually, and I was aware that the IASP was on the agenda. Unfortunately, I couldnt go to the initial meeting at Issaquah, because I was on duty. So I missed it, to my eternal disappointment [he laughs], I must say. But as soon as I arrived back in Australia, John Bonica called me and said hed like me to become a vice president for the Pacific Region -- in those days we had regional vice presidents; theyre not there any more -- so I certainly of course agreed. AI think it was about 1976 that I attended my first Council meeting, which was in Lisbon. I, of course, felt like a neophyte amongst a group of giants. I can remember people like Fred Kerr, Bill Sweet, Peter Nathan, Ainsley Iggo, Mme. [Denise] Albe-Fessard, and at that meeting in fact, John [Bonica] was in hospital, having one of his many, many operations, and nevertheless he dictated responses to virtually every item on the agenda. But not only had he done that; he also contacted some of his, in quotations, constituencies among the Council, including the Italian constituency, which at that time included Paolo Procacci and [Carlo] Pagni. I would say on every item on which John Bonica had expressed an opinion, those two individuals voted consistently -- MELDRUM: [she laughs] Along with that. COUSINS: Thats right, and a few other people hed also spoken to. But everything John had proposed went through. I remember Ainsley Iggo saying, I dont know; hes not here, but by George, you can see the influence he has. [both laugh] So he was sort of acting president for that meeting. But it was wonderful. Pat Wall, of course, and Ron Melzack were there; I think Dick Sternbach in those days, and John Liebeskind, of course, was on Council at that time. It was a wonderful experience for me as a very young person in this field to meet at first hand the people whose papers Id been reading. MELDRUM: Right. How exciting. COUSINS: And who clearly were the leaders. In those days, of course, the leaders were few in number. MELDRUM: Right. So you could really get them all together. COUSINS: It was a club. Theres no doubt about it. It was a rather exclusive club, and to some extent that was helpful, because it meant that there was very close and ready interchange among the people who were playing a part in developing this new field. But, on the other hand, I think it was something that had to change because there was a very great need to include rather than to exclude. That was a feeling that perhaps didnt develop until a bit later. But nevertheless I felt it to be a great privilege to be involved, and I was invited, not long after that, to become chairman of the finance committee. Im not quite sure how that was; I guess I was so aware of the terrible imperative to obtain END OF TAPE MICHAEL J. COUSINS INTERVIEW TAPE TWO, SIDE ONE MARCIA MELDRUM: Were starting Tape Two of my interview with Dr. Michael Cousins on October 19. You were saying youve been put on the finance committee of the [IASP] Council. MICHAEL COUSINS: Oh, right, right. So that was, I suppose, an interesting challenge, really, because in those early days, finances were extremely limited for the IASP; I think it could be described as being very much a shoestring operation. We had very little money for programs, and in fact, were spending virtually nothing on programs. I determined that I would try to find some method of consolidating the finances so we could actually start funding some programs. I felt that the IASP had to show its members that it was actually doing something. For me that became a theme that lasted into the days of my presidency quite a long time after. It also provided me with a rather fascinating challenge early on; John Bonica had been helping the IASP by providing Louisa Jones in essence gratis to the IASP, since Louisa was his editorial assistant, and when IASP took off, it became apparent that IASP would really need somebody full time. So Louisa moved into the IASP as -- I forget what her original title was; I think it was probably Secretary. MELDRUM: Right. I think something like that. COUSINS: John suddenly found that he had no secretary, and indeed had no support from the university either, because at that stage he was moving out of his chair. So he put up a proposal to the IASP to assist him, at least in the early days, with some financial input to, I suppose, in some sense repay -- MELDRUM: Repay him for his work, yeah. COUSINS: -- some of the gratis time that he provided with Louisa. I have to say that some of my colleagues on the Council were not terribly receptive to that approach; and they gave me the unpalatable task of sitting down with John to break this news to him. For a neophyte at my stage to approach the Grand Man with this news was a very daunting task, Id have to say. But we managed to reach a compromise in the end, which involved a little bit less support than was originally requested, but we still maintained some input. But I will never forget that interview. MELDRUM: [she laughs] COUSINS: I was quaking in my boots. But John and I became very, very firm friends and developed a very strong mutual regard for each other which lasted for many, many years until his death. I think really, in many respects, John was my father in the field of pain management, as he was to many people, of course, and a lot of the things that I have persevered with, Ive done because of his example. Theres no doubt that he gave an extraordinary example of dedication and perseverance, often against insuperable odds. I know of no one in the field of pain management who has really followed a tough pilgrim path as he did, and just pressed on and pressed on. So its unfortunate, I think, that probably some of the younger people coming in now dont have access to that example. Hopefully this project will enable them to do that. MELDRUM: Yes, I think that could be very crucial, because I think the story here is indeed so interesting and the characters of men like Bonica, probably him above all -- COUSINS: I think Johns story is a rather unique one in the field of medicine. These days there are few people in medicine who can be solely responsible for putting a new discipline on its feet, and John did that -- not only from the point of view of developing it as a clinical discipline, but also of really almost badgering the basic scientists into becoming relevant in their research work, and focusing on pain and influencing so many people to come into the field. MELDRUM: Yes. Such a wide-ranging influence. COUSINS: I think its wonderful that he had the satisfaction, before he died, of seeing this new specialty pretty much come of age. Very, very few people in medicine these days have the opportunity to be the father of a new field. So I believe he was a unique man -- MELDRUM: In any age, really. MELDRUM: -- in any age; a very complex man, but a wonderful person. MELDRUM: Yes. Thats a standard assessment, but its also remarkable how many people speak it with affection as well as admiration. COUSINS: Yes. He was, I think, misinterpreted by some people; he apparently had a very tough side, and theres no doubt that if he decided to be tough, he could be very tough. But inside of that was a very warm heart, I think; a family man of enormous affection and really a wonderful person to know. So for me, hes one of the, perhaps the most remarkable person Ive met in the field of medicine. Yes. MELDRUM: Amazing. So at what point then did the Australian chapter -- COUSINS: The Australian chapter, it started as just that. In fact, it was the Austral-Asian chapter of the IASP; it was formed in 19 -- Ill have to check this date, but I believe it was 1978. I was the first president, and we had the initial meeting in Surfers Paradise, up on the Gold Coast, in Queensland. It was a very small meeting. Brian Dewire was there and helped me a great deal in getting the chapter going. Sydney Sunderland, I suppose, who was the first Australian to be a Councillor of the IASP and the first to be an honorary member -- Sydney really was our sort of patron. He was there in the background, being helpful; I suppose, helping us to bring in some basic scientists as well as clinicians, because he was seen as being both. He was a wonderful man. Again, he remained a friend until he died quite recently, and I think hes one of the giants of research in the field of pain management. His book, Nerves and Nerve Injuries, I believe, is an absolute classic. He was just a wonderful man in the same sort of genre as John Bonica, but obviously not the same sort of sized figure. So he was there, and I believe Arthur Duggan was there, but it was probably a group of only a couple dozen people, a very small meeting. MELDRUM: Were there other countries involved? COUSINS: Oh, no, no. MELDRUM: Austral-Asian, but it was all Australia. COUSINS: Austral-Asian. I cant even remember if we had any New Zealanders at that initial meeting. Issy Palowsky of course was there; the second meeting we started to really encourage New Zealanders to be present, and Im sure they were at the second meeting. The third meeting we actually had at Flinders Medical Centre. In those days we were trying to keep the meetings very, very low price, and I remember we made the abstract books by photocopying and hand binding, so they cost nothing; I think the registration for the meeting was about ten dollars; we put people up in university halls of residence; we managed to get the university lecture theaters for nothing, and we got a bit of drug company sponsorship. So it was a very low-budget meeting, but it was a wonderful meeting, and John Liebeskind, in fact, was our invited speaker. MELDRUM: Oh, how exciting. Yes. Im glad you told me. COUSINS: John gave an extraordinary presentation. He used no slides; he had his whole lecture typed out on sheets of paper, and when he first started to do this, I thought this was not going to be good, to have an oral presentation read from notes. But in fact he carried it off wonderfully well, covered an extraordinary amount of material in the time, and really gave a wonderfully comprehensive coverage, in fact, of the like that I dont think Ive ever heard since. Ive never heard somebody in the course of an hour hold peoples attention and cover pretty well every relevant facet of a particular field. So I sat there absolutely fascinated, and it was a great start to our invited speakers, and I think really set the standard. So that was a wonderful meeting, and then weve continued on. Since that time, the meetings have grown bigger and bigger; weve very much embraced all of the relevant disciplines, and the society now, I think per capita, is one of the largest societies in the IASP. We decided, after a short time, that saying we were going to be the Austral-Asian Chapter of the International Association of the Study of Pain was a little bit too long, so we abbreviated it to the Australian Pain Society because the New Zealanders wanted to have their own society. Theyre both thriving extremely well now. MELDRUM: At some point you -- lets see; you became President-elect in 1984. COUSINS: 1984, thats right. 1984 to 87, I was President-elect, thats right. It was a very interesting era. Ron Melzack was President in 1984, and he and I had an enormous rapport. We seemed to be thinking along very similar lines as to where the IASP should go; and it was at that stage that I started to push my idea that the IASP so far had been identified with chronic pain, to some extent with cancer pain, although John Bonica had put in a lot of work with the WHO to try to pioneer cancer pain. But that had not been seen as being an IASP initiative as much as a John Bonica initiative. Whether that was appropriate or not, the reality was that the perception of IASP was that it was a chronic pain organization. I felt that was terribly wrong, that the IASP should be very much involved in acute pain. I might say some of the board members opposed me strongly on that -- Council, as it was called. I also felt that we had done far too little in the area of cancer pain, and I was strongly supported in that view by Kathy Foley, who was on the Council at that point. So, fortunately, Ron Melzack shared that view with me. During that period of his presidency and my vice presidency, we started to develop those ideas and to start to have some task forces. The idea of the task forces was to target a particular area and really move things on. I cant actually remember what all the task forces that Ron developed. I think probably the Task Force on Acute Pain Management did not start until my presidency commenced, but that was one that we both agreed would be necessary; and the Task Force on a Core Curriculum also commenced at the start of my presidency. But Ron certainly started the concept of having task forces. I think the other aspect that Ron and I both agreed very strongly about was that we needed to increase the membership. We needed to try to make it possible for people from currency-restricted and developing countries to become members and not be seen as being second-class citizens. Again Id have to say that some of the previous Council members had not been terribly sympathetic towards bringing in people from those two categories, because their attitude was, well, if they couldnt pay the fees, they couldnt be members. I felt that was terribly wrong because, after all, they wanted to have the scientific and clinical interchange that we were trying to foster and were just hampered by lacking the funds to do it. So we worked towards that; we werent able to achieve it initially, but in fact, some time after 1987, I remember we had a series of meetings, in John Loesers house in Seattle, that I came across for, and we finally hammered out, would be the right way to describe it, a strategy whereby we could admit those people to some appropriate membership to the IASP. That provided us with an opportunity then, to interact with people in a whole host of countries that had just never connected with the IASP before. MELDRUM: And not very much of probably many medical societies around the world. COUSINS: Thats exactly right. I suppose the things that I hold most dear, during my own presidency, were the developing of the Task Force on Acute Pain and announcing to the general community that the IASP was very much focused on acute pain, and I think the little manual that Brian Ready and his task force produced was valuable. It was of course complemented by other things, such as the AHCPR [Agency for Health Care Policy and Research] document. But it got the IASP into the field of acute pain, got the acute pain researchers and clinicians to the IASP meetings, and quite frankly, many of them didnt know anything about pain. These were people who used to go around and twiddle PCAs and infusions; they had no idea of the explosion of the knowledge about pain in general. Of course much of it did apply to the field of acute pain management, and certainly applied to identifying patients with post-surgical or post-trauma pain, who were developing subacute and chronic pain. So I think this is a terribly important step for IASP to take. The other area that I was keen to see developed was a core curriculum for professionals, and I saw this as being crucial to IASP establishing the substance of this field. It just would not have been possible to get consensus on a core curriculum before 1987. We didnt know enough before that time. There was not enough agreement on what was right and what was wrong. But I perceived that the time had arrived to do it, and I think I was -- either chose well or was fortunate to choose Howard Fields to lead that group and Howard did an absolutely superb job and made it happen. Theres no doubt that in the dealings that Ive had, for example, with the Australia and New Zealand College of Anaesthetists, the availability of that core curriculum enabled me to say this field does have a substance; its well defined; its scientifically valid; its now an emerging specialty. Without that, I would have not even got to first base. MELDRUM: Right. Because heres something you can actually teach to medical students; its not nebulous. COUSINS: Exactly. Well, of course, the medical student one was a separate issue. Wed -- John Bonica had in fact proposed, many, many years ago, that we should have a curriculum for medical students, and it just hadnt happened. If I remember correctly, it was during Ron Melzacks presidency that we agreed that Issy Palowsky should be the one to do this, and he had a group of people who put together -- a task force who put together, first of all, a curriculum for medical students; and then, later on, that group was supplemented to have a curriculum for dentists, for nurses, et cetera. So that was an independently important step, a much less comprehensive curriculum, of course, than the one for health professionals, which has now been revised by Howard, and, incidentally, will be the basis of the curriculum for our diploma course in the Australia and New Zealand College. So they were two things that were very dear to my heart, and I was very pleased that we achieved them before the Adelaide Congress in 1990. Another one that I was pretty determined to see happen was to develop a document on desirable characteristics for pain management centers, and that was one where we were told that this would be impossible; this would be too sensitive, too many disagreements would occur -- MELDRUM: Right. A difficult thing to do. COUSINS: We would not be able to do it. I was fortunate there that John Loeser was doing a sabbatical with me in Adelaide, and I twisted Johns arm into taking this task on, and he and I worked a lot on this together. We bounced ideas to and fro, and in his inimitable style he pressed on right down the center of the road. Again, by the Adelaide meeting, we managed to achieve that. Despite warnings of dire consequences, of legal suits and people being very unhappy, we had no ripple of any problem whatsoever, and those guidelines have really been, I think, accepted pretty much throughout the world as being a very good reference point. So those were some of the things that I can remember clearly. MELDRUM: Actually, Louisa Jones, in her interview, she said that Ron Melzack was kind of like the first activist president -- COUSINS: Yes, yes. Yes. MELDRUM: That previous to that, Bonica had pretty much been the boss. But then Melzack was, and then you were an activist president. COUSINS: Yes. MELDRUM: And its fairly clear -- well, you could comment on that if you wanted to -- I just was wondering about what messages you were getting from the organization as a whole, or were you drawing from a small group -- the small Council group? COUSINS: Initially, yes, initially, I think there was concern about this move. For example, a number of the basic scientists were very opposed to IASP embracing, fostering the clinical development of acute pain management and fostering the clinical development of cancer pain management. They just didnt see this as being part of it. I can remember having some -- I felt very strongly about this -- having some extremely heated exchanges with some of these individuals, but always in a good spirit. But as -- I think during Rons presidency, the attitude changed to a degree; people became more enthused about IASP becoming more proactive in developing more programs and more initiatives. That certainly -- I made it clear during my presidency thats the way it was going to be, and if they didnt like it, that was tough. MELDRUM: [she laughs] COUSINS: But that was what was going to happen. I guess I learned something from John Bonica! So an extraordinary number of things happened during those three years. Another one that I felt very strongly about was the development of refresher courses. I felt that many people gained a lot from the scientific presentations, but there were others who really just needed to have updates pitched to the fairly fundamental level, and there were yet others who worked in one discipline, who needed to learn about what was happening in another discipline. Because after all that was what the IASP was meant to be about. So again, against very, very strong opposition I eventually got the council to agree that we would run refresher courses. The first refresher course was really a resounding success. Large numbers of people attended; we produced a refresher course booklet, which many attendees took away and used as a source of material. The refresher courses, of course, do continue to this day, and at the next meeting in Vienna will be even larger. So that was something that I felt was a rewarding endeavor for IASP. I mentioned the membership of currency-restricted and developing countries; I think thats something that has helped us actually to develop a lot more chapters. Some of them are chapters in formation, because they dont yet have the wherewithal to have the required number of full members, but a lot of new chapters have developed. We also started a very vigorous membership drive, quite deliberately tried to bring in people from various disciplines who previously were not members, and the membership increase started to rise quite significantly during Rons term and that continued during my term, and I think is on the rise. MELDRUM: Yeah, it continues to grow. COUSINS: I think, starting about 1984, you can see the curve go up, and its just kept going up. So that was something that we all felt; this is such a diverse problem that surely there should be a bigger membership. What else? Ive made a list of these things that happened during that era, and I remember sending it to Louisa and saying, Louisa, I now have not been president for about two months, so I havent thought about this at all, but I was suddenly sitting the other day and I started to make a list of the things that wed done -- not Id done; wed done -- over the last three years, and it absolutely astounded me how many things the Council had managed to take on board and act on during this three-year period. I think there were about ten items, and for the life of me I cant today remember what they all are. But Im sure Louisas got it. MELDRUM: Im sure she does. COUSINS: Ill go back and have a look at it, and if I can find it somewhere, Ill send it to you. But Ive given you about half of them, I think, so far. It was an exciting time. Well, of course, another one that we started that, I think, has really been important, but incredibly controversial -- I decided that we needed to have a document on pain in the workplace. This was again thought to be a very dangerous and controversial one, and I had no hesitation in appointing Bill Fordyce to do this, because I thought he had incredible insight in this area. I believe he did an extraordinary job, because he pulled together not just health professionals, but people from every walk of life, who had any sort of impact on pain in the workplace. And I think the document he produced really does encompass that societal issue of low back pain in the workplace. The document has been grossly misinterpreted by some people, and I wont comment on some of the other responses that have occurred, but in the big picture, when all the dust settles down, it will have been -- and I stand by the document -- some people have even threatened to take legal action over the document, of which youre probably aware -- MELDRUM: Yes, John mentioned that. COUSINS: -- but I stand behind it. I think if one reads it in a generous and broad manner, that it has made an important contribution. Of course, there are some aspects that some people would like to see emphasized more than others, but I think it very much makes us aware that back pain is not just a medical but also a societal problem, and a very, very major one. MELDRUM: Right. A really important one. COUSINS: And for that, I think thats a watershed. So Im very proud that I got Bill Fordyce to do that. No doubt somebody will update it, and no doubt theyll do it in a slightly different manner; they may even start from scratch again. But at least the issues on the table there, and were starting to address it. So that was a rather exciting one for me, and the response was even more exciting than Id anticipated. MELDRUM: Well, its certainly an important area. A lot of people seem to spend their working life -- anyone whos worked in an office sees this, people who suffer on a continual basis. I always think Australians do have a kind of international outlook, which is -- COUSINS: Its dropped off. [Pause] MELDRUM: Okay, we can start going again. The Australians have a kind of international outlook, because, in developing your careers, you really find yourselves having to travel and having to connect with people in other countries. What Im interested in is two questions, if you want to comment on that, if youve always sort of seen your career in an international light, and also if theres an Australo-Asian aspect to it -- in other words, if you have much interaction with any of the other Asian chapters at all, in any particular sense. COUSINS: Well, the first part, yes, indeed. In fact, I think anybody in Australia who is working in a new field finds that they need to spend a lot of time interacting with colleagues internationally, and even in a more established field. Its essential. In my life, I suppose in my professional life, thats played a very, very crucial part. I dont think I could have gone back and worked in Australia, without maintaining a lot of links that I have in North America and Europe and other parts of the world. With respect to the Asian region, Ive spent quite a lot of time, really, in many Asian countries playing some sort of a part in trying to help pain management to either develop de novo or to develop further. Those countries have included, for example, Singapore, Malaysia, which really were starting from scratch, Thailand -- John Loeser and I in fact went up there together and helped to initiate the IASP chapter there. Japan is rather a different situation in that they had a large number of clinicians doing nerve blocks there, and I suppose theyre still in the stage of deciding whether theyll evolve to the sort of IASP style of approach, and thats by no means clear, whether they will do that. Ive had some interaction with Indonesia, although thats pretty early at this stage, and personally little interaction, really on an individual basis, with China. So that remains another area. Weve already had inquiries from all of those countries, and also Korea for our university diploma course, so I suspect Im about to start interacting there because part of our teaching program will be via the Internet; were going to set up an interactive group on the Internet, and I think thats just dawning. But, yes, very much so; I think this is a field where its developing so quickly that one needs to have good international communication. Ive just remembered another thing that was interesting in that 84 to 90 era. I suppose as a result of a number of our feelings that we should develop cancer pain more, we had on our council a man called [Mohammed] Abdulmoumene, who was a physician who also held a position in the WHO [World Health Organization]. We began to discuss whether IASP should have some more official role with the WHO, and he said, Well, if youd like to do it, Ill tell you how to make the application. Its very complicated; its a very long process; its very frustrating. But if you decide to do it, I think we could make it work. I immediately picked that up and said, Well, look, I think we absolutely should do this. Now that the WHO has a cancer pain program, and were now saying that we should be involved in cancer pain, we must do it. Kathy Foley supported that very strongly. Id say that there was not a very overwhelming support for that idea, but to his great credit, Ron Melzack also supported it very strongly, and we went ahead. It took, I think, about three years or perhaps even more than that to push it all through, but we then became one of the very, very few international organizations who had developed a nongovernment-organization relationship [NGO] with the WHO. I believe that it was important. MELDRUM: Yes. I think you can see the effects of that in several areas. COUSINS: Yeah. So that was an interesting one. Of course, the other one that we havent talked about yet is the IPF -- MELDRUM: The International Pain Foundation. COUSINS: -- which is the International Pain Foundation. I think it was a significant chapter in the IASP development. If I remember rightly, the seeds of that really started before Rons presidency, at a [Council] meeting in Buenos Aires, in Argentina. We were then starting to really consider that we had to have more programs in the IASP, that we just werent doing enough. Immediately, I remember it coming to me as I flew in on the plane, and I actually wrote some hand-printed proposals that we needed to change the name of the IASP; it needed to be shorter and punchier. We needed to do this, so that we could promote ourselves to funding bodies to get funding. I had this typed out as soon as I got to the meeting, and I tried to distribute this to the Council, but I was trying to remember -- I think Ainsley Iggo was the president then -- he didnt want this to happen; this was not on the agenda. MELDRUM: [she laughs] Uh-oh! COUSINS: This was not part of the Council papers. It didnt get distributed, but I managed to say some words about it. At the same time John Liebeskind had obviously been mulling over the idea of having a separate body, a body that would actually seek to raise funds. I guess those ideas came together, and as the Council proceeded, there seemed to be increasing support for the idea that maybe having a pain foundation -- although I think the support was fairly lukewarm at that stage. But John [Liebeskind] really persisted and of course managed to get Bob Wall interested in providing the funding. And I think the IPF, for all of us, was a very, very challenging and I suppose, to some extent, emotional experience. MELDRUM: Yes. John certainly felt that. COUSINS: It was for me, and I know it was for John Loeser and Ron Dubner. Ulf Lindblom was less involved in this; I think he felt so far removed from this sort of thing that, although he was a member of the initial IPF board, he tended to sort of sit there and keep out of it. But we were all determined that it was going to succeed; we put an enormous amount of time and effort into it, and at times the meetings were very emotional. I think we found it all very difficult, frankly, because we were not used to this sort of thing. At this stage, I hadnt had the experience Ive now had in raising money from the community, and we all had such enormous hopes. We even had concepts of developing a body which would be as successful as the Red Cross. I still believe that there is such an appalling lack of access to pain management in the world; there are so many people suffering at this very moment that the need is of the same magnitude as that addressed by the Red Cross. But, sadly, we just didnt quite have the right formula at that time, and I think the decision that I had to take as president to, in essence, retract the IPF into the IASP was probably the hardest thing Ive ever done -- not only because I didnt want to see that happen, but it was very difficult for me as a personal friend of Johns, who was then President of the IPF, to have to reach that conclusion. He was not happy about it at the time; theres no doubt about that. I would hope in retrospect that he eventually saw that we didnt have any other course, but we were in danger of losing quite a lot of money. MELDRUM: Yes. That can be a real problem. COUSINS: We just didnt have the funds to do that at the time. MELDRUM: Yeah. So you kind of had to close the Foundation down; because otherwise, it would, the IASP, essentially would lose money -- COUSINS: A lot of money, actually. MELDRUM: -- and at that point there wasnt much prospect of raising money. COUSINS: No. Well, we also had to face the issue that our responsibility to our members really did not extend to being able to expend the sort of funds that we were facing on the IPF, because, really, the members had not given their approval for that sort of expenditure. So we had no alternative. I viewed it more as not closing down the IPF, but retracting it into the IASP. MELDRUM: Absorbing the activity. COUSINS: In fact thats very much whats happened. Because what the IPF clearly achieved was moving IASP into an era of raising funds for its programs, which we badly needed to do. We of course already had tax-exempt status for the IASP, so it was not difficult to do that. IASP, I think, has now been moderately successful in raising funds for its programs, which is what we identified as being the potential strength of the IPF -- that if the IPF focused on the important programs of the IASP, it should be able to raise funds. Sadly, I think what weve learned is that its very hard for an international organization to raise funds. MELDRUM: Yes. Yes. Too many constituents. COUSINS: Because international programs, unless you get a Ted Turner or somebody like that, and I would very much like to go after Ted Turner for the IASP -- MELDRUM: [she laughs] He seems appropriate, yes. COUSINS: -- or one of his friends that hes identified -- theyre the sort of people who are prepared to have a global perspective. There, I think, lies a wonderful opportunity for the IASP now, to find an individual like that and open his or her eyes to the fact that this is the new frontier of medicine, theres no question about that. MELDRUM: No, I think certainly John sensed that. I think its really clear in several fields that this kind of national boundary stuff, its just too restrictive; knowledge no longer flows that way. COUSINS: Its very small thinking, but its the type of thinking, of course, that occurs in many commercial organizations in many countries of the world, and its understandable. But we need a big thinker like Ted Turner whos prepared to donate a large amount of money to something that will help all of mankind -- not just those in one country. MELDRUM: Have you met George Soros or talked to him at all? COUSINS: Yes, I have met him on one occasion, and Im well aware, of course, of the wonderful program that Kathy Foley has started. MELDRUM: Youre certainly right, if we can identify more individuals like that. So I wanted to talk a little bit about your more recent research, or at least things we havent talked about -- spinal cord injury and injury response, which I dont -- youll have to explain that to me a little bit more. COUSINS: Well, I suppose I became interested in the injury response because of the early work I did at McGill, where quite clearly we were aiming not just to relieve the pain in vascular surgery patients, but also to improve the blood flow in their vascular grafts and the survival of the graft. I dont think I really understood in those days the close connection between pain and the response of the body to the surgical or other trauma, because thats what the injury response is. It actually harks back to another person that I learned of in Montreal, Hans Selye, who was the father of the stress response. He called it the General Adaptation Syndrome, the sum of all the responses that occur in humans, in response to stress or injury. But we now realize that thats what were looking at. The strange thing is that, again, a lot of the physicians involved in treating acute pain were just fiddling around with analgesics; they werent thinking about this interaction between the injury that was occurring to the patients body and all of the responses, in addition to pain. Some of our recent work has tried to, I suppose, really capitalize on minimizing the injury response and, at the same time, improving the pain relief, with the overall aim of what Ive called acute rehabilitation. Thats a term that I believe I coined, but it was picked up very quickly by my friend and colleague Henry Kellett, whos a surgeon in Copenhagen, and he, I think, really has outstripped our group by a long way, by doing an extraordinary number of very, very helpful studies to show that one can indeed optimize the use of good multimodal pain management approaches, using different targets but combining that with a very rigorous strategy of rehabilitation: avoiding things that slow down the patients recovery, doing other things that speed the recovery -- in other words, I think if you want to put it in a nutshell, it means taking advantage of the improved pain management to be able to do constructive things to get the patient better. Now, that concept, I believe, is exactly the concept that were using in cancer pain and chronic non-cancer pain. Again, it emphasizes this common core of knowledge that runs across from acute to chronic to cancer pain. For me, this is another concept that I really hold very dear. Weve developed a multidisciplinary pain management center so that we have all of our programs -- and thats what we call them, programs -- housed under the one roof. So our acute pain program staff, our chronic and cancer pain program staff, and our cognitive behavioral program staff all interact in the same milieu. And I believe thats been very helpful in strengthening the program. So some of our more recent work on the injury response has looked at what, I think, is probably one of the most debilitating aspects of major surgery, and that is that patients lose their body muscle mass. It was previously thought to be inevitable, and in the days following surgery, you would lose, you know, like a couple of kilograms every few days in body muscle. This occurs because the protein is broken down to nitrogen, and some of the essential building blocks in the muscle are actually burned up. MELDRUM: Is this the effect of the trauma of the surgery -- ? COUSINS: Yes. MELDRUM: -- or just being forced -- COUSINS: No, no, its the effect of, partly the effect of the trauma, and we believe now that some of the chemicals that are released in the area of the injury actually trigger off the breakdown of the body protein. Its a very primitive response, you see, partly aimed at preserving the nutrients that an injured animal may not be able to get, because theyre immobilized. We now know in humans, that if you just put them to bed, even if they havent had any injury, theyll start to break down muscle. So laying in bed is dangerous -- MELDRUM: [she laughs] COUSINS: -- well, apart from an overnights sleep. This is another motivation, of course, to provide good enough pain relief so the patients can get out of bed. But it appears thats not enough; you have to do other things to combat this loss of body protein. We have a young man, who actually is our first Ph.D. student after I moved to Sydney, whos just now completing his Ph.D., and one of his major papers has shown that, with a very powerful pain management regimen which involves giving an epidural with an opiate plus a local anesthetic and also using a non-steroidal drug, in fact, Ketorolac -- So we have a sort of three-pronged approach there -- But at the same time giving the patients intravenous nutrients, including protein, and getting them out of bed immediately after surgery. Were fortunate to be able to measure with a body scanner all of the protein in a patients body, and weve shown, with that approach, we can stop the loss of body protein, whereas with the standard analgesia, patients lose protein very quickly after surgery. So were continuing with that work, looking at various aspects of the metabolism of the body and the injury response, so thats one major area. Our other big focus is really on nerve damage pain, both in terms -- END OF TAPE MICHAEL J. COUSINS INTERVIEW TAPE TWO, SIDE TWO MARCIA MELDRUM: Okay. Were starting to record again on Side B of Tape Two. MICHAEL COUSINS: So, our other areas of basic research interest focused predominantly on neuropathic pain, injury pain, either in terms of major nerves, such as the sciatic nerve, and also particularly spinal injury-associated pain. In the first category, my colleagues Deborah White, Arthur Duggan, and more recently Kevin Keay, whos an anatomist, experimental anatomist-- MELDRUM: K-E-Y? COUSINS: K-E-A-Y, are working. In terms of the spinal injury pain, Philip Siddall, whos a clinician, neurophysiologist, were collaborating with a group at Cambridge in the Department of Anesthesiology and the anatomy department there, and weve been able to develop a spinal injury model in a rat which is very reliable, and weve already been able to show that the genetic changes, the c-fos and the other genetic changes described in other types of nerve injury occur very, very strongly above the level of the spinal injury. Theyre also associated with sprouting of touch fibers into the more superficial layers of the spinal cord where the pain fibers are located. This is, of course, this is a phenomenon thats been well described with other types of nerve injury. But were using this model with both spinal subarachnoid and epidural catheters to test the potential usefulness of spinally administered opiate and nonopiate drugs. We found, in fact, in the animal model that if we combined morphine and clonidine, we could relieve the hyperanalgesia that is produced in this spinal animal model. In parallel with that, and I guess this sort of exemplifies the sort of approach that weve tried to take in our clinical studies of spinal-injured patients, were in the early stages but weve already been able to show that a certain category of patient responds to intrathecal clonidine and morphine and were now in fact implanting patients with permanent pumps to receive clonidine and morphine. This has been exciting for me because up until two or three years ago I could not effectively treat severe neuropathic pain in patients with spinal injury. There are other groups overseas who have been obtaining similar results; Zsusanna Weisenfeld-Hallin has a different model of spinal injury, and shes also found that a combination of morphine and clonidine is effective for her model of spinal injury pain. So, were on the brink of a new era of spinal injury pain. We are in the early stages of using some other exciting experimental drugs in this particular model--calcium channel blockers, nitric oxide synthase blockers, and some of these look very, very promising. The other important area we pursued in the spinal injury work is again in the clinic, where weve done what I believe is the first longitudinal epidemiologic study. So, weve taken patients right from the emergency room way through into the rehabilitation phase. In fact, weve gone as far as two years following injury and perspectively documented the incidence of pain and the type of pain. The bottom line is that we find that even two years after injury, still sixty percent of patients have spinal injury-related pain, which is a much, much higher incidence than had been previously been documented. In fact, some clinicians state that pain is never a problem after the first couple of weeks after spinal injury. Recently we published what I think is the first detailed classification of spinal injury pain, which I hope will be adopted by the IASP taxonomy group since there is no classification in the current taxonomy. So, we continue to pursue mechanisms and treatments of neuropathic pain, whether it be in terms of nerve injury or spinal injury. We have a new dimension now with the addition of another basic neuroscientist to our group, Richard Bandler, who I guess like John Liebeskind has pioneered the periaquaductal gray area. Bandler really picked up where John left off and has done a great deal of work on central control mechanisms that overlap between pain, respiratory control, and cardiovascular control. Philip Siddall also has a background in that area. So, with Richard were now pursuing work on central mechanisms of pain and potential treatments at that level, and for us that will be a rather new area and potentially I think a very exciting one. MELDRUM: That really is exciting. You have sort of gone through the whole process, moving up the spinal cord to the brain. COUSINS: Yes. We now have research workers working at the periphery, at the spinal cord and also the brain level, and as part of that we have a national research grant-funded study to look at peripheral versus spinal cord versus brain actions of various types of opiates and nonsteroidal drugs. That of course is emerging as a very interesting new area with the potential to develop drugs that dont act on the brain but act at the periphery, be they N-SAIDS or opiates and the reverse. A number of groups of course are now working on this area. So, were I think now entering our productive phase after moving, and were still trying to pursue this idea of getting our clinicians to work very closely with our basic researchers and to try to bounce our studies from one to the other. MELDRUM: So really youve started two major centers in one country. COUSINS: Thats right. MELDRUM: Probably kind of-- COUSINS: Its not an advisable thing to do. MELDRUM: [laughs] No! It sounds like two major headaches! COUSINS: I would definitely recommend against it. MELDRUM: But you probably at that point sort of quadrupled the productivity in pain management. COUSINS: To some extent, because I think you learn from the first experience. We have much more emphasis in this current program of basic pain neurophysiology; we are doing work at the molecular level with the c-fos and were also doing in situ hybridization work, which Kevin Keay is starting. But then we go right up the epidemiologic level; we actually have a little pain epidemiology group in our unit with a qualified, number of qualified epidemiologists, and were doing a lot of outcome work. Every patient going through our clinic is part of an outcome study. For example, we are currently examining patients with implanted pumps and stimulators, and our early results are very interesting. We find that pain is relieved, and we can document that very well. But their function often does not improve, and we found its then necessary to then enroll them in a cognitive behavioral program to get them back to function. MELDRUM: Right. To stop thinking of themselves as a pain patient. COUSINS: But when we do that, they do regain function, whereas without the pain relief, very often they cannot cooperate with the program, and they therefore dont return to function. So, one of our clinical psychologists, Mike Nicholas, he is focusing on the outcome work, and I think thats going to be a very interesting area. MELDRUM: Yeah, thats quite interesting. So, any particular developments you see coming up in pain management in Australia that would be significant? COUSINS: I think they come down to the work that the individuals are doing, quite frankly. I believe the development of the degree in pain management is an important one; I think our diploma course will certainly help to give things a stimulus in the Asia-Pacific region. MELDRUM: Certainly sounds like its going to be exciting. COUSINS: I think then it comes down really to the individual contributions of the people doing the research, as it does in every country, of course. MELDRUM: Yeah. Very much. COUSINS: All right? Well, thats probably more-- MELDRUM: Okay. Anything else you want to add to this? COUSINS: I think thats covered it pretty well. MELDRUM: Okay. Well, sort of a general question, though; do you think, on the whole, now that youre in mid-career-- COUSINS: Not sure its mid-career; I hope so, yeah. MELDRUM: [laughs] --that your career has given you the rewards that you would have sought? What kind of rewards do you think you have gotten from this? COUSINS: Thats a difficult question. I guess because of my exposure to people like John Bonica, its hard not to become--and Ive seen this happen to some of the younger people whove worked with me, actually--one tends to develop a sense of responsibility to this field. Thats partly of course due to the patients one treats. So, I think it tends to turn things around the other way; its more a matter of deciding whether youre meeting your obligations to the field rather than whether youre gaining the satisfaction. MELDRUM: I see. COUSINS: But of course it is satisfying to be able to treat patients that one could not previously treat--not only satisfying; exciting. Its obviously satisfying to be able to interact with a very diverse group of people who range from molecular pharmacologists to clinical psychologists to epidemiologists; thats rewarding to have that sense of camaraderie, I suppose, which is rather similar to what I experienced in that very first council meeting of the IASP. And for me one of the most rewarding things is being able to bring together a group of some fifty people now who truly do work as a team, have a lot of mutual regard for each other, and I think as a result of that are really very productive. So, thats rewarding. But another very rewarding thing is to see I think over the last twenty-five years Ive had close to thirty fellows whove worked with me, and many of them have gone back to--a lot of them come back to North America, in fact. I have a fellow who started the pain center at Stanford, another fellow who started the pain center at the University of St. Louis, and several fellows who started pain centers in Canada, et cetera. To keep contact with those fellows and to see what theyre doing is extremely rewarding. So, I think its a field thats enormously demanding. Its incredibly debilitating sometimes to deal day after day-- MELDRUM: I think nearly all of the interviewees say that. COUSINS: --with patients in whom sometimes you can do nothing. That can sometimes grind you down. But the potential rewards are very great, and I think its a wonderful era of medicine to practice, no doubt about it. MELDRUM: Well, thank you very much, Dr. Cousins. COUSINS: Thank you, Marcia. Good. MELDRUM: Well conclude the interview at this time, and its ten minutes past five. 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"SystemyΜWMy--@Times New Roman--- O2 v-0 John C. Liebeskind History of Pain Collection              2 vy0   @Times New Roman---  2 0     2 0     2 0   @Times New Roman--- ,2 0 Oral History Interview       2 40    2 y0 with   2 0    2 80 Michael    2 80 J.  2 80 Cousins    2 80   ---  2 U0     2 q`0     2 `0   @ Arial--- &2 -0 Ms. Coll. no. 127.     2 0 10   2 0   ---  2 `0     2 `0     2 `0    2   0 Conducted:    2  0 19 October    2 0 1997   2 #0    2 5 0 Interviewer:       %2 5w0 Marcia L. Meldrum        2 540     2 Q*0 Duration: ca.       2 Q0 3  2 Q0 .0   2 Q0   2 Q0 hours    2 Q0    2 m[0 Pages:    2 m0 i  2 m0 v  2 m0 ,  2 m0 44   2 m0     2 `0     2 `0     2 `0     2 `0   @Times New Roman---  2 0    82 0 History & Special Collections         2 0 fo   2 0 r the Sciences     2 X0    ;2 &  0 UCLA Library Special Collections            2 &'0    .2 >0 Los Angeles, California        2 >0   2 >0 90095   2 >0 -  2 >0 1  2 >0 798   2 >40     2 V0     2 n0    2 G0 2004  2 s 0 , revised    2 0 2016   2 0   @Times New Roman--- --  00//.. ՜.+,D՜.+,  hp  UCLA 'HOWARD FIELDS INTERVIEW.John C. Liebeskind History of Pain CollectionOral History InterviewwithMichael J. CousinsConducted: 19 October 1997/History & Special Collections for the Sciences!UCLA Library Special CollectionsBiographical SketchInterview History)Topical Outline (Scope and Content Note)Access to the InterviewTerms and Conditions of UseCitation Information>Related Material in the Liebeskind History of Pain CollectionEditorial NoteQThe interview transcript has been annotated -- with notes offset in [square bracAcknowledgmentsQSupport for the John C. Liebeskind History of Pain Collection and its Oral Histo[PHOTO PORTRAIT NEEDED]Michale J. Cousins, MD+Professor of Anaesthesia & Pain ManagementMICHAEL J. COUSINS INTERVIEWTAPE ONE, SIDE ONEMICHAEL J. COUSINS INTERVIEWTAPE ONE, SIDE TWO Title Headings&Hd_AdHocReviewCycleID_NewReviewCycle_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnceTMichael Cousins transcript (UCLA John C. Liebeskind History of Pain Collection)rjohnson@library.ucla.eduJohnson, Russell  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-.012345689:;<=>?@ABCDEFGHIJKLMNOPQSTUVWXYZ[]^_`abchRoot Entry Fg4zjData /1Table75WordDocument\SummaryInformation(RDocumentSummaryInformation8\CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q