NEWSLETTER OF THE NORTH BRITISH PAIN ASSOCIATION - SPRING 2003

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FROM THE EDITOR:

Welcome to the spring edition of Threshold,which, like the last issue, has kindly been sponsoredby Janssen Cilag. The winter scientific meetingseems a long time ago now. The long winter monthsare now at an end. Spring is here, heralded by sunnydays, birds singing in the trees and the sound ofThreshold dropping through your let ter box.Unfortunately, all is not rosy in the world and theseare troubled times. Perhaps, by the time you readthis, the war in Iraq will be over with, we hope, asfew casualties as possible. Current events make thesubject of the Spring Meeting, �Pain in Conflict� allthe more relevant.

As I was working on this issue of Threshold, thePain Society newsletter arrived. The new Editor,Stephen Ward, has produced an excellent �new look�first issue. Now, being of a competitive nature, I triedtel l ing myself that we are not r ivals butcomplementary publications. I don�t feel pressuredat all, I don�t�. not at all�.. absolutely not.

I have, in fact formulated bold plans forThreshold, but on consultation with my colleagues Ihave been advised that it would not be proper at thisjuncture to turn Threshold into the �Loaded�magazine of the pain world. Oh well, never mind.

The winner of last issue�s caption competition isannounced over the page and for this issue, as wellas the caption competition, Mike Basler has providedus with an interesting anagram competition.

As ever, there is much to keep us busy, includingthe Pain Society meeting in Glasgow, the SpringNBPA meeting and of course summer holidays tolook forward to.

The deadline for the NBPA essay competition hascome and gone. There has not exactly been a floodof entries but those submitted have been of thehighest standard. The winner will be announced atthe Spring Scientific Meeting. Information on nextyear�s competition will be given in the Autumn issue.

If you have an article you would like to submit,a topic you would like covered, or a news item youwould like to be included in the next issue, pleasesend it to the address below. Any photographs,embarrassing or otherwise, suitable for the captioncompetition would be much appreciated. Post themto: -

Dr Colin P. Rae,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.ukNBPA website www.nbpa.org.uk

NEWS FROM NBPA COUNCIL

Clinical Information Subgroup

At the last NBPA Council Meeting, Dr. RobinMcKinlay from Stirling floated the suggestion offorming a Clinical Information Subgroup. The groupwould advise on information technology and auditissues, including the maintenance of the NBPAwebsite. We are all aware of the need to audit ouract ivi t ies and outcomes. There is a generalrecognition that many centres have struggled to setup and utilise the PACS national database for avariety of reasons. The importance of support for thisproject was recently highlighted in an Editorial in�Anaesthesia�. It was agreed that Robin wouldapproach three other individual with an interest inthese matters to form the group. If anyone hasexpertise in this field and would like to be involvedthen please speak to Robin at the next meeting inEdinburgh or contact him at Stirling Royal Infirmary.

NBPA Website

There are ongoing discussions about the cost,location and future of the NBPA website which iscurrently located on the University of Newcastleserver. Dr. Semple is to investigate other options andwill report back to council.

DATES FOR YOUR DIARY

NBPA Spring Scientific Meeting Friday 9th May2003 �Pain in Conflict�

NBPA Winter Scientific Meeting Friday 21stNovember 2003 �An Inflammatory View of Pain�

REPORT FROM WINTERSCIENTIFIC MEETING

Friday 22/11/02�Hard nuts to crack�

The meeting was kindly sponsored by MerckSharp and Dohme, Napp Pharmaceuticals, Pfizer andJanssen Cilag.

The day started with an excellent lecture givenby Dr Roger E Cull, Consultant & Senior Lecturerin Neurophysiology, Western General Hospital,Edinburgh. The title of his lecture was �Diagnosisof migraine and other headaches�.

Migraine is defined as: - �A familial periodicdisorder characterised by recurrent attacks of

headache in which the pain is often unilateral,pulsating in quality and usually accompanied byanorexia, nausea and vomiting.� In some cases, itmay be preceded or accompanied by focalneurological, especially visual, symptoms. Thelifetime risk of suffering from migraine is 25% andthe prevalence in the general population is 10% -15%. It is 2 � 3 times more common in women thanmen, especially during the reproductive years. Thecommonest age of onset is in the second or thirddecade. A positive family history is present in 70%of cases and other risk factors include female sex,age, menstruation, early pregnancy, stress, diet,sleep, travel, exercise, head injury, SLE and certaindrugs.

Migraine can be sub-divided into different types.The commonest is migraine without aura affecting80%-90% of sufferers, followed by migraine withaura affecting 10% - 20%. Migraine with aura canbe further subdivided into basilar artery migraine,which causes double vision and speech slurring,hemi-plegic, dysphasic/dysmnesic and dysphoric.

Migraine without aura generally lasts between 4and 72 hours. The headache should have two of thefollowing four features: -

- Unilateral- Throbbing- Moderate to severe intensity- Exacerbation by physical activity

There may be associated symptoms ofphotophobia, nausea and vomiting.

Typical features of migraine with aura includethose for migraine without aura with at least threeof the following characteristics: -

- One or more fully reversible aura symptoms- Aura symptoms develop over more than four

minutes- Aura lasts less than 60 minutes- Type of aura may change during attack- Headache follows within 60 minutes- Visual prodomata including teichopsia and

scintillating scotoma

Dr Roger Cull and Dr Charlotte Feinmann

Various trigger factors for migraine have beenidentified and include:

- Relief of stress- Hormonal changes- Physical exertion- Change of routine- Visual glare, vivid patterns- Weather and atmospheric pressure changes- Foods and alcoholic drinks

The differential diagnosis of migraine include:

1. Tension type headache. These affect 70% - 80%of the population, have a variable duration withmild to moderate pain, often bilateral which istight, pressing or band-like. The headache isoften frontal, temporal or occipital, there isusually no nausea, vomiting or photophobia andit is often triggered by stress and relieved byrelaxing.

2. Cervicogenic headache. These are less wellestablished than tension type headache. Theytend to occur daily, with occipital headacheassociated with neck pain that may radiate to thetemporal region. The headache is worse withcertain postures and there are limited and painfulneck movements.

3. Cluster headache (Migrainous Neuralgia). Thisaffects men 5 � 8 times more commonly thanwomen. I t is a rare disorder af fect ingapproximately 1 in 1000 people.Characteristically, there are clusters of one ormore daily headaches over a period of severalweeks, followed by painfree periods. They arecommoner in smokers. They are characterisedby severe retro-orbital pain, lasting 15 � 90minutes. Attacks are often nocturnal andassociated with epiphora, nasal congestion andHorner �s syndrome. In contrast to migrainesufferers, people with cluster headache tend towalk around and may be aggressive.

4. Temporal arteritis. This condition should also beconsidered in older patients with a new headachewhether uni or bilateral. There may be associatedtenderness over the temporal region or in theoccipital area and there may be systemicsymptoms including malaise, weight loss, fever,polymyalgia and visual loss. If there is asuspicion of temporal arteritis, an ESR shouldbe taken to confirm or exclude the diagnosis.

5. Raised intra-cranial pressure headache. Thisheadache is characterised by diffuse pain that isworse on bending. Vomiting may occur (withoutnausea). There may be visual obscuration,seizures, focal neurological symptoms, optic discswelling and daily morning headache.

6. Sub-arachnoid haemorrhage. This ischaracterised by sudden onset, blow-like painoften to the back of the head. It may radiate tothe neck and be associated with collapse,vomiting and neck stiffness. The latter sign maybe absent early. Exertion is a trigger for sub-arachnoid haemorrhage and patients may havealterat ion in their conscious level withirritability, drowsiness and focal neurologicalsigns. Examination of the optic fundi may revealsub-hyaloid haemorrhages. Urgent CT scanningis indicated.

7. Cranio-vertebral anomalies. There may becongenital anomalous development at the baseof the skull with descent of the inferiorcerebellum. This is associated with cough-induced headache and cerebellar, brain stem andpyramidal signs. The diagnosis is confirmed byMRI scan. Treatment is surgical decompression.

8. Benign occipital epilepsy. This normally presentsin childhood with idiopathic focal seizuresaccompanied by visual hallucinations that areoften described as being circular in shape andmulti-coloured. EEG demonstrates occipitalspike wave discharges and the condition respondswell to treatment with anti-convulsants.

Dr Cull concluded by emphasising theimportance of taking a detailed history, thoroughlyexamining the patient and undertaking investigationsif the history is suspicious, clinical signs are presentor the headache cannot be categorised. He advisedextra caution when dealing with patients with aprevious neoplasm and also older patients with a newheadache.

Dr Charlotte Feinmann, Reader in Psychiatry,Behavioural Sciences and Dentistry, Eastman DentalInstitute and Royal Free and University CollegeMedical School, gave the second lecture. The subjectof the talk was �Oro-facial Pain�.

associated with a suppression or mis-attribution ofmood�.

The basis of treatment is to consider thefunctional somatic symptoms together. Apsychosocial approach with an empathic interviewermay help the patient to recognise the problem. Healthbeliefs can be explored and appropriate reassurancegiven although premature reassurance may not havethe desired effect. The aim of management is tochange the patient�s focus of attention.

The pain team at the Eastman Dental Instituteincludes psychiatrists, psychologists, nursingpractitioners, restorative specialists, neurologists andan anaesthetist. Treatments include the use ofantidepressants, cognitive behavioural therapy,informed reassurance, hypnosis, relaxation and splinttherapy. Clinicians must take a full history in anattempt to make a diagnosis. Investigations andphysical treatments, however, may make pain moredifficult to treat, can exacerbate anxiety anddepression and frustrate both patient and clinician.

In conclusion, Dr Feinmann stressed theimportance of adequate assessment, informedreassurance, team management, antidepressants, theuse of cognitive behavioural therapy and hypnosis.

There followed the usual high quality lunch inthe conservatory.

Dr Feinmann started by giving an overview ofthe complexity of pain. Melzack and Wall were thefirst to describe pain as the result of afferent upstreamprocesses within the spinal cord with downstreammodulation. We are aware that the brain can generatepain in the absence of input from peripheralnociceptors, for example in phantom limb pain. Sheemphasised the cognitive model of pain which takesinto account both physical and psychosocial aspectsand described the common problem of being able toexplain to a patient what is not wrong with them butnot what is wrong with them.

She then reported the results of a series ofstudies. In 1985, Bridges and Goldberg, found thatone in five new consultations in primary care are formedically unexplainable symptoms. One third ofthese persist and cause distress and disability.

In 2002, MacFarlane et al published a populationbased cross sectional survey of 2504 adults agedbetween 18 and 65 in the journal Pain. It reportedthat 23% of patients questioned described oro-facialpain, 6% described widespread pain only and 4%described both. There were high levels ofpsychosocial distress.

Predictors of chronic facial pain are: -1. Widespread pain within the facial region.2. Widespread pain outside the facial region.3. Inactivity.

An outpatient three year retrospective case notereview study published by Koenke and Mangelsdorfin 1989 reported an incidence of 30% in women and21% in men of facial pain. The highest incidencewas in the 18 � 25 age group and the lowest in the56 � 65 age group. Only 46% of people sought helpwith 17% taking time from work. Less than 2% ofpatients received an organic diagnosis.

In patients with chronic temporo-mandibularjoint pain, there is no relationship between earlysigns and symptoms and severity of physicalabnormalities in the joints. There is, however, astrong relationship with depression, anxiety andsomatisation. Often there will be a history of highlevels of health care use and of other chronicallypainful conditions.

Simon and Von Korff in 1991 demonstrated thatpatients may misattribute normal bodily functions aspain. We are aware that experience of pain isinfluenced by childhood exposure to illness, possiblerecall of physical or sexual abuse, depression, anxietyand phobias.

The definition of somatisation is: -�An amplification of normal bodily sensations

Dr Mike Basler from Glasgow Royal Infirmarychaired the afternoon session. Dr Tom Brown,Consultant Liaison Psychiatrist based at the Westernand Gartnavel Hospitals in Glasgow started theafternoon. The title of his lecture was �Chronicfatigue syndrome and its management�.

Dr Andrea Harvey and Dr Charlotte Feinmann

Drs Carlin Thomas, Tom McCubbinand Joanne Wood enjoy lunch

The lecture started with a very entertainingSimpson�s video which nicely demonstrated people�sfear of being thought to be �at it�. One of theproblems of patient doctor interaction is that patientspresent to doctors with illness (behaviour) anddoctors diagnose and treat diseases. He discussedthe classification of chronic fatigue syndrome andits relationship to other disorders such as irritablebowel syndrome, atypical chest pain,hyperventilation syndrome, non-epileptic seizures.There is also a marked overlap between chronicfatigue syndrome and fibromyalgia.

The prevalence of chronic fatigue symptom is0.4% to 2.6% of the general population. It is twiceas common in women than in men and is commonestbetween the ages of 20 and 40. It has been suggested

Dr Tom Brown, Consultant LiaisonPsychiatrist, Glasgow

that disturbance of the hypothalamic pituitary axiswith associated low levels of cortisol and enhancedserotonin function is important in i tspathophysiology. This is in contrast to depressionwhere there is reduced serotonin function.

Ef fective interventions in chronic fatiguesyndrome can be categorised into behavioural,immunological, antiviral, pharmacological anddietary.

Of four randomised control trials of cognitivebehavioural therapy, benefit was shown in three.There was improvement in fat igue, physicalfunctioning and global measures of well-being.There were no differences in depression. A five-yearfol low up in one study demonstrated thatimprovement was generally maintained.

Other treatments used include graded exerciseprogrammes, immunological therapies such as IgGand drug treatments such as Interferon, Acyclovirand Gamcyclovir. There is no evidence for thebeneficial effect of antidepressants or steroids.

Lisa Manchanda, Special is t Registrar inAnaesthesia at the Western Infirmary, Glasgow, gavethe next talk. She presented her winning entry tothe North Bri t ish Pain Associat ion EssayCompetition, Spring 2002.

Below is a transcript of her winning essay.

The North British Pain AssociationEssay Competition Spring 2002

Is Surgery The Answer?Dr Lisa Manchanda SpR,

Western Infirmary, Glasgow

IntroductionDuring an evening of pre-assessments, I noticed

an unusual entry on the normally routine renalsurgery list. As I was unfamiliar with the procedure� a renal auto-transplantation � I discussed the casewith the attending surgeon.

The patient was a young female who had sufferedchronic loin pain for over ten years. She was toundergo this surgical procedure in an attempt toalleviate her pain, which mainly affected the left sidebut was occasionally bilateral. She also experiencedspontaneous exacerbations of severe pain and nothingwould alleviate her symptoms. The pain greatlyaffected her daily activities and as a result she hadsuffered psychological distress. After years ofextensive negative investigations she was finallydiagnosed as having loin pain haematuria syndrome(LPHS).

renal capsule and cortex follow the same pathwayand most fibres terminate in the sympathetic systemwith some following the vagus nerve.

Visceral renal pain may be experienced as achingand non-specific in the area of the costovertebralangle and may be due to inflammation of the kidneysor acute ischaemia due to thrombus in the renalvasculature. Patients without this pathology may alsoexperience a similar type of pain and may in fact haveloin pain haematuria syndrome.

Loin Pain Haematuria SyndromeLoin pain haematuria syndrome (LPHS) was first

described by Little et al in 1967. Patients oftenpresent with recurrent episodes of loin pain(unilateral or bi lateral) and some degree ofmicroscopic or gross haematuria, which may beintermittent. The onset of pain may precede thepresence of haematuria. The pain is often severe anddebilitating and may radiate to the abdomen, thighor groin. Although the majority of patients withLPHS are female and present between the ages oftwenty and forty, it can also occur in children.

LPHS is rare and unfortunately the syndromeremains a diagnosis of exclusion reached whenurological investigations do not reveal adequatepathology to account for the symptoms. As a result,patients should be assessed by a renal physician withexperience of LPHS and should have adequateinvestigations including an ultrasound, intravenouspyelogram, cystoscopy and renal isotopescintigraphy. Ureteroscopy, angiography and renalbiopsy should also be considered.

Abnormalities detected following a renal biopsyhave included mesangial proliferation and immunecomplementation C3 deposition in the arterioles. Oneseries showed that nearly 50% of patients had thinglomerular basement membrane disease. Changes inintrarenal arterioles, the presence of cortical infarctsand the occurrence of microaneursyms have beendetected on renal angiography. Decreased heparin-thrombin clotting time and elevated plasma serotoninconcentration suggests evidence of a platelet orcoagulation disorder.

These abnormalities provide evidence thatsuggests the presence of a vascular disorder.However, surprisingly, these patients do not go onto develop impaired renal function. Serum creatinineand renal concentrating ability remain normal.

Psychological FactorsIn the original description of LPHS, some

patients were described as anxious, demanding ofmedical attention, and inclined to fabricate medicalevidence. Furthermore, Lucas et al proposed asrecently as 1995 that LPHS was a psychogenic painand a form of somatisation. This idea has furtherperpetuated the belief that the syndrome had aprimary psychological aetiology.

In contrast, Bultitude et al published a study inPain in 1998, showing that psychological disabilityimproves as the pain symptoms improve. Theyassessed 26 patients before and after a recognisedtreatment option and found that the psychologicaldistress is secondary to the pain and the disability itcauses.

Pain ManagementPatients diagnosed with LPHS are often very

challenging to manage. They commonly experiencesevere pain requiring high dose opioid medication.On review of our Pain Management Clinic database,it was found that the management of patients, whopresented with similar symptoms, included treatmentwith opioid analgesics, tricyclic antidepressants,TENS application and local anaesthetic nerve blocks.The success of treatment was usually of a limitedduration and varied across the patient population.

Regional techniques used for the treatment ofLPHS include intercostal, interpleural, paravertebraland epidural local anaesthetic nerve blocks. Lumbarsympathetic and splanchnic nerve blocks have alsobeen described in case literature. Implant able devicesreleasing intrathecal opioids have also been used.

In 1995 Bultitude first described the use of acapsaicin solution for the treatment of LPHS. Itinvolved ureteric catheterization with instillation ofa capsaicin solution into the renal calyx and ureter,performed under general anaesthesia and requiredprolonged epidural anaesthesia. In humans the nervesupply to the renal pelvis and ureter is proportionallyrich in C fibres. Capsaicin is said to cause intensestimulation of these nerves with release andsubsequent depletion of substance P from thenociceptors of the urothelium. It has been reportedto give 65% of patients short to medium term painrelief. However questions have been raised over thesafety of its use. In one study two patients developeddeterioration in their renal function followingcapsaicin treatment. Capsaicin could not be excludedfrom contributing to this complication. Anotherpatient suffered mucosal ulceration in the bladderafter extravasation of the solution.

Surgical interventionsSurgery is rarely appropriate for the management

of chronic pain conditions. It can worsen the patient�ssymptoms and cause further chronic postoperativepain. However, surgical techniques have now beendeveloped for the treatment of LPHS and are aimedat denervating the kidney. They include renal nerveexcision, surgical sympathectomy, removal of therenal capsule, nephrectomy and renal auto-transplantation. Renal nerve excision has providedtemporary pain relief, however case studies report ahigher incidence of pain recurrence compared to autotransplantat ion. In an extreme example of asuccessful outcome, a patient was able to return toemployment following a bilateral nephrectomydespite the need for dialysis.

Renal auto transplantation surgery was firstdescribed by Aber and Higgins in 1982 and isextremely rare is this country. It is performed as aform of nephron-sparing denervation therapy. Thisprocedure involves removing the affected kidneyfrom the loin and retransplanting it in the iliac fossa.Most of the available literature on renal autotransplantations is from small case studies. In 1998Chin et al looked at the results of 26 patients whohad undergone renal auto transplantation for LPHS.The mean fol low-up t ime was 7 years withapproximately 70% of patients having sustained painrelief and returning to normal activities. Theprocedure however carries the significant risks ofmajor renal surgery including graft failure and acuterenal fai lure. Other complicat ions includerecurrence of the pain in the graft site and areassumed to be due to renal reinnervation. Thistheory is probably too simplistic to explain therecurrence of pain. The procedure may be carried outbi lateral ly as new pain can develop on thecontralateral side years later.

The risks of performing surgery as an isolatedtreatment option for chronic pain are huge and mayactually worsen the patient�s symptoms and function.This approach perpetuates a patient�s belief that thedoctor will alleviate chronic pain rather than assistthe patient in managing their symptoms in order toimprove their functions of daily living. It is thereforecritical to meticulously screen surgical candidatesincluding a full psychological assessment. Ignoringthe multifactorial biopsychosocial model of anypatient with chronic pain will decrease the chancesof successful management.

Giving the varying long-term success togetherwith the risks and complications, the decision toperform surgery is often taken at a late stage intreatment and may be the last resort.

Case HistoryFollowing diagnosis, the patient described in the

beginning, was managed with oral opioid analgesiawith little improvement in her symptoms. She wasreferred to the Pain Management Team who treatedher with tricyclic antidepressant medication as anadjunct to her opioid medication. This unfortunatelyhad no effect on her symptoms. Other managementincluded a trial of transcutaneous electrical nervestimulation, which had a beneficial effect for alimited duration only. Over the years she hadnumerous paravertebral nerve blocks with varyingdegrees of success.

Renal PainPain due to a renal aetiology is often elusive and

difficult to explain. This is partly due to the complexinnervation of the renal system. The kidney isinnervated by the renal plexus that is situated behindthe origin of each renal artery at the level of T12 toL2. There is an autonomic contribution from thecoeliac ganglia, aorticorenal ganglion, the aorticplexus and the first lumbar splanchnic nerve. Thesefibres follow the renal artery into the kidney hilussupplying the vessels, glomerular structures andtubules. Afferent fibres arising in the region of the

Lisa Manchanda, Sarah Morrisand Kenneth Pollock

Throughout the duration of management, thepatient had expressed a strong interest in surgicalintervention. As the previous treatments wereunsuccessful in providing sustained pain relief,surgery was now a viable option.

OutcomeSo did surgery improve the patient�s symptoms?

In the immediate postoperative period, she hadexcellent pain relief provided by epidural analgesia.However, her symptoms of loin pain recurred severalweeks after her operation. Fortunately, severalmonths on, her symptoms improved and she no longerrequired opioid analgesia. The long-term outcomefor this patient is, as yet, unknown.

Can her pain relief be attributed to a direct effectfrom the surgery? No. Many factors were involvedin this successful outcome. It was possible that thepatient perceived surgery to be a �cure� for hersymptoms. However, as illustrated by one case series,nearly one third of patients show spontaneousresolution of symptoms within four years.

ConclusionAn integrated multidisciplinary approach at an

early stage, involving both the renal specialists andthe Pain Management Team, is vital for successfullymanaging patients with LPHS. In addition, a fullbiopsychosocial assessment is critical before adecision is made to proceed to surgery. Although notalways the answer, it can be concluded that surgerywas possibly the best option for this patient and, atpresent, has significantly improved her quality of life.

References1. Little P.J., Sloper J.S. and de Wardener H.E. A syndrome

of loin pain and haematuria associated with disease ofperipheral renal arteries. Quart.J. Med (1967) 36:253.

2. Burke J.R., Hardie I.R. Loin pain haematuria syndrome.Pediatr Nephrol (1996) Apr 10(2) 216-20.

3. Lucas P.A., Leaker B.R., Murphy M. and Neild GH. Loinpain and haematuria syndrome: a somatoform disorderQ.J.Med 1995 88: 703

4. Bultitiude M, Young J, Bultitude M, Allan J Loin painhaematuria syndrome: distress resolved by pain relief.Pain 1998 May; 76(1-2): 209-13

5. Allan J.D.D., Bultitude M.I.B., Bultitude M.F., Wall P.D.and McMahon S.B. The effect of capsaicin on renal painsignaling systems in humans and Wistar rats. Lancet 1995345, 921-922

6. Chin J.L, Kloth D, Pautler S.E, Mulligan M. Renalautotransplantation for the loin pain-hematuria syndrome:the long term followup of 26 cases J Urol 1998 Oct; 160(4): 1232-5

7. Sheil AG, Chui AK, Verran DJ, Boulas J, Ibels LSEvaluation of the loin pain/haematuria syndrome treatedby renal autotransplantation or radical renal neurectomy.Am J Kidney Dis 1998 Aug; 32(2): 1215-20

8. Aber GM, Higgins PM The natural history andmanagement of the loin pain/haematuria syndrome. B JUrol 1982 Dec; 54(6): 613-5

9. T. Armstrong, A.D.McLean, M.Hayes, B.T. Morgans andD.N. Tulloch Early experience of intraureteric capsaicininfusion in loin pain haematuria syndrome. BJUInternational 2000, 85,233-237

Sarah Morris, Clinical Nurse Specialist in PainManagement at the Southern General Hospital inGlasgow then spoke on �Pain Management inAddictive Disease�.

She first stated that there is no evidence that theprevalence of addictive disease is any greater inchronic pain patients than in the general population.Drug addiction is a major problem in the GreaterGlasgow Health Board area, with 6,980 drug misuserelated emergency admissions between 1993 and1999.

Addiction is defined as �A primary chronicneurobiological disease with genetic, psychosocialand environmental factors influencing i tsdevelopment and its manifestations, characterised byimpaired control of drug use and impulsivebehaviour�. Risk factors for addictive disease are afamily history of addiction, psychiatric history or ahistory of substance abuse.

Tolerance is defined as �A state where anincreased dose of a psycho-active substance is neededto produce the desired effect�. Cross-tolerance iswhere repeated administration of one psycho-activesubstance induces tolerance manifested towardsanother substance to which the individual has notbeen exposed.

The aims of the pain management team in patientswith addictive disease are prevention of withdrawaland effective and safe analgesic treatment. Patientassessment may be more difficult with scoringsystems not being as reliable. It is important toestablish which drugs the patient is addicted to andhow much of these drugs they normally take and bywhat route. They may be on a Methadonemaintenance programme or may be an ex-user. Thesefacts can be validated with their GP. Patients withan addictive disease may at times be abusive, requestanalgesics by name or by injection, refuse oralanalgesics and are well-known to be unreliableattenders for out-patient appointments.

A scoring system has been developed for theassessment of withdrawal in an individual andincludes scores for pupil size, skin temperature andsweating, nasal congestion, agitation and cardio-vascular and gastrointestinal symptoms. Withdrawalis normally treated with Dihydrocodeine in areducing dose and Diazepam. It is useful to limitthe number of staff dealing with the patient. Ingeneral, we must accept the patient�s report of painand develop a management plan for them on anindividual basis. There should be an open and honestdiscussion with the patient. No Pethidine or agonist/antagonist drugs are prescribed and addictionspecialists may be consulted. If the patient is on aMethadone programme, this is continued. Abalanced analgesic approach which may include non-steroidals and other simple analgesics is used andthe least invasive options for each medicationutilised. TENS machine may be useful.

Acute pain strategies may include regionaltechniques, patient controlled analgesia withbackground infusion. Patients are monitored forexcessive analgesic intake and for symptoms ofwithdrawal. Excessive sedation may occur whendrug combinations are used. Patients are changed tonon-opioid analgesics as soon as possible.

In the chronic pain management setting, a moveis made towards time contingent use of analgesicswith long-acting preparations. Agreement must bereached between the patient, primary care and thepain management consultant for prescription andmonitoring of compliance.

The final presentation of the day was given byAlice Ong, Medical Student, University of Glasgowon the Treatment of Neuropathic Pain with Ketamineand Lignocaine Infusions.

She described a double blind, cross over, placebocontrolled study investigating the effects of druginfusions on the severity of pain. Six patients with adiagnosis of neuropathic pain where recruited toundergo three infusion sessions at weekly intervals.These lasted two hours each and during them, thepatient received Ketamine 0.4mg/kg, saline orLignocaine 5mg/kg. Immediate and long term effectson spontaneous pain, mechanical allodynia andmechanical hyperalgesia were measured.

The VAS for spontaneous pain were reduced bylignocaine, approaching statistical significance atp=0.059. Pain relief lasting over 12 hours occurredin lignocaine 3/6, ketamine 2/5, placebo 0/5.Ketamine and lignocaine showed a significant shortterm reduction in VAS score for sensitive pain.Ketamine and lignocaine showed trends of increasingsensory and pain threshold on the painful side andreduction in dynamic allodynia and hyperalgesia. Nolong-term benefit could be demonstrated.

Alice Ong, Mike Basler, Lisa Manchandaand Sarah Morris

Pain News and Gossip

Gavin McCallum from the Southern General inGlasgow is currently serving in the Gulf and we sendhim and any other friends and family of NBPAmembers involved in the conflict our very bestwishes.

On a completely different note, Glasgow hasrecently received recognition from the Royal Collegeof Anaesthetists as a training centre in PainManagement.

Dr. Gail Gillespie, Specialist Registrar inAnaesthesia in the West of Scotland has recentlybeen appointed as the new Glasgow pain fellow. Shewill follow in the footsteps of Lars Williams whohas done an excellent job.

Dr. Pauline Adair, Clinical Psychologist ,originally in Dundee, then in Glasgow, has movedon to Belfast and we send her our very best wishesfor the future.

Holly Daniel, physio at Glasgow Royal isreturning to work in the states and will be greatlymissed. Again, our best wishes go with her.

Dr. Ivan Marples has recently been appointed toa Consultant post in Anaesthesia and Painmanagement at the Western General Hospital inEdinburgh.

Finally, congratulations to Andrea Harvey andLesley Colvin on the birth of their daughters. I thinkwe�re going to have to start a bonny baby section inThreshold!

Anagram CompetitionAll correct entries to the anagrams below will

be put into a hat and the winner announced in thenext issue. All anagrams are relevant to the world ofthe NBPA.

Thin conning maniacal porn

This impotent rascal Leper creation

Sandra Lee welcomes delegatesat the reception desk

Caption CompetitionThe winning caption is �That�s another fine mess

you�ve gotten me into Stanley� submitted by DrMartin Dunbar, Clinical Psychologist, Glasgow. Welldone, Martin. Many thanks to all who sent in entries.Please try again, the odds of winning are quite high!!

Entries for this issue�s Geordie captioncompetition should be emailed or posted to me atthe address on the front cover.