...........................................................................................................................................................................
NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2002
FROM THE EDITOR
This edition of Threshold is sponsored
by A. Menarini. I would like to thank
Napp for their sponsorship of the
newsletter last year. Many thanks to both
companies.
After this edition, I will hang up my
keyboard, so to speak, and pass the mantle
of editorship onto Dr Colin Rae,
Consultant in Anaesthesia and Pain
Management at Stobhill Hospital,
Glasgow. It has been an interesting three
and half years, which has seen the
membership of the NBPA grow, and its
scientific meetings increase in stature.
Until Colin takes up his post, please
send me your news and views.
You can contact me at:
Department of Anaesthetics
Walton Building
Glasgow Royal Infirmary
84 Castle Street
Glasgow G4 0SF
Tel: 0141 211 4621
Fax: 0141 211 4622
E mail:
gri.pain@northglasgow.scot.nhs.uk
I am sure that those going to San Diego
in August for the IASP Congress can
furnish the editor with suitable mementoes
of North Brits abroad!
Ruhy Parris
NEWS FROM
NBPA COUNCIL
The Spring Scientific Meeting is on
Friday 10 May at the usual venue of John
MacIntyre Centre, Pollock Halls of
Residence, University of Edinburgh. The
theme is “Pain of Urogenital Origin”.
(Ed. Note: If, like me, you are an
anaesthetist with a regular urology list,
you will know exactly the sort of
challenging patients our urology
colleagues refer to the pain clinic!)
Dr Lyndia Green (Glasgow) replaces
Nicky Springford as a clinical psychology
representative. Many thanks to Nicky
(Durham) for her services to Council.
Dr Dil Kapur, our secretary, has
recently left Newcastle for pastures new.
He has gone down under (Ed. Note: No,
he is not joining the cast of Neighbours,
or Home and Away), to work in Adelaide
with Dr Dave Cherry. Dil will be sorely
missed in North British territory, having
worked as a pain specialist both in Perth,
and Newcastle. Australia has gained. I
am sure that he will act as our antipodean
correspondent.
In the meantime, Dr Mick Serpell has
stepped into the breach as locum
Secretary. Mick, as many will recall, for
quite some time performed a juggling act
being both the Secretary and the Treasurer
of the NBPA. Any queries, or membership
information can be directed to him at:
Pain Management Clinic
Gartnavel General Hospital
Great Western Road
Glasgow G12 OYN
Tel: 0141 211 3288
Email: mgserpell@altavista.net
NBPA website (including online
Threshold) is: http://www.nbpa.org.uk
Dr Dil Kapur and Dr Mick Serpell
WINTER SCIENTIFIC MEETING
30 November 2001
Pollock Halls, Edinburgh
The theme of the meeting was “New
Solutions To Old Problems”. The meeting
was kindly sponsored by Napp, RDG
Medical, Medtronic, Pfizer, Pharmacia,
and Janssen Cilag. Prior to the start of
the meeting, Dr Ed Charlton thanked
NBPA members for participation in a
survey of manpower in pain management
clinics in the region. He informed
everyone of an impending editorial in
Anaesthesia concerning pain services in
the UK. Drs Doug Justins and Alf Collins,
representing the Pain Society, would be
meeting government representatives
concerning implementation of
recommendations from the CSAG report
(2000).
Dr Ed Charlton and
Dr Murray Carmichael
The morning session, chaired by Dr
Mick Serpell, was devoted to
Cannabinoids. We were privileged to
have Lord Perry, Chairman of the House
of Lords Select Committee on cannabis,
share with us aspects of the ongoing
debate on the use of cannabis in medicine.
The committee was appointed in 1997
with the remit of looking at evidence for
relaxing restrictions on medical uses of
cannabis.
The first mention of cannabis goes back
to the 7th century BC, in Assyrian tablets.
Queen Victoria used it for labour pains.
It was in the British Pharmacopeia until
1932. Under the Medicines Act of 1968,
cannabis had a licence of the right to
prescribe. In 1973, the licence was
removed, making it illegal to possess,
supply or prescribe cannabis.
Cannabis has over 60 cannabinoids
present. ∆9-tetrahydracannbinol is the
most common. It is fat soluble, slowly
absorbed orally, and degraded in the liver.
Smoking cannabis leads to rapid action
and absorption, entering body fat, and
takes a long period to be eliminated.
There is an endogenous cannabinoid
system with CB1 and CB2 receptors.
Nabilone is a synthetic cannabinoid.
There is no recorded death from an
overdose of cannabis. It has toxicity from
the dangers of smoking. It can induce
mild psychosis, and cause tolerance in high
doses. It is unclear as to whether or not
it leads to dependence. Cannabis is helpful
in relieving the intractable pain of multiple
sclerosis.
The 1985 Misuse of Drugs Act has
Schedule 1 drugs which cannot be
prescribed, and Schedule 2 drugs eg
cocaine, heroin, which can be prescribed.
Cannabis preparations are considered as
“new medicines” since they were deleted
in 1973.
In 1998, the committee produced its
first report recommending clinical trials
as an urgency. It recommended that
cannabis be moved to Schedule 2 to allow
prescription. This was turned down by
the government. The committee made no
recommendation as to recreational use of
cannabis. A second report was produced
in 2001. The remit was to examine current
research and therapy. MRC trials
examined the use in spasticity in multiple
sclerosis, and also for postoperative pain.
GW Pharmaceuticals’ aim is to obtain a
licence from the Home Office to cultivate
cannabis plants, and also to get pure THC.
Stage I and II trials have been completed
via the Medicines Controls Agency. The
aim is to complete clinical trials by 2003.
As yet there is no change in the law
following these two reports. The Home
Secretary, David Blunkett, wants a review
of laws on cannabis, making it a class C
drug as opposed to a class B drug. As yet
there is no decriminalisation of cannabis.
There is an argument that much police
time is spent on people in possession of
small quantities of the drug. The
Medicines Controls Agency is still keen
on long term toxicity trials of
cannabinoids. (Ed. Note: A lot of
controversy since this meeting on cannabis
and its uses. Further clarification is vital.)
Lord Perry
Lord Perry was followed by Professor
Roger Pertwee from the University of
Aberdeen who gave us a detailed review
of the pharmacology of “Cannabinoids as
Analgesics”. ∆9-THC is the main
psychotropic constituent of cannabis.
Dronabinol and nabilone are the two
cannabinoids licensed for clinical use in
the UK. Nabilone (1 mg capsules) is used
as an antiemetic.
Cannabinoids are fat soluble. There are
CB1 and CB2 receptors. These receptors
are not distributed evenly in the brain.
CB1 receptors are mainly in the
hippocampus, cerebral cortex, basal
ganglia, globus pallidus, cerebellum. They
are also found on pain pathways. There
are four groups of cannabinoid receptor
agonist. One of the agonists is
anandamide which is CB1 selective, but
not very stable in the body. Many more
CB1 agonists are being developed. There
are many CB2 agonists.
There are antagonists for CB1 and CB2
receptors. These can be used as
antiobesity agents. Current therapeutic
uses of cannabinoids are for stimulation
of appetite, and suppression of nausea and
vomiting. The potential therapeutic uses
will be in multiple sclerosis, and
neuropathic pain. However the known
unwanted effects of cannabis are
psychotropic effects, aggravation of
existing psychoses, and elevation of heart
rate. Strategies to minimise central effects
include the use of partial agonists.
From animal studies there is evidence
that endogenous cannabinoids such as
anandamide regulate nociception. It is
possible to exploit synergistic interactions
such as a CB1 agonist and an opioid for
analgesia, or a CB1 agonist and a
benzodiazepine or baclofen for spasticity.
Cannabinoids and opioids interact
synergistically for the production of
antinociception, as shown with the mouse
tail flick test.
Important areas for future study are the
modes of action of endocannabinoids, and
also issues to do with solubility and
delivery of cannabinoids. An experimental
drug, 0-1057, has been developed which
is water soluble, binds to both CB1 and
CB2 receptors, and is more active and
potent than THC.
The morning session ended with a
presentation by Dr Bernhard Frank,
Research Fellow, Pain Management Unit,
Royal Victoria Infirmary, Newcastle. He
spoke on “The Clinical Use of
Cannabinoids in Pain Management”. He
is involved in a multicentre trial on the
efficacy of nabilone in neuropathic pain.
Herbal cannabis is cultivated at home and
either smoked as a joint or taken in the
oral form. Dronabinol is licensed for use
in anorexia associated with AIDS in the
USA. Nabilone is licensed for use as an
antiemetic, associated with chemotherapy
in the UK. Nabilone comes in 0.25mg and
1mg capsules. It is available in the UK as
a hospital only prescription, and can be
ordered by every pharmacy.
Dronabinol and nabilone have different
molecular structures. Nabilone binds
particularly to CB1 receptors. Absolute
contraindications for use are
hypersensitivity to cannabinoids, and
hypersensitivity to the sesame oil used in
the manufacture of dronabinol. Relative
contraindications are a history of
cardiovascular disease (hypotension,
hypertension, tachycardia, syncope),
substance misuse, and pregnancy.
Cardiovascular side effects include
palpitations, tachycardia, and
vasodilation. Digestive tract side effects
include abdominal pain, nausea and
vomiting. Central nervous system effects
include anxiety, confusion, and
depersonalisation.
He described the use of nabilone in the
RVI from 1999 – 2001. All nabilone
prescriptions were recorded in the
pharmacy controlled drugs book. Of 60
patients, 43% were still on nabilone.
There were 20 female and 40 male
patients. The age range was 31 –89 years.
The dose distribution was 1 – 2mg (range
0.5 – 4.0mg). 34 patients stopped taking
nabilone as it did not help their symptoms.
Of the 26 patients still on nabilone, 17 had
neuropathic pain. When recording
previous analgesic use, 53/60 had had
antidepressants, 39/60 had had
anticonvulsants, 39/60 had had opioids,
and 14/60 had had NSAIDs. There were
8 groups of pain diagnoses. For two of
the patients, the GPs took over the
prescriptions. All the other patients on
nabilone obtained it from the RVI
pharmacy. His conclusions were that
neuropathic and visceral pain had
responded best to nabilone, and that it was
worth trying if nothing else had helped.
Further multicentre RCTs with nabilone
and dronabinol are taking place.
Dr Bernhard Frank and
Professor Roger Pertwee
The afternoon programme was chaired
by Sister Ann Kelly from Dundee.
Professor Ian Power from Edinburgh,
shared some of his thoughts on the topic
of “Acute and Chronic Pain Teams – An
Artificial Distinction?”. He suggested
further integration of acute, chronic, and
cancer pain services. There was some
discussion on the use of the terminology
“pain management” or “pain medicine”.
There needs to be better recognition of
symptoms of neuropathic pain following
surgery or trauma, in order for it to be
treated appropriately. On the educational
side, he mentioned the MSc in Pain
Management (University of Wales), which
is a multidisciplinary distance learning
course for health professionals in acute,
chronic and cancer pain management.
Having recently returned from Sydney, he
also mentioned the MSc in Pain Medicine
which has been set up there.
Professor Ian Power
and Dr Cliff Barthram
The next speaker was Dr Ian Marshall,
from the Medical Physics Department,
Western General Hospital, Edinburgh. He
spoke on “Functional MRI and Pain
Imaging”. Functional imaging relies on
BOLD (brain oxygen level dependence).
Patients lie in the scanner, undergo
psychological testing, and the MRI scan
is then performed. Brain images are
collected rapidly and continuously whilst
the subject carries out a “cognitive
paradigm”. These “paradigms” include
visual, auditory, and physical stimuli.
There are push button responses, so
speaking is not involved. The whole brain
is scanned every 2 – 3 seconds. Scanning
is synchronised with the paradigm. He
then described a phantom limb pain fMRI
study which had been carried out at the
Western General Hospital.
Dr Ian Marshall
The final session of the afternoon was
devoted to “Information Technologies”.
Dr Robin McKinlay, Consultant in
Anaesthesia and Pain Management at
Stirling Royal Infirmary spoke about the
Pain Audit Collecting System (PACS) of
the Pain Society. This is coordinated by
the CISIG (Clinical Information Special
Interest Group). Robin is the Scottish
coordinator. We require to collect pain
data for a variety of reasons. They include
being a small specialty with potential
isolation, a perception of being poorly
resourced, the need for the best possible
activity/outcome data, to satisfy requests
for better assessment practices, collecting
meaningful data on individual conditions,
and to demonstrate the value of pain
management. The PACS Database is a
balance between useful information and
too much information. It is valuable for
clinical governance as an audit tool, for
clinical effectiveness, and risk
management. It also facilitates research.
The new version 4.1 is more
comprehensive with sections on diagnosis,
outcome measures, reports, user
identification, treatment, PMP, personal
portfolio, and primary care links. He then
shared with us the results of the PACS
2000, which included 10,516 patients
from 46 centres (9 from Scotland). The
system is not ideal but there are clinical,
research, and political advantages of
togetherness. And also, it is free!
Dr Robin McKinlay
Dr Cliff Barthram, Consultant in
Anaesthesia and Pain Management, Perth
Royal Infirmary, was the final speaker of
the day. He has been seconded for a year
to the TECCI project (Tayside Electronic
Clinical Communication Implementation).
The background of the project is political.
The aim is to electronically link up every
GP surgery with outpatient clinics by
2002! There is a 3 phase National Roll
out.
ECCI objectives are electronic patient
referral (non protocol, and protocol),
electronic discharge and clinic letters,
direct booking of outpatient appointments
by the GP, and shared care. Non protocol
ERS (electronic referral system) includes
the patient visiting the GP, recording
information on the HER (electronic health
record), details of past history and
medication. The GP completes and sends
an electronic referral letter straight to the
hospital. The hospital acknowledges
receipt and sends an appointment. The
benefits are cutting out several sources of
delay such as post, medical records, and
internal mail. The decreased paperwork
saves trees! The ERS has a SIGN format.
Protocol based referrals act as a
gatekeeper to specific clinics. The benefit
is a decrease in inappropriate referrals.
The pitfalls however are that protocols
change, they act as a guide not a law, there
are a plethora of different web pages
covering lots of protocols.
The benefits of electronic discharges
are elimination of postal delays, a brief
structured document, and one accurate
immediate discharge document.
Direct booking of outpatient
appointments by the GP can decrease
DNAs, allow the patient a convenient
time, hence planning ahead. The GP and
patient can plan a waiting time strategy.
The pitfalls are a long waiting time, patient
pressure, a decreased ability for
consultants to prioritise patients, and the
risk of inappropriate urgency.
 Shared care is facilitated electronically, CAPTION COMPETITION
with EHR, clinical messaging, and a
secure email system. We look forward to
hearing more from Cliff when the project
is further developed.

Further exciting developments may

well ensue.

SCOTTISH PARLIAMENT

Dorothy Grace Elder, MSP,

coordinated a debate in the Scottish
Parliament on 27 February 2002. This was
following a petition concerning lack of
resources throughout Scotland to manage
services for pain sufferers. This appears By popular demand, I have reintroduced the caption competition. What do you think
to be the first time that any parliament in Dr Keith Rogers (Glasgow) is up to here? Your thoughts to the Editor (details as
the world has discussed chronic pain. previous). The prize is a book token.

NEWS FROM THE REGIONS
GLASGOW
Welcome to new psychology
colleagues, Dr David Craig (Victoria
Infirmary and Southern General Hospital),
Dr Martin Dunbar (Gartnavel General
Hospital, and Stobhill Hospital), and Dr
Theresa Houseman (Glasgow Royal
Infirmary, and Stobhill Hospital). Mrs
Alison Crofts (Physiotherapy) has joined
the team at Glasgow Royal Infirmary from
Belfast. Sister Lisa Henderson has joined
the teams at Glasgow Royal Infirmary and
Gartnavel General Hospital. Lisa has
seven years experience in the Pain
Management Programme in Bath. Sister
Sioban Calwell has taken on some chronic
pain sessions at Stobhill, balancing this
with her acute pain commitments.
Guidelines for the management of pain
in primary care have been launched. A
rolling programme of education for GPs
and practice nurses is ongoing.
Standardised referral letters will come into
action imminently (guideline based). A
Glasgow wide ,physiotherapy led Back
Pain Service has also been launched,
following a successful pilot project in the
North East sector. This involves 9
community based physiotherapists
working closely with the primary care
team.
Plans are also at an advanced stage for
the building of a community based Pain
Management Programme.
Further developments are afoot with
bids for increased resources for
contributions to Palliative Care, via the HIP.

Dr Adrian Shanks and

Dr Janet Braidwood

Dr Dennis Martin Dr Mick Serpell and

and Mrs Alison Crofts Dr John Hodkinson

Mrs Alison Crofts and
Mrs Lisa Henderson
Professor Daniel McQueen
and Dr Margaret Cullen
AND FINALLY
I have to say “Adieu”. I am sure that
Colin Rae, the next Editor, will perform
sterling service (and reach print deadlines
more promptly!). My thanks have to go
to my technical adviser over the years, Iain
(my son). He is now sitting GCSEs, and
so has an excellent knowledge of pain. He
has stated most categorically though that
he does not wish to pursue a career
involving working with children, animals,
or anything to do with “counselling” (Ed
Note: Reckon that rules out most of the
field of pain!). Included is a photo of
mother and son!
Ruhy Parris