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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - AUTUMN 2005


FROM THE EDITOR
Welcome to Threshold, the newsletter of world to attend this IASP congress but I
the North British Pain Association. I would can’t wait to jet off to the next one in three
like to thank Napp pharmaceuticals once years, I wonder where that is going to
again for their support without which be….??
Threshold would not be possible. This Finally, it is now three years since I
summer there have been many became Editor of Threshold and, much as I
developments in pain management at both have enjoyed producing this little treasure,
a local and national level. We have the ear I feel it is time to hand over to an
of the Health Minister (and we’re not giving enthusiastic new Editor. I hope to be
it back until he helps us) and are possibly announcing the identity of the new Editor
closer than ever before to developing a at the meeting on Friday 11th November. If Drs. Gavin Gordon, Ruhy Parris
and Mick Serpell
national strategy for chronic pain. There has you would like to be considered, feel free
been a consensus conference to discuss the to drop me a line.
McEwen report at which there was great Many thanks for reading Threshold over need to be externally audited and Dr.
consensus amongst everyone present apart the last three years and I’m looking forward Braidwood was going to investigate this.
from the Deputy Chief Medical Officer, Dr. to an NBPA meeting without writing Five positions on council have become
Aileen Keil. The Kerr report has also been furiously and pestering people for their vacant due to the retirement of Kath Smith,
published. There is much talk of managed photograph. Mhoira Lheng, Lyndia Greene, Anne Kelly
clinical networks, community health In the meantime my contact details are and Professor Danny McQueen. Dr. Sue
partnerships, integrating primary and below:- Fleetwood-Walker has been appointed the
secondary care, the role of the voluntary Dr. Colin P. Rae new basic sciences representative. She will
sector and patient centred management. It’s Consultant in Anaesthesia and Pain be known to many of you already and has
just as well you can rely on Threshold to Management, presented at a previous NBPA meeting.
translate all this management lingo for you Department of Anaesthesia, Dr. Martin Dunbar (Glasgow) was voted
- so read on. Stobhill Hospital, in as new psychology representative, Judith
The main meeting of the summer was 133, Balornock Road, Laird (Dundee) as nursing representative
the IASP Congress in Sydney, Australia. I Glasgow. and John McLellan (Edinburgh) as
am indebted to Jonathan McGhie, Specialist G21 3UW physiotherapy representative.
registrar in anaesthetics from Glasgow, who Tel. No. 0141 201 3005 Congratulations to all of them. New North
acted as Threshold roving reporter and has Fax. No. 0141 201 4167 of England and Palliative Care
submitted a summary of the goings on. I Email colin.rae@northglasgow.scot.nhs.uk representatives have yet to be appointed.
am afraid I was unable to travel round the Website www.nbpa.ac.uk Winners of the prize raffle from the
NBPA stall at the Pain Society meeting in
Edinburgh were Sharon Dolan who won
£70 worth of book tokens and Shona Yates
REPORT FROM ANNUAL and Kate Scullion who received USB sticks.
GENERAL MEETING No entries had been received for the
Friday 6th May 2005 prize essay competition and this matter will
be under discussion at forthcoming council
The Annual General Meeting was meetings.
attended by 63 members. In the Chairman’s
report, Dr. Nicola Stuckey outlined the
activities of the previous year. Both the
Spring Scientific Meeting “Needles and
Pins” and the Winter Scientific Meeting
“Pain in the Brain” were very successful. Dr. Mike Basler, IT whiz kid
The McEwen report had been published and
Council were involved in taking this as she does like to shop(only joking). The
forward. There had been a draft document main expenditure had been items including
circulated from NHS QIS Scotland on T-shirts, pens and prizes for the highly
chronic pain management which was under successful NBPA stall at the Pain Society
review. meeting in Edinburgh. The stall had resulted
Dr Janet Braidwood gave the treasurers in the recruitment of 18 new members. Phil Sizer of Pain Association Scotland,
report. Since she had been in office there Due to a change in charities law there is Heather Wallace of Pain Concern
had been a great increase in expenditure, a possibility that the society’s accounts will and Colin Rae, Threshold Editor
REPORT FROM SPRING Eight of the mainland boards have
SCIENTIFIC MEETING dedicated psychologists in their pain
Friday 6th May 2005 services. Lothian has the highest number.
No other board is near the 1994
“The McEwen Report recommendation of 1 whole time
equivalent psychologist per 200,000 of
– The Way Forward”
the population.
Professor McEwen recognised the
Dr. Ruhy Parris chaired the morning
complex case-mix in chronic pain and the
session. Dr. Nicola Stuckey started the
importance of ensuring appropriate staff
session with a summary of the 16
and resources are available. He
recommendations of the McEwen
recommended that pain management
report. Due to lack of space, these can
programmes should be provided by each
be found on the NBPA website. Dorothy Grace Elder addresses the meeting
health board and that training and
employment of generic pain professionals
Dr. Mick Serpell, from Glasgow, Quite how he managed to link this in to a
should be examined.
followed Nicola with “The 10 Point talk on Managed Clinical Networks I
There is a national shortage of staff in
Plan”, reporting an action plan for can’t remember. He recounted the
all areas of psychology but funding issues
Scotland which had been formulated by Glasgow experience. Glasgow has a
rather than recruitment difficulties is
a Working Party on Pain consisting of population of 866,000 and has over 20
often the problem. Current postgraduate
members from pain medicine, medical chronic pain sessions with some
trainees are keen to do placements in
rheumatology, pharmacy, Quality nursing, physiotherapy and psychology
chronic pain which may help recruitment
Improvement Scotland (QIS), Pain input. The Victoria Infirmary area
in the future.
Association Scotland (PAS) and primary catchment borders Lanarkshire.
317 clinical and applied psychologists
care. The 10 action points are as follows:- Lanarkshire has a population of 533, 000
work in Scotland. There are 61 places in
1. There should be full commitment to and only has 3 medical sessions for
Scotland for postgraduate training in
the declaration that pain relief is a chronic pain. It is this type of
psychology.
human right. (WHO, Geneva, 11 geographical inequality that it is hoped
Of people with chronic pain attending
October 2004) Managed Clinical Networks will address.
the pain management programme, 25%
2. The social and financial impact of A Managed Clinical Network(MCN) is
were moderately depressed and 22%
chronic pain needs to be recognised a way of working. The model should be
severely depressed. 47% had a medium
and the necessary resources for developed by a partnership of patients,
to high fear of harm and damage from
effective management should be a clinicians and managers and therefore
activity with 66% requiring individual
high priority on the health agenda for should be effective in delivering care in
work rather than a group PMP.
Scotland. a local context. A MCN focuses on a
There were high levels of suicidal
3. Health Service providers and disease or condition. The purpose of a
ideation, post traumatic stress disorder,
commissioners should implement MCN is to improve patient care by
previous sexual and physical abuse,
integrated care pathways for chronic improving access, quality and co-
relationship and family breakdown,
pain, which involve community, ordination. Work undertaken is evidence
driven behaviour, heightened anxiety and
primary and secondary care. based, outcomes are measured and an
anger control issues.
4. Education in the management of pain annual report is produced. Networks are
Nicola concluded that all boards
should form part of the core multiprofessional with patient
should provide adequate psychology
curriculum for doctors, nurses, allied involvement.
coverage for their population.
and other health care professionals. What would the advantages of a MCN
Appropriate triage of patients should
5. Health service providers and for pain management services? At present,
occur which will require significant
commissioners should make a there is little co-ordination of staff
psychological input. Research skills
commitment to provision of training between primary, secondary and tertiary
should be encouraged to provide a clear
in pain management for all healthcare care. There is a lack of clarity of roles.
evidence base for psychological
professionals. Referral patterns to secondary care pain
treatment.
6. To improve services for people with clinics are haphazard depending on
chronic pain the NHS should work individual General Practitioners and
with the voluntary sector. clinic guidelines. There is a lack of
7. Management of chronic pain should evidence base for many of the treatments
be patient-centred in partnership with used in a pain clinic and concerns about
healthcare professionals. the use of resources.
8. People in all geographical areas Several MCNs have already been
should have equality of access to developed in Scotland, the most
appropriate services for the comprehensive being diabetes, stroke and
management of their pain. ischaemic heart disease. Others include
9. Evidence-based pain management and palliative care, epilepsy and vascular
best clinical practice should be used services.
and audited by the healthcare While MCNs are not a direct
providers. mechanism for increasing your budget,
10. Research into pain management they are a mechanism for implementing Dr. Nicola Stuckey and Professor Ian Power
should be promoted and conducted to standards (SIGN, NQIS) and they do fit
fill the current evidence gaps. in neatly with the recommendations of The next talk was given by yours truly
These action points fit in well with the McEwan. Downsides to MCNs are many and was titled “The Integration of
recommendations of the McEwen report. time consuming meetings, difficulties in Primary and Secondary Care for the
engaging primary care and potential Management of Chronic Pain”.
Dr. Gavin Gordon, Consultant friction between specialists and Many of the themes had been covered
Anaesthetist from Glasgow gave the next generalists. in previous talks. The merits of primary
talk of the day on ‘Managed Clinical and secondary care were contrasted and
Networks’. NBPA President, Dr. Nicola Stuckey a case history involving Granpaw Broon
Dr. Gordon is a keen Aberdeen then spoke on “The McEwen Report on getting the shingles used to illustrate
supporter and he started by looking back Chronic Pain services in Scotland – a some of the deficiencies in
on a glorious year for the Dons – 1983. psychological perspective”. communication between these two
settings. This nicely highlighted the on an individual and their family. They to the geographical area in question and,
fragmented journey the average use a biopsychosocial model. liaising with the pain teams in that area,
individual with chronic pain has through Many topics are covered within the deliver a PMP to a pre-selected group of
the current healthcare system. standard PAS programme and outcomes patients. There would be a varying degree
Other chronic illnesses including are monitored with a coping strategies of involvement by the local team. The
diabetes and depression have moved to a chart and a variety of validated idea had been explored in Tayside and
more integrated service and devolved a questionnaires. Patients come to PAS Glasgow but so far there were no firm
large proportion of management to from pain clinics, primary care, self offers on the table. The concept created a
primary care via the development of a referral and from training days. PAS has good deal of interest amongst the
MCN. been involved in setting up the West Fife audience.
Primary Care Pain Pilot Project which has
The afternoon session was chaired by produced encouraging results. The final talk was given by Professor
Dr. Bill MacRae and was divided in to Phil summarised the role of PAS as to Ian Power from Edinburgh. He had been
five lectures. improve coping skills and understanding asked to talk on The integration of Pain
of chronic pain, improve quality of life Medicine. He had taken part in a debate
The first lecture, ‘NHS QIS – What despite pain and to enable the transition at the Pain Society meeting in
we do’, was given by Jan Warner, from clinical to a community based Bournemouth in 2002 titled ‘This House
Director of Performance Assessment and approach. Believes that Acute and Chronic Pain
Practice Development, NHS QIS. teams should merge’. Professor Power
NHS Quality Improvement Scotland believes that acute, chronic and cancer
was established in 2003 by the merger of pain share common mechanisms and that
six organisations. They work closely with there should be a merger of these
the Scottish Medicines Consortium and specialties.
the Scottish Health Council. Professor Power was heavily involved
The aim of NHS QIS is to improve the with the Faculty of Pain Medicine in
quality of healthcare in Scotland by Australia. He is very aware of the benefits
setting standards, then reviewing and and recognition that formation of a pain
monitoring performance against these faculty had brought to the specialty.
standards. A recent exciting development in the
Twenty five sets of standards have UK is the appointment of Regional Pain
been finalised to date. Most have been Advisors and the formation this year of a
condition or service specific. Dr. Blair Smith and Dr. Bill MacRae Faculty of Pain Medicine within the
Performance assessment is a large part of Royal College of Anaesthetists.
QIS work. The afternoon session continued with
A Best Practice statement for Chronic Dr. Blair Smith from the University of
Pain had been undertaken in 2005. There Aberdeen on ‘The McEwen report: a
had been a wide consultation process and primary care viewpoint’.
WORLD PAIN
the draft document had attracted many It is easy to forget in secondary care CONFERENCE UPDATE
comments. There followed a wide ranging that the majority of healthcare is provided Dr. Jonathan McGhie
debate on the role of the QIS document, in the primary setting. Blair published an
the consultation process, it’s relevance to article in Rheumatic Disease in Practice
the multidisciplinary nature of chronic in 2002 titled ‘Chronic Pain: a primary
pain management and whether it would care condition.’
be used as a standards document. He pointed out that all the professions
involved in a multidisciplinary pain
There followed two talks from management team are present in primary
representatives from the voluntary sector. care.
Heather Wallace from Pain Concern 15-22% of all consultations in primary
gave a talk on ‘The Role of the Voluntary care are for chronic pain. These patients
Sector’. She outlined the work of Pain consult five times more frequently. The
Concern. They provide a listening ear consultations are often unsatisfactory due The 11th World Congress on Pain took
through the Pain Concern telephone to communication issues, mis-matched place in Sydney in August. The
helpline and via email correspondence to expectations and cure seeking as opposed conference was well received by over
try and break the isolation of many to rehabilitation approach. 5000 delegates. Working in Sydney this
chronic pain sufferers. They provide Many management options are year, I was fortuitously placed to take in
information leaflets on a variety of available in primary care and pain clinic the congress and Colin has kindly invited
chronic pain topics and also publish a referral is a rarity. Patients will return to me to summarise the main topics for this
magazine ‘Pain Matters’. primary care after the pain clinic issue of Threshold.
Pain Concern campaigns in the media, treatment. Although criticized by some attendees
working with journalists, providing Blair felt that referral guidelines are as having too great a ‘basic science’ slant
articles for health columns and there is needed. He hoped for primary care pain in the plenary sessions, the main lectures
even to be a chronic pain story line in a clinics, better education and of the conference provided the most
soap opera! They are active on the Cross communication systems. insight into new developments and future
Party Working Group for chronic pain at paths for pain medicine. The overall
the Scottish Parliament and also at The penultimate talk was given by Dr. theme was of movement from the
Westminster. Ian Yellowlees on ‘A Peripatetic Pain traditional teaching of anatomical tracts
Management Programme’. Peripatetic of pain and simple neuronal transduction
Phil Sizer from Pain Association means working between two or more and transmission to an awareness of the
Scotland (PAS) gave the next talk titled establishments (of course). We are all plasticity of the CNS at all levels. Most
‘Who we are. What we Do’. PAS is aware of the lack of pain management of the scientific work concentrated on the
sixteen years old. It is a charity that programmes in many parts of Scotland. dorsal horn. The first lecture, by Clifford
provides community based self- Ian had the idea of a mobile PMP as a Woolf, outlined that more than 1200
management training and support for solution to this problem which might be genes alter in the DRG and dorsal horn
people with chronic pain regardless of the attractive to clinicians and to health following nerve injury. The difficulty now
diagnosis. They are professionally led and boards. Ian works with a team of lies in unravelling the importance of these
focus on dealing with the impact of pain healthcare professionals who would travel changes.
transmitting solely visceral pain. UPDATE FROM THE
Experiments on pelvic and abdominal SCOTTISH PARLIAMENT
pain in animals showed that ablating the
spinothalamic tracts had little impact on As many of you will be aware,
symptoms, whereas a midline myelotomy following the NBPA Spring Scientific
obliterating the PSDC was almost Meeting discussing the McEwen report
universally effective. and the consensus conference, there has
Just when you thought that boosting been a further meeting of the Cross Party
serotonin and noradrenaline would working Group. This meeting was
provide enhancement of descending attended by Andy Kerr, the Health
pathways, evidence is mounting Minister. I understand that this meeting
implicating 5HT 3 receptors in pain was constructive, the clinicians present
Dr. Jonathan McGhie in Sydney facilitation in the dorsal horn. Not helpful were able to present a strong case and that
if you are still trying to master the he was able to grasp the key issues
Of particular interest is the role of the serotonin receptor subtypes in headache involved. We await developments with
‘glue’ of the neurons – the glia and other and triptan therapy! New receptor specific interest.
support cells in the peripheral and central drugs may allow us to fine-tune the
nervous system. Evidence of autocrine analgesia we can offer in the future.
and paracrine transmission from these The biggest highlight for acute pain was
cells is accumulating implicating them in the launch of the second edition of the DATES FOR YOUR DIARY
initiating and sustaining central Acute Pain Management: Scientific
sensitisation. The work mainly The date of the NBPA Spring 2006
Evidence. These guidelines are
concentrated on purinergic (ATP) Scientific Meeting is Friday 5th May and
comprehensive and up to date covering all
it is likely to have a palliative care theme.
receptors and neurotropins (BDNF), but aspects of acute pain. They are core
was further developed in the workshop The date of the Autumn 2006 Scientific
reading for the syllabus in Australia,
on muscle hyperalgesia where the role of Meeting will be announced soon.
endorsed by the Australian government
nitric oxide and nerve growth factor as (NHRMC) and also by the Royal College
key mediators in afferent windup in of Anaesthetists (UK). They will prove to
musculoskeletal pain was discussed. be a valuable resource in improving acute CAPTION COMPETITION
Subsequent workshops on CRPS pain management across Scotland and the
developed the cytokine theme and link below will provide access to a pdf The winner of the caption competition
focused on inflammatory mediators version. http://www.fpm.anzca.edu.au/ from the Spring issue is Dr. Jonathan
through new evidence of raised TNF and Overall the conference provoked Bannister from Dundee with “No, really,
interleukins in the ‘oedema’ of CRPS debate and challenged existing ideas. these SI joint injections have changed my
patients. Anecdotal treatment with anti- However, each lecture added further life!”
TNF therapy in these patients improved complexity to the understanding of the
symptoms. The area is far from simplified cellular mechanisms, transmission and
as animal experiments suggest that some management of pain, with too few
of the immune cells and cytokines may solutions or concrete answers!
by anti-nociceptive peripherally, in If you would like further information
inflamed tissue, but cause pain centrally or references any of the topics above then
in the dorsal horn. please contact me on the email address
Even gross anatomy was challenged in below.
the lectures, with new evidence of a post- Jonathan McGhie
synaptic dorsal column pathway (PSDC) jmcghie@doctors.org.uk

The competition this time is to come


up with a snappy one liner for this photo
of two well known members of the NBPA.
The lucky winner will receive the usual
£25 book token. You don’t know how
easy it to win!

Marion Hodge, Jacqueline Peacock Enjoying the sun


and Sioban Calwell

I have included all the news I am aware


of in the previous sections so sorry if I
have missed out any major developments
in your area. Feel free to keep the new
Council have an earnest discussion Dr. Martin Dunbar and John MacLennan Editor updated for the next issue!