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NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2001


FROM THE EDITOR He can be contacted at: congenital abnormalities such as spina
Pain Management Unit bifida, are relatively common. Terminal
Welcome to the real new millennium Royal Victoria Infirmary disease also features, whether neoplastic
(for the purists)! This year Threshold is Queen Victoria Road or chronic conditions such as renal failure
sponsored by Napp. Many thanks for their Newcastle upon Tyne and cystic fibrosis.
support. The world of pain expands. NE1 4LP
More people are hearing of the CSAG Tel/Fax: 0191 282 4412 The principles of pain management in
report (Services for Patients With Pain). E mail: dilkapur@netcomuk.co.uk children echo those in adults, with
Hopefully, increased awareness will lead NBPA website: http://www.netcomuk. emphasis on adequate information, control
to an increase in resources to enable co.uk/~dilkapur/index.htm of pain, reassurance, increasing levels of
implementation of the recommendations. activity, and improving sleep (child and
Many of you will know that MSPs are WINTER SCIENTIFIC MEETING parent!).
interested in chronic pain, with the 8 December 2000 The team approach cannot be
formation of a crossparty parliamentary Pollock Halls, Edinburgh overemphasised. Pharmacological
working group. methods and nerve blocks all have a place
The theme of the meeting was “Pain alongside encouragement by nursing,
Please let me know of news and views. in Children”, following last year’s highly physiotherapy, and clinical psychology
You can contact me at: successful “Pain in the Elderly”. The colleagues to increase function.
Department of Anaesthetics meeting was kindly sponsored by RDG,
Walton Building Pfizer, Sims Portex, Elan, Rusch, and Children (as any parent thankfully
Searle. knows) grow up, and long term followup
Glasgow Royal Infirmary
84 Castle Street of patients is an area where improved
The first speaker of the morning was liaison with adult pain services is vital.
Glasgow G4 0SF
Dr John Currie, Consultant Anaesthetist
Tel: 0141 211 4621
at the Royal Hospital for Sick Children,
Fax: 0141 211 4622
Glasgow. He is originally a Liverpool
E mail: john@jparris.demon.co.uk graduate, and has worked in Edinburgh,
Great Ormond Street, Ayr, and for the last
Ruhy Parris eight years in Glasgow. He has been the
Regional Education Advisor for
anaesthetists for the last 18 months. His
NEWS FROM remit was “Running a Chronic Pain
Service for Children”. He currently has
NBPA COUNCIL
5 or 6 referrals per month of patients with
chronic pain. The approach is
SPRING SCIENTIFIC MEETING multidisciplinary, and of course involves
As the two annual fixtures are currently the whole family. Paediatric pain is unique
March and December, it was felt that it in that everything occurs with a
would be more balanced to spread the background of growth and development.
meetings out a bit more (is this pacing?).
The December meeting stays as it is, He concentrated on the need for
however the next Spring meeting now adequate infrastructure (space, secretarial Dr John Currie
moves to May. For your diaries, the date support) and most of all time. There is
is Friday 11 May 2001, at the usual venue, much emphasis on liaison with other The next speaker of the morning was
Pollock Halls of Residence, University of agencies such as schools, physiotherapy Ms Zoe Sully, Physiotherapist at the Royal
Edinburgh. The theme of the meeting will and community nursing. He sees children National Hospital for Rheumatic Diseases,
be “Psychosocial Factors in Chronic with a wide spectrum of conditions such Bath. She has been involved with the adult
Pain”. as complex regional pain syndrome, pain Pain Management Programme for 5 years.
after surgery (eg phantom limb pain), and She was then given the remit for
The secretary, Dr Dil Kapur, will also atypical pains such as facial pain. developing a feasibility and business plan
circulate registration forms imminently. Being paediatric practice, pain from for an adolescent Pain Management
Programme. This has been up and running summary for the referrer, and patient. Group Standing Committee on Medicines.
for 18 months. Her presentation was on Follow-up occurs 3 months, 9 months and The conclusions were to choose medicines
“Pain Management in Adolescents”. 2 years post programme. Telephone which offer the best prospect of benefit
Adolescents (again as parents will attest) support is available. Both the young for the child with due regard to cost,
present unique challenges. Adolescence person and their parents are assessed on informed use of unlicensed medicines is
is a period of transition from dependence various measures such as pain of child, necessary in paediatric practice, health
to independence (Ed: my own children mood, anxiety and depression. To date, professionals need access to quality
bear more than a passing resemblance to the adolescents have improved on physical medicines information, Trusts and Boards
Kevin and Perry), when young people are measures, and the parents show less stress, should support therapeutic practice which
challenging boundaries (Ed: “you’re not anxiety and depression. It may well be commands peer support. It is important
going out dressed like that!”), changing that a major factor is changing the to have seamless prescribing solutions
schools, and developing their sexual attitudes of the parents who then mediate between secondary and primary care, such
identities. There is clinical demand for change in adolescents. as using joint formularies, shared care
an adolescent service, indeed some 10% protocols, and of course effective
of adults had pain in childhood. The final speaker of the morning was communication.
Dr Norman Lannigan, Chief Pharmacist
Factors associated with adolescent pain of Lothian Universities NHS Trust. He
presentation are a family in crisis, stress, has previously worked in Perth, Glasgow
school and social difficulties, physical and Inverclyde. His background is in
difficulties, and changes is family analytical chemistry. Special interests
dynamics. Pain associated disability include chronic pain, palliative medicine,
(PADS) in a young person includes low and quality of pharmaceutical services.
mood / high anxiety, low self confidence, He spoke on “Using Medicines Out of
dependence at a time of growing License – Considerations in Prescribing
independence, reduced fitness, poor for Childre n”. The Health Select
school attendance, reduced activity and Committee (1999) described unlicensed
social withdrawal. These issues then medicines use in children as “…an
impinge on the wider family. In the unsatisfactory state of affairs”. The
programme, again the emphasis is on a Medicines Act (1968) requires medicines
team approach with the psychologist, to have a product license in order to
physiotherapist, occupational therapist, protect society from inappropriate
nurse, paediatric rheumatologist, and marketing by manufacturers. It is not
researchers. intended to prevent competent clinical Dr Norman Lannigan
practitioners from prescribing in the best The afternoon programme was chaired
The programme is a 3 week residential interests of their patients. Indeed, medical by Dr Mhoira Leng. The first session was
one with parental involvement. practitioners have the right to prescribe a presentation by Dr Martin Ward Platt,
Accommodation is B & B to encourage unlicensed medicine, pharmacists can Consultant Paediatrician, Royal Victoria
independence. There is a pool, and dispense them, and nurses are allowed to Infirmary, Newcastle, titled “Pain in
therapy space. Cognitive behaviour administer them following the direction of Children – Involving Families”. He spoke
therapy is the mainstay of the programme the medical practitioner. “Named patient” on the necessity to speak separately to the
with skills training, family understandings, products can be prescribed, also child, exploring their particular fears and
physical rehabilitation, goal planning, unlicensed medicines may be used in anxieties. Pain may be a form of
pacing and relaxation. There are clinical trials. Medical practitioners can communication within the family, an
opportunities for sessions for parents / use unlicensed medicines outwith Specific avoidance strategy (school or a family
carers only, and conversely sessions for Product Characteristics (SPC). member), or a safety valve. It takes time
the young people on their own. Following to uncover the real issues, unpick
discharge, there is a comprehensive Turner et al (BMJ Jan 1998) estimated relationships, reveal unspoken fears, and
that 36% of children in hospital received identify the locus of control (adult or
an unlicensed medicine during admission, child). A thorough physical examination
and that 25% of all prescriptions for is mandatory, and to listen to the story
children in hospital were for unlicensed given. Once these have been done, it is
medicines. An unlicensed medicine may vital to formulate the problems in terms
be used “off label” (route, dose, age, of how the family sees them and how the
indication). Manufacturers have a health professionals see them. Once this
dilemma when considering clinical trials
in children such as ethical problems
(placebo controlled, exposure of children
to experimental medicines, informed
consent), and also liability issues (adverse
drug reactions, long term growth/
development). This has implications for
practitioners if prescribing outwith
product license as the liability is with the
practitioner not manufacturer.

In February 2000 a policy statement


was produced by the Joint Royal College
of Paediatrics and Child Health and Dr Martin Ward Platt
Zoe Sully Neonatal and Paediatric Pharmacists and Dr Mhoira Leng
is done it is then possible to negotiate 16 has capacity if they understand the amelioration the book is both relevant and
solutions with all parties concerned, and nature and possible consequences of the valuable. For instance on page 153 Wall
agree ways forward with communication proposed treatment. In Scotland there are asks the question. ‘What are the
with the GP, parents etc. two relevant Acts, namely the Age of appropriate motor responses to the arrival
Legal Capacity Act 1991, and the Children of injury signals?’
Dr Bob Leckridge from the Glasgow Act 1995. In England & Wales courts can
Homoeopathic Hospital, who is the overrule a child’s refusal of consent to They attempt: first to remove the
President of the Faculty of Homoeopathy, treatment if under 16, but the situation is stimulus; second, to adopt a posture to
spoke on “Using Homoeopathic less clear in Scotland. In Scotland a child limit further injury and optimise recovery;
Medicines in Children”. He comes from under 16 can consent to “procedures and and third, to seek safety, relief and cure.
a general practice background, and has treatment” for nontherapeutic research, The youngest, most inexperienced animal
been working using a homoeopathic but probably cannot in England & Wales. may attempt a series of these responses
approach in the department of In England & Wales an unmarried father triggered by in- built mechanisms. As the
developmental neurology, Royal Hospital cannot have access to a child’s health animal grows in experience, the reactions
for Sick Children, Glasgow for a number records, but the situation is less clear in will become more subtle, elaborate and
of years. He described chronic pain as Scotland. Laws keep changing so it is sophisticated .If the sequence is frustrated
something which cannot be understood in important to keep abreast of them where at any stage, the sensation and posture
terms of tissue damage alone. He litigation involves children. remain.
emphasised the importance of “narrative
based research” where the story is This paragraph alone could perhaps
recounted, in detail, in the patients’ own offer a lifetime of study and on a practical
words. Understanding suffering is the key BOOK REVIEW level it is one most therapists deal with
task of any doctor. Homoeopathic daily!
therapeutic modalities are based on “like Our intrepid physiotherapist, Ian
treats like”. “Remedies” are “potentised” Stevens, currently in Dunblane (ex The book is full of case histories from
preparations. Remedies are prepared by Glasgow) has contributed a book review our own familiar culture and contrasts
serial succussions and dilutions. of Patrick Wall’s “Pain The Science of other cultures’ approaches to dealing with
Naturally, there are questions about Suffering”, below. pain. Some cultures display amazing
standards of training and practice and stoicism, some religions encourage it
about regulation. It is vital to have “Pain The Science of Suffering” However, change the situation, alter the
evidence based homoeopathy as a way Patrick Wall circumstances and man’s biological
forward for the future, with meta- Weidenfield and Nicholson 1999 reaction to pain is universal.
analyses, RCTs, outcome studies, case isbn 0 297 84255 2
series, and qualitative research. Interestingly there is a section of the
Don ‘t judge a book by it’s cover. In book describing the treatment of pain
The final speaker of the day was Dr this case you could easily ignore this whose cause is known and approaches to
Graham Carey, Medical Advisor to the advice. The book reviewed here has a the management of conditions whose
Medical and Dental Defence Union of really eye catching cover with human cause is not. For Physiotherapists most of
Scotland, who addressed “Legal Issues in forms interlaced with a myriad of shapes, the painful conditions routinely treated are
the Treatment of Children”. There are arrows, squares and a maze of spirals . in the second category!
The maze of shapes makes no sense and
the arrows and lines move easily between For Physiotherapists there are
the peripheral body to the head and back interesting, challenging discussions on the
again. waxing and waning in terms of popularity
of acupuncture, the important placebo
Such is the case with the subject of the phenomenon and the role of restoring
book. The contents weave between the patients to functional health in ongoing
periphery to central relay sensations and pain.
cognition - no area dominates , all areas
are ripe for study, all ripe for intervention. Most importantly the book
demonstrates the importance of movement
We all like certainties and pain is far in pain and the role that movement has in
from certain. Patrick Wall has spent a restoring bodily health. The book dashes
lifetime studying pain and the contents of any notions of dualistic interpretations of
this book demonstrate not only a depth pain and does not offer any hope of finding
of understanding of the subject but a real a pain ‘centre’ . What Patrick Wall does
awareness of the focus of the book - man offer is a humane need to offer individual
and his suffering. care to individuals suffering pain,
something Physiotherapists strive to offer
The book is no dry academic diatribe on a daily basis . Given the growth in
on a complex perplexing subject but an literature such as this it is hoped that the
Dr Graham Carey example of how scientific medicine can be. understanding and management of those
The contents of the book are aimed at the in pain will only improve.
differences in legal aspects between lay reader but no one who has an interest
England and Scotland. Children differ in trying to understand pain will be Ian Stevens BSc MCSP
from adults legally with regard to consent, disappointed by its contents.
access to health records/Data Protection
Act, and litigation. Over the age of 16 a For Physiotherapists interested in
person has capacity, but a person under movement restoration and pain
SCOTTISH NETWORK FOR NEWS FROM THE REGIONS
CHRONIC PAIN RESEARCH
GLASGOW: It is an exciting time here, NEWCASTLE: Our illustrious secretary,
The 2nd Expert Group Meeting of the planning services (now funded) for the Dr Dil Kapur, has expanded his family.
Network was held in Stirling city. Many challenges and opportunities Welcome to baby Ben.
Management Centre on 6 November for all concerned. Only one new baby this
2000. time, Felix Fraser-Krauss to Heidi
(formerly of Glasgow Interdisciplinary
The morning session consisted of School of Pain), now resident in Fife.
presentations of ongoing and planned EDINBURGH: NBPA Council Member
research into chronic pain issues: Daniel McQueen, has just been appointed
to a Chair in Pharmacology. Dr Lesley
Pain in non-verbal individuals who Colvin has been appointed consultant
have learning disabilities. Brian Scott anaesthetist at the Western General
(Stirling University) Pain exercise and Hospital. Members will recall her
a g e i n g : c u r re n t & f u t u re n e t w o r k presentation on neuropathic pain last year.
research. Dr. Lindsey Carroll (Stirling Welcome back to Scotland for Ian Power
University) who now is Professor of Anaesthesia. He
Biopsychosocial needs-assessment of exiled himself first to Wales and then Ben Kapur and his big sister
c h ro n i c p a i n s u f f e re r s i n t h e Australia, but has returned home.
development of a community-based pain
management support programme Linda
Bates (Pain Association Scotland/Queen DUNDEE PAIN DISCOVERY DAY
Margaret University College)
Chronic non-malignant pain: health- Thursday 19 April, West Park Conference Centre, Dundee. The morning will
care professionals’ beliefs and attitudes. feature presentations on the basic science of pain. The afternoon will focus on back
T and Dr. Denis Martin (on behalf of pain and the keynote address (Tom Houston Memorial Lecture) will be delivered by
Derek Jones, Queen Margaret University Professor Gordon Waddell.
College/Pain Association Scotland) It was with great sadness that NBPA members learnt of the death of Dr Tom
Chronic non-malignant pain: paths Houston. He was a Founder Member of the NBPA.
t h ro u g h t h e c a re m a z e D r. C l a i r e
Mortimer (Queen Margaret University
College). AND FINALLY
Following lunch, the group split up Please keep sending letters, e-mails, photos, articles etc. My son Iain (who now
into two workshops - one on the CSAG towers above me) has, as ever, been an invaluable source of criticism, advice, technical
report Services for Patients with Pain knowledge, and loans his digital camera for ever increasing bribes.
and the other on pain and the individual. Ruhy Parris

The next one day scientific meeting


will be held on 18 May 2001 at the
Stirling Management Centre (9.30am –
CAPTION COMPETITION
4.30pm). Speakers in the morning
include Professor Sir Michael Bond, Dr. Gavin McCallum and Dr. Pete McKenzie (Glasgow)
Professor Ian Power, and Professor Ian
Russell. The afternoon programme
consists of workshops discussing
subjects such as the CSAG report, and
pain and the individual.

Further information from Mrs


Mohinder Watson, mwatson@gmuc.ac.uk
or 0131 554 8160 or SNCPR, Queen
Margaret University College, Duke
Street, Edinburgh, EH6 8HF.

Dr Denis Martin from QMUC has


introduced a new e mail discussion list
for the research, clinical and education
communities interested in the
management of people with pain. The
simplest way is to go to the pain list
www pages at: www.jiscmail.ac.uk/lists/
pain.html, alternatively send a message
to jiscmail@jiscmail.ac.uk with the
message join pain Denis Martin
(replacing Denis Martin with your own The winning caption is
forename and family name). “Pete, these new spinal cord stimulator leads are difficult to handle”
The prize of a £20 book token goes to Dr Mike Basler, Glasgow Royal Infirmary.