NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2002

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FROM THE EDITOR

This edition of Threshold is sponsoredby A. Menarini. I would like to thankNapp for their sponsorship of thenewsletter last year. Many thanks to bothcompanies.

After this edition, I will hang up mykeyboard, so to speak, and pass the mantleof editorship onto Dr Colin Rae,Consultant in Anaesthesia and PainManagement at Stobhill Hospital ,Glasgow. It has been an interesting threeand half years, which has seen themembership of the NBPA grow, and itsscientific meetings increase in stature.

Until Colin takes up his post, pleasesend me your news and views.

You can contact me at:Department of AnaestheticsWalton BuildingGlasgow Royal Infirmary84 Castle StreetGlasgow G4 0SFTel: 0141 211 4621Fax: 0141 211 4622E mail:gri.pain@northglasgow.scot.nhs.uk

I am sure that those going to San Diegoin August for the IASP Congress canfurnish the editor with suitable mementoesof North Brits abroad!

Ruhy Parris

WINTER SCIENTIFIC MEETING30 November 2001

Pollock Halls, Edinburgh

The theme of the meeting was “NewSolutions To Old Problems”. The meetingwas kindly sponsored by Napp, RDGMedical, Medtronic, Pfizer, Pharmacia,and Janssen Cilag. Prior to the start ofthe meeting, Dr Ed Charlton thankedNBPA members for participation in asurvey of manpower in pain managementclinics in the region. He informedeveryone of an impending editorial inAnaesthesia concerning pain services inthe UK. Drs Doug Justins and Alf Collins,representing the Pain Society, would bemeeting government representativesconcerning implementation ofrecommendations from the CSAG report(2000).

The morning session, chaired by DrMick Serpell , was devoted toCannabinoids. We were privileged tohave Lord Perry, Chairman of the Houseof Lords Select Committee on cannabis,share with us aspects of the ongoingdebate on the use of cannabis in medicine.The committee was appointed in 1997with the remit of looking at evidence forrelaxing restrictions on medical uses ofcannabis.

The first mention of cannabis goes backto the 7th century BC, in Assyrian tablets.

Dr Ed Charlton andDr Murray Carmichael

NEWS FROMNBPA COUNCIL

The Spring Scientific Meeting is onFriday 10 May at the usual venue of JohnMacIntyre Centre, Pollock Halls ofResidence, University of Edinburgh. Thetheme is “Pain of Urogenital Origin”.(Ed. Note: If , l ike me, you are an

anaesthetist with a regular urology list,you will know exactly the sort ofchallenging patients our urologycolleagues refer to the pain clinic!)

Dr Lyndia Green (Glasgow) replacesNicky Springford as a clinical psychologyrepresentative. Many thanks to Nicky(Durham) for her services to Council.

Dr Dil Kapur, our secretary, hasrecently 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 Adelaidewith Dr Dave Cherry. Dil will be sorelymissed in North British territory, havingworked as a pain specialist both in Perth,and Newcastle. Australia has gained. Iam sure that he will act as our antipodeancorrespondent.

In the meantime, Dr Mick Serpell hasstepped into the breach as locumSecretary. Mick, as many will recall, forquite some time performed a juggling actbeing both the Secretary and the Treasurerof the NBPA. Any queries, or membershipinformation can be directed to him at:

Pain Management ClinicGartnavel General HospitalGreat Western RoadGlasgow G12 OYNTel: 0141 211 3288Email: mgserpell@altavista.net

NBPA website (including onlineThreshold) is: http://www.nbpa.org.uk

Dr Dil Kapur and Dr Mick Serpell

Queen Victoria used it for labour pains.It was in the British Pharmacopeia until1932. Under the Medicines Act of 1968,cannabis had a licence of the right toprescribe. In 1973, the licence wasremoved, making it illegal to possess,supply or prescribe cannabis.

Cannabis has over 60 cannabinoidspresent. ∆9-tetrahydracannbinol is themost common. It is fat soluble, slowlyabsorbed orally, and degraded in the liver.Smoking cannabis leads to rapid actionand absorption, entering body fat, andtakes a long period to be eliminated.There is an endogenous cannabinoidsystem with CB1 and CB2 receptors.Nabilone is a synthetic cannabinoid.

There is no recorded death from anoverdose of cannabis. It has toxicity fromthe dangers of smoking. It can inducemild psychosis, and cause tolerance in highdoses. It is unclear as to whether or notit leads to dependence. Cannabis is helpfulin relieving the intractable pain of multiplesclerosis.

The 1985 Misuse of Drugs Act hasSchedule 1 drugs which cannot beprescribed, and Schedule 2 drugs egcocaine, heroin, which can be prescribed.Cannabis preparations are considered as“new medicines” since they were deletedin 1973.

In 1998, the committee produced itsfirst report recommending clinical trialsas an urgency. It recommended thatcannabis be moved to Schedule 2 to allowprescription. This was turned down bythe government. The committee made norecommendation as to recreational use ofcannabis. A second report was producedin 2001. The remit was to examine currentresearch and therapy. MRC trialsexamined the use in spasticity in multiplesclerosis, and also for postoperative pain.GW Pharmaceuticals’ aim is to obtain alicence from the Home Office to cultivatecannabis plants, and also to get pure THC.Stage I and II trials have been completedvia the Medicines Controls Agency. Theaim is to complete clinical trials by 2003.

As yet there is no change in the lawfollowing these two reports. The HomeSecretary, David Blunkett, wants a reviewof laws on cannabis, making it a class Cdrug as opposed to a class B drug. As yetthere is no decriminalisation of cannabis.There is an argument that much policetime is spent on people in possession ofsmall quantit ies of the drug. TheMedicines Controls Agency is still keenon long term toxicity tr ials ofcannabinoids. (Ed. Note: A lot ofcontroversy since this meeting on cannabisand its uses. Further clarification is vital.)

Lord Perry was followed by ProfessorRoger Pertwee from the University ofAberdeen who gave us a detailed reviewof the pharmacology of “Cannabinoids asAnalgesics”. ∆9-THC is the mainpsychotropic constituent of cannabis.Dronabinol and nabilone are the twocannabinoids licensed for clinical use inthe UK. Nabilone (1 mg capsules) is usedas an antiemetic.

Cannabinoids are fat soluble. There areCB1 and CB2 receptors. These receptorsare not distributed evenly in the brain.CB1 receptors are mainly in thehippocampus, cerebral cortex, basalganglia, globus pallidus, cerebellum. Theyare also found on pain pathways. Thereare four groups of cannabinoid receptoragonist . One of the agonists isanandamide which is CB1 selective, butnot very stable in the body. Many moreCB1 agonists are being developed. Thereare many CB2 agonists.

There are antagonists for CB1 and CB2receptors. These can be used asantiobesity agents. Current therapeuticuses of cannabinoids are for stimulationof appetite, and suppression of nausea andvomiting. The potential therapeutic useswill be in multiple sclerosis, andneuropathic pain. However the knownunwanted effects of cannabis arepsychotropic effects, aggravation ofexisting psychoses, and elevation of heartrate. Strategies to minimise central effectsinclude the use of partial agonists.

From animal studies there is evidencethat endogenous cannabinoids such asanandamide regulate nociception. It ispossible to exploit synergistic interactionssuch as a CB1 agonist and an opioid foranalgesia, or a CB1 agonist and abenzodiazepine or baclofen for spasticity.Cannabinoids and opioids interactsynergistically for the production of

antinociception, as shown with the mousetail flick test.

Important areas for future study are themodes of action of endocannabinoids, andalso issues to do with solubility anddelivery of cannabinoids. An experimentaldrug, 0-1057, has been developed whichis water soluble, binds to both CB1 andCB2 receptors, and is more active andpotent than THC.

The morning session ended with apresentation by Dr Bernhard Frank,Research Fellow, Pain Management Unit,Royal Victoria Infirmary, Newcastle. Hespoke on “The Clinical Use ofCannabinoids in Pain Management”. Heis involved in a multicentre trial on theefficacy of nabilone in neuropathic pain.Herbal cannabis is cultivated at home andeither smoked as a joint or taken in theoral form. Dronabinol is licensed for usein anorexia associated with AIDS in theUSA. Nabilone is licensed for use as anantiemetic, associated with chemotherapyin the UK. Nabilone comes in 0.25mg and1mg capsules. It is available in the UK asa hospital only prescription, and can beordered by every pharmacy.

Dronabinol and nabilone have differentmolecular structures. Nabilone bindsparticularly to CB1 receptors. Absolutecontraindications for use arehypersensitivity to cannabinoids, andhypersensitivity to the sesame oil used inthe manufacture of dronabinol. Relativecontraindications are a history ofcardiovascular disease (hypotension,hypertension, tachycardia, syncope),substance misuse, and pregnancy.Cardiovascular side effects includepalpitations, tachycardia, andvasodilation. Digestive tract side effectsinclude abdominal pain, nausea andvomiting. Central nervous system effectsinclude anxiety, confusion, anddepersonalisation.

He described the use of nabilone in theRVI from 1999 – 2001. All nabiloneprescriptions were recorded in thepharmacy controlled drugs book. Of 60patients, 43% were still on nabilone.There were 20 female and 40 malepatients. The age range was 31 –89 years.The dose distribution was 1 – 2mg (range0.5 – 4.0mg). 34 patients stopped takingnabilone as it did not help their symptoms.Of the 26 patients still on nabilone, 17 hadneuropathic pain. When recordingprevious analgesic use, 53/60 had hadantidepressants, 39/60 had hadanticonvulsants, 39/60 had had opioids,and 14/60 had had NSAIDs. There were8 groups of pain diagnoses. For two ofthe patients, the GPs took over theprescriptions. All the other patients on

Lord Perry

Dr Bernhard Frank andProfessor Roger Pertwee

nabilone obtained i t from the RVIpharmacy. His conclusions were thatneuropathic and visceral pain hadresponded best to nabilone, and that it wasworth trying if nothing else had helped.Further multicentre RCTs with nabiloneand dronabinol are taking place.

The next speaker was Dr Ian Marshall,from the Medical Physics Department,Western General Hospital, Edinburgh. He

The final session of the afternoon wasdevoted to “Information Technologies”.Dr Robin McKinlay, Consultant inAnaesthesia and Pain Management atStirling Royal Infirmary spoke about thePain Audit Collecting System (PACS) ofthe Pain Society. This is coordinated bythe CISIG (Clinical Information SpecialInterest Group). Robin is the Scottishcoordinator. We require to collect paindata for a variety of reasons. They includebeing a small specialty with potentialisolation, a perception of being poorlyresourced, the need for the best possibleactivity/outcome data, to satisfy requestsfor better assessment practices, collectingmeaningful data on individual conditions,and to demonstrate the value of painmanagement. The PACS Database is abalance between useful information andtoo much information. It is valuable forclinical governance as an audit tool, forclinical effectiveness, and riskmanagement. It also facilitates research.

The new version 4.1 is morecomprehensive with sections on diagnosis,outcome measures, reports, useridentification, treatment, PMP, personalportfolio, and primary care links. He thenshared with us the results of the PACS2000, which included 10,516 patientsfrom 46 centres (9 from Scotland). The

Dr Cliff Barthram, Consultant inAnaesthesia and Pain Management, PerthRoyal Infirmary, was the final speaker ofthe day. He has been seconded for a yearto the TECCI project (Tayside ElectronicClinical Communication Implementation).The background of the project is political.The aim is to electronically link up everyGP surgery with outpatient clinics by2002! There is a 3 phase National Rollout.

ECCI objectives are electronic patientreferral (non protocol, and protocol),electronic discharge and clinic letters,direct booking of outpatient appointmentsby the GP, and shared care. Non protocolERS (electronic referral system) includesthe patient visiting the GP, recordinginformation on the HER (electronic healthrecord), details of past history andmedication. The GP completes and sendsan electronic referral letter straight to thehospital. The hospital acknowledgesreceipt and sends an appointment. Thebenefits are cutting out several sources ofdelay such as post, medical records, andinternal mail. The decreased paperworksaves trees! The ERS has a SIGN format.

Protocol based referrals act as agatekeeper to specific clinics. The benefitis a decrease in inappropriate referrals.The pitfalls however are that protocolschange, they act as a guide not a law, thereare a plethora of different web pagescovering lots of protocols.

The benefits of electronic dischargesare elimination of postal delays, a briefstructured document, and one accurateimmediate discharge document.

Direct booking of outpatientappointments by the GP can decreaseDNAs, allow the patient a convenienttime, hence planning ahead. The GP andpatient can plan a waiting time strategy.The pitfalls are a long waiting time, patientpressure, a decreased abil i ty forconsultants to prioritise patients, and therisk of inappropriate urgency.

Dr Ian Marshall

Professor Ian Powerand Dr Cliff Barthram

Dr Robin McKinlay

The afternoon programme was chairedby Sister Ann Kelly from Dundee.Professor Ian Power from Edinburgh,shared some of his thoughts on the topicof “Acute and Chronic Pain Teams – AnArtificial Distinction?”. He suggestedfurther integration of acute, chronic, andcancer pain services. There was somediscussion on the use of the terminology“pain management” or “pain medicine”.There needs to be better recognition ofsymptoms of neuropathic pain followingsurgery or trauma, in order for it to betreated appropriately. On the educationalside, he mentioned the MSc in PainManagement (University of Wales), whichis a multidisciplinary distance learningcourse for health professionals in acute,chronic and cancer pain management.Having recently returned from Sydney, healso mentioned the MSc in Pain Medicinewhich has been set up there.

spoke on “Functional MRI and PainImaging”. Functional imaging relies onBOLD (brain oxygen level dependence).Patients lie in the scanner, undergopsychological testing, and the MRI scanis then performed. Brain images arecollected rapidly and continuously whilstthe subject carries out a “cognitiveparadigm”. These “paradigms” includevisual, auditory, and physical stimuli.There are push button responses, sospeaking is not involved. The whole brainis scanned every 2 – 3 seconds. Scanningis synchronised with the paradigm. Hethen described a phantom limb pain fMRIstudy which had been carried out at theWestern General Hospital.

system is not ideal but there are clinical,research, and political advantages oftogetherness. And also, it is free!

AND FINALLY

I have to say “Adieu”. I am sure thatColin Rae, the next Editor, will performsterling service (and reach print deadlinesmore promptly!). My thanks have to goto my technical adviser over the years, Iain(my son). He is now sitting GCSEs, andso has an excellent knowledge of pain. Hehas stated most categorically though thathe does not wish to pursue a careerinvolving working with children, animals,or anything to do with “counselling” (EdNote: Reckon that rules out most of thefield of pain!). Included is a photo ofmother and son!

Ruhy Parris

SCOTTISH PARLIAMENT

Dorothy Grace Elder, MSP,coordinated a debate in the ScottishParliament on 27 February 2002. This wasfollowing a petition concerning lack ofresources throughout Scotland to manageservices for pain sufferers. This appearsto be the first time that any parliament inthe world has discussed chronic pain.

Shared care is facilitated electronically,with EHR, clinical messaging, and asecure email system. We look forward tohearing more from Cliff when the projectis further developed.

Further exciting developments maywell ensue.

CAPTION COMPETITION

By popular demand, I have reintroduced the caption competition. What do you thinkDr Keith Rogers (Glasgow) is up to here? Your thoughts to the Editor (details asprevious). The prize is a book token.

Alison Crofts (Physiotherapy) has joinedthe team at Glasgow Royal Infirmary fromBelfast. Sister Lisa Henderson has joinedthe teams at Glasgow Royal Infirmary andGartnavel General Hospital. Lisa hasseven years experience in the PainManagement Programme in Bath. SisterSioban Calwell has taken on some chronicpain sessions at Stobhill, balancing thiswith her acute pain commitments.

Guidelines for the management of painin primary care have been launched. Arolling programme of education for GPsand practice nurses is ongoing.Standardised referral letters will come into

action imminently (guideline based). AGlasgow wide ,physiotherapy led BackPain Service has also been launched,following a successful pilot project in theNorth East sector. This involves 9community based physiotherapistsworking closely with the primary careteam.

Plans are also at an advanced stage forthe building of a community based PainManagement Programme.

Further developments are afoot withbids for increased resources forcontributions to Palliative Care, via the HIP.

Professor Daniel McQueenand Dr Margaret Cullen

NEWS FROM THE REGIONS

GLASGOWWelcome to new psychology

colleagues, Dr David Craig (VictoriaInfirmary and Southern General Hospital),Dr Martin Dunbar (Gartnavel GeneralHospital, and Stobhill Hospital), and DrTheresa Houseman (Glasgow RoyalInfirmary, and Stobhill Hospital). Mrs

Dr Mick Serpell andDr John Hodkinson

Mrs Alison Crofts andMrs Lisa Henderson

Dr Dennis Martinand Mrs Alison Crofts

Dr Adrian Shanks andDr Janet Braidwood