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