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Context Knowledge is limited regarding pain assessment and management practices, as well as pain-related outcomes in hospice care. Objectives To generate national estimates of pain assessment and management practices and outcomes of pain control among patients 65 years or older receiving hospice care in the U.S. and identify hospice discharge and agency characteristics predicting study outcomes. Methods The 2007 National Home Health and Hospice Care Survey was analyzed. Multivariate logistic regressions were estimated to identify discharge and agency characteristics predicting guideline-concordant pain assessment and management practices and pain control outcomes. Results A high percentage of discharges had pain assessment at admission (97%) and before discharge (93%); use of valid pain rating scales was relatively low (69% and 54% for first and last assessments, respectively). Almost 95% of patients received pain medication, but only 42% received nonpharmacologic therapies. About 70% of patients assessed with a valid pain scale saw improvement in the level of pain or remained free of pain from admission to discharge. Non-Hispanic blacks were less likely to have pain assessments, and Hispanics were less likely to receive opioid analgesics or to have pain-free status at discharge, compared with non-Hispanic whites. Patients receiving care from for-profit (vs. nonprofit) agencies were more likely to receive pain assessment with a valid scale before discharge but less likely to experience pain control or improvement. Conclusion Greater use of valid pain assessment scales and nonpharmacologic therapies constitutes areas for improvement in hospice care. Targeted interventions are needed to address disparities in pain care by patient race and/or ethnicity and agency ownership status.

Approximately 80% of patients with advanced cancer report pain and receive opioids. Information is limited about deviations from prescribed opioid doses and barriers to pain control, but poor opioid adherence has been reported in 49%-70% of patients.To evaluate the frequency and severity of self-reported opioid deviation and barriers to opioid pain management in outpatients with advanced cancer.We surveyed 198 patients and collected pain scores (0-10), prescribed opioid dose, confidential patient-reported opioid prescription dose and intake (as long as there was no severe opioid deviation), barriers to pain management (Barriers Questionnaire-II [BQ-II]) scores, and adherence scores. Opioid deviation was defined as70% or130% of the prescribed dose.Median patient age was 55 years; 91 (46%) were female. Median pain intensity and morphine equivalent daily dose were 4 (interquartile range=3-7) and 120mg (interquartile range=45-270mg), respectively. Prescribed and patient-reported prescribed doses were highly correlated for regular (r=0.90, P0.001) and regular plus breakthrough opioid intake (r=0.94, P0.001). Nineteen (9.6%) patients deviated. Deviation was more frequent in males (P=0.039) and nonwhites (P=0.0270). Nonwhite patients had higher scores on the BQ-II than white patients (P=0.038). Low adherence scores were significantly associated with higher BQ-II scores (1.99±0.80) for lower motivation score vs. 1.61±0.77 for higher score, P=0.007; and 2.13±0.79 for lower knowledge score vs. 1.57±0.72 for higher score, P=0.001.Very few patients reported dose deviations, which were mostly toward lower dose. More research is necessary to better characterize the frequency and predictors of opioid deviation in this population.

Context No consensus exists about the most appropriate dose ratio for conversion from parenteral to oral ketamine. Objectives To confirm that a 1:1 dose ratio is suitable for converting subcutaneous (s.c.) to oral ketamine in cancer patients. Methods Patients with opioid poorly responsive cancer pain, who responded to 0.4, 0.6, or 0.8mg s.c. ketamine bolus, were treated with 0.1, 0.15, or 0.2mg/kg/h ketamine infusion, respectively. Switching to the oral route, by applying a 1:1 dose ratio, was carried out in patients who experienced adequate pain relief and continued to need ketamine as a coanalgesic. Pain, somnolence, feelings of insobriety, confusion, and cardiovascular parameters were assessed throughout the process. Results Twenty-nine patients were enrolled in the study. Ketamine infusion decreased pain intensity from severe to no pain or slight pain in 23 of 29 and six of 29 patients, respectively. The median of s.c. ketamine doses was 0.2mg/kg/h (range 0.1–0.5). After oral switching, 27 of 29 patients remained as successfully controlled as when receiving s.c. ketamine. The other two patients needed a slight dose ratio readjustment, to 1:1.3 and 1:1.5, to maintain pain control. The median of oral ketamine doses was 300mg/day (interquartile range 240–382.5). Seven of 29 patients receiving s.c. ketamine developed moderate and transitory side effects, such as feelings of insobriety and somnolence. No side effects were present while receiving oral ketamine. No significant changes were observed in cardiovascular parameters. Conclusion A 1:1 dose ratio for conversion from s.c. to oral ketamine is safe and effective in cancer pain patients.

This paper summarizes the experiences of 327 Australian health care chaplains with regard to their involvement in issues concerning pain control within the health care context. The findings indicate that approximately 60% of surveyed chaplains had provided some form of pastoral intervention directly to patients and/or their families dealing with issues concerning pain, and that approximately 36% of chaplains had assisted clinical staff with issues concerning patient pain. Differences of involvement between volunteer and staff chaplains are noted, as are the perspectives of chaplaincy informants regarding their role in relation to pain control. Some implications of this study with respect to chaplaincy utility and training are noted.

With the aging of the world's population, cancer pain will become an increasingly important health issue. The purpose of this study was to describe the cancer pain experience of Americans (n = 60) and Israelis (n = 39) 65 years and older. Outpatients in teaching hospitals in the U.S. and in Israel completed study questionnaires. Thirty percent of the total variance of worst pain was explained by age, symptom severity, and cancer stage, and 40% of the total variance of pain interference was explained by whether they were American or Israeli, symptom severity, and sense of coherence. Israeli patients had significantly higher scores on worst pain and pain interference, and significantly lower pain management index (PMI) and knowledge and attitudes toward pain and pain control scores. Studies with larger samples and across different cultures are needed to confirm these findings in order to develop culturally appropriate interventions.

For a small number of cancer patients, good pain control remains difficult to achieve despite adequate assessment and medical management. In nine cases, effective control of intractable pain from malignant pelvic disease was achieved by open thoracic cordotomy. The technique was well tolerated, with no major complications. Eight of the nine patients decreased their median daily oral morphine requirement from 560 mg (range 360-2600 mg) to 160 mg (range 40-1000 mg). Maximal survival time post-cordotomy was 830 days, with a median of 107 days. No patient experienced recurrent pain in the initially painful site. For patients with intractable pain associated with advanced pelvic malignancy, the use of an open cordotomy should be considered when satisfactory pain control is not achieved by medical or minimally invasive methods.

The role of a Palliative Medicine Liaison Consultation Service (LCS) in a large tertiary referral teaching hospital was examined by the prospective evaluation of 50 cases consecutively referred, together with the subsequent advice/recommendations (4 categories: pharmacological, non-pharmacological, clarification of goal of treatment, care system upon discharge) given during the consultation. The utility of a simple scoring system in quantifying the impact (4 grades: deleterious, no effect, positive, very positive) of the advice given on individual patient outcome, scored by both the referring team and the LCS, was studied. Eighty percent of cases had a cancer diagnosis. Pain was the most common symptom (50% cases) and "pain control" the most common referral reason cited. The median number of recommendations per patient was 3.0 and the majority (70%) concerned symptom control recommendations. Advice was given regarding discharge planning in nearly two-thirds of cases and such advice dealing with the care system upon discharge was judged by the referring team to have the highest positive impact of all recommendations. Nearly three-fourths of cases (74%) were graded by the referring team as having at least one recommendation with a positive impact. The simple scoring system used is demonstrably a useful outcome assessment tool. The LCS is perceived to have a positive impact on patient care in an acute hospital setting and appears to fill a gap in the multi-specialty provision of care.

The purposes of this study were to (a) test the feasibility of the Cancer Total Quality Pain Management™ (TQPM™) Patient Assessment Tool in a population of oncology inpatient and outpatients; and (b) identify factors associated with poor pain relief. The Cancer TQPM Tool was adapted from the American Pain Society's Quality Assurance Standards on Acute Pain and Cancer Pain and was tested in a convenience sample of 200 patients. The majority of patients reported that the TQPM Tool was easy to understand and to use, providing evidence for the feasibility of the tool. Factors associated with higher pain intensity included the inpatient setting, the presence of metastatic disease, hesitancy in bothering the nurse, and concerns regarding tolerance and addiction. Although there was a strong relationship between concern about addiction and concern about tolerance, fear of tolerance appeared to have a greater effect on pain intensity scores than did fear of addiction. The findings from this study suggest that the Cancer TQPM Patient Assessment Tool can be used effectively in both inpatients and outpatients to determine outcomes and the quality of cancer pain management, as well identify factors associated with poor pain control. Clinical implications include more effective education of patients and caregivers, including equivalent emphasis on tolerance and addiction.

The present study explored the effect of positive intrasurgical suggestion during the anesthetic state on postsurgical pain. One-half of the patients who were undergoing elective cholecystectomy or hysterectomy received strong positive intrasurgical suggestion directed specifically towards reducing pain. The control patients received information about pain without suggestion content. There was no effect on postsurgical pain measured by the McGill Pain Questionnaire and a visual analogue scale. The lack of effect on postsurgical pain indicates that intrasurgical suggestion does not provide a therapeutic method to achieve pain control.

The purposes of the study were to determine the knowledge and attitudes about cancer pain management (CPM) among practicing physicians in six Minneasota communities and to determine the physician-related barriers to optimal CPM. Eligible community physicians were surveyed by telephone. The study analyzed responses of 145 physicians (response rate, 87%). The majority of the physicians were primary care specialists (73%). Significant knowledge deficits were identified in nine of 14 CPM principles, but inappropriate attitudes were found in only two of nine CPM concepts. Medical specially had the strongest influence on knowledge and attitudes, with primary care physicians having significantly better outcomes than surgeons or medical subspecialists. Effective education strategies must address knowledge deficits, attitudes, and motivations of the relevant per group influencing physicians, as well as those of individual physicians. The Minnesota Cancer Pain Project is testing strategies to enhance CPM by physicians and improve patient outcomes.

Ventricular assist devices (VADs) have been shown to improve survival and overall quality of life, but there are limited data on pain control and functional status in this patient population.This study examined changes in pain, functional status, and quality of life over time in VAD patients.Patients were enrolled in this prospective cohort study before or as early after VAD implant as possible and then followed for up to 48 weeks. The Brief Pain Inventory was used to assess pain. The Katz Independent Activities of Daily Living questionnaire was used to assess functional status. The Kansas City Cardiomyopathy Questionnaire, a 23-item questionnaire covering five domains (physical function, symptoms, social function, self-efficacy, and quality of life), was used to assess quality of life and health status.Eighty-seven patients were enrolled at four medical centers. The median Brief Pain Inventory severity score was 2.8 (interquartile range 0.5-5.0) before implantation and 0.0 (interquartile range 0.0-5.3) 48 weeks after implantation (P = 0.0009). Katz Independent Activities of Daily Living summary scores also demonstrated significant improvement over time (P 0.0001). Kansas City Cardiomyopathy Questionnaire summary scales demonstrated significant improvement with time (P 0.0016).This study demonstrated that patients with VADs experienced improved pain, functional status, and quality of life over time. These data may be useful to help patients make decisions when they are considering undergoing VAD implantation.

The use of intrathecal diamorphine via an implanted portal system is described for pain control in a patient suffering from vertebral metastatic disease. The complication of myoclonic spasms affecting the lower half of the body occurred after 14 days, when increasing the bolus dose to 40 mg. The spasms lasted for 3 hr and then gradually subsided. Diamorphine was subsequently restarted at a lower dose of 15 mg twice daily. On increasing the dose to 20 mg diamorphine 10 days later, severe distressing myoclonic spasms recurred 20 min postinjection. Myoclonus could only be controlled by instituting a local anesthetic intrathecal block. The patient was finally managed with 20 mg diamorphine per day by intrathecal infusion, and the pain was reasonably well controlled for the following 10 weeks without any recurrence of myoclonic spasms.

During the last 5 yr, a number of palliative care programs have been developed in Latin America. All these programs benefit from the strong personal motivation of leaders who commit a considerable amount of their own time and resources to the success of their programs. Financial problems, the lack of adequate knowledge of pain control and other palliative care issues, difficulties in communication and obstacles related to local legislation are common to all programs, although each group has dealt with these problems in different ways. International programs have helped in the development of many of the local leading groups. Improved communication between different local groups, national governments, and international WHO Collaborating Centers will, hopefully, further promote the development of palliative care in Latin America in years to come.

Physiotherapists, whether trained in intensive care or internal medicine, must be attentive to patients at the end of their lives. Palliative-care physiotherapy requires basic training in rehabilitation techniques; the integration of a rehabilitation professional in a caregivers team; a profound communication with the patient, leading to an effective accompaniment and direct response to the patient's needs; and recognition of the patient's functional needs. The involvement of the physiotherapist can extend to the very end of life. In a series of 56 geriatric patients (35 suffering from cancer, 21 from other pathologic conditions) who died at the Center of Continuous Care, 44 (79%) had a treatment of respiratory physiotherapy until their last 24 hr.

Three hundred and eighteen (318) nursing staff members at an acute care teaching hospital in Montreal, Canada, were surveyed to identify their knowledge of pain assessment and management. Two pain instruments were combined and adapted for use. The final instrument consisted primarily of true/false responses and took about 10 min to complete. The mean score was 63.9%. Overall results indicated that nurses lacked knowledge and understanding of opioid addiction, equivalent dosing, properties of opioids, and differences in acute and chronic pain. No statistically significant differences were found in the scores by level of educational preparation or by years of experience. Presentation of the results unit by unit demonstrated that the instrument is suitable as an educational tool as well as an effective strategy to introduce nursing staff to nursing research.

On admission to a pain management unit, 92.5% of 174 cancer patients suffered from more than moderate pain despite prior treatment. This inefficacy was mainly due to underdosage of drugs, inadequate intake schedule, and hesitation to use strong opioids. Following introduction of an oral drug therapy based on World Health Organization (WHO) guidelines, more than 80% of all patients described their pain as ranging between "none" and "moderate" on a six-step verbal rating scale at all times. To obtain these results, it was necessary to adapt the therapy to increasing pain in the course of terminal disease. Step III (strong opioids) gained more and more importance with time, and step I (nonopioids) was finally useful only in a minority of patients. Side effects played a minor role as a reason to change therapy. Oral drug therapy following these guidelines led to sufficient pain control in most patients over the whole study period (7,400 days); only 11% of the patients required other methods of pain management.

Nursing care of the patient receiving spinal opioids for pain control is reviewed in a comprehensive manner. Selection of patients, nursing management and patient outcomes are discussed. Three pain control techniques are described: epidural opioid injection for cancer pain, epidural opioid infusion for acute postoperative pain, and single dose spinal opioids for postcesarean section pain. Monitoring and pharmacologic aspects common to all three forms of spinal opioid treatment are given, and specific nursing interventions for each therapy are delineated.

We present a case supporting the use of radiation therapy for palliation of joint pain associated with acute myelogenous leukemia. Prior to radiation therapy to the affected joints, and despite standard pain management, this patient was entirely bedridden and in significant pain. Following radiation, she was able to participate in physiotherapy with minimal to no pain until her death several weeks later. A brief literature review of joint involvement in acute myelogenous leukemia is discussed.

Good policies lay the groundwork for an effective health care system and society. They facilitate the implementation of palliative care programs aimed at providing care for all people in need of these services, and they ensure equitable access to affordable medications and therapies. The lack of good policies can lead to unnecessary suffering and costs for patients, families, and society. Three-quarters of cancer patients worldwide are incurable when diagnosed. Because the size of the problem--and the suffering associated with cancer--is enormous, development of a national cancer control policy is an effective point of entry to begin integrating palliative care into a country's health care system. To be comprehensive, every cancer center must include palliative care. Ideally, palliative care is incorporated as a priority within all aspects of each country's national health plan, so that all patients living with or dying from any chronic disease may have their suffering relieved, including children and the elderly. To this end, policies that address essential medicines must include a list of palliative care medications. Supplies of affordable, generic medications that are "equally efficient" must be adequate and available throughout the country wherever patients live (especially opioids for pain control).

Nurses play a crucial role in cancer pain control, but little is known about how well-prepared nurses are to manage cancer pain in Taiwan. The purpose of this study was to examine the level of knowledge about pain management among Taiwanese nurses with different background characteristics and to determine the predictor(s) of nurses' pain management knowledge. Nurse subjects were recruited by a cross-sectional nationwide survey with stratified sampling from nine hospitals distributed in the four major geographic regions of Taiwan. The Nurses' Knowledge and Attitudes Survey-Taiwanese version (NKAS-T) and a background information form were used to collect the data. Of 1900 surveys distributed, 1797 valid questionnaires (94.5%) were analyzed. The average correct response rate was 50.5%, with rates ranging from 7-86% for each survey question. Results from stepwise regression showed that nurses with higher mean correct answer scores had BS or higher degrees, had received pain education at professional conferences, had more prior hours of pain education, had longer clinical care experiences, and always worked with cancer patients. Nurses who worked in intensive care units, however, had significantly lower mean correct scores. The results strongly suggest an urgent need to strengthen pain education in Taiwan. The results also provide the direction for developing pain education.

Objectives 1. Discuss how early collaboration among services can lead to enhanced ability to provide palliative care to patients and families. 2. Discuss strategies to expedite early collaboration. I. Background. Large numbers of patients with advanced and life threatening illnesses with acute symptomatology are admitted to ICU’s and often receive initial, very aggressive care, with minimal consideration of their personal choices and overall goals of care. II. Case Description. A very functional 62-year-old male with T4N1M1b esophageal cancer, refractory to chemotherapy and radiation, presented to the ER with acute onset of severe abdominal pain associated with nausea and vomiting. On exam he had a quiet, exquisitely tender abdomen, and markedly elevated WBCs. CT abdominal findings were consistent with intestinal necrosis and peritonitis. Immediate surgical and palliative care consultations were requested. The consensus among patient, family, and physicians was that surgery offered no hope of cure or even survival. The interdisciplinary palliative care team in collaboration with the surgical and ICU teams, after extensive conversations with the alert patient and large extended family, jointly instituted a care plan based on patient’s choice of optimal comfort and desire to be surrounded by his loved ones, outside of the ICU setting. Aggressive pain management was undertaken with a morphine PCA pump, hourly reassessments, and calibration of pain control regimens. The patient’s pain decreased from a 10/10 to 1/10, he was moved to a private room on the designated palliative unit. The patient passed away in comfort, peaceful, and surrounded by his loved ones less than ten hours after entry into the ER. Timely and early collaboration of the surgical, critical care, nursing, and palliative care teams enabled this patient to have his goals of care communicated, respected, and executed. III. Conclusion. The collaborative approach supported the grieving family, the dying patient, and the healthcare professionals. Potential chaos and procedures were replaced by a purposeful calm in the pursuit of comfort, caring, sharing, and a dignified good death. Characterizing Care Cost and Intensiveness of Hospice Patients in the Hospital Setting (739) Molly Olsen, Mayo Clinic, Rochester, MN. Ann Bartlett, Mayo Clinic, Rochester, MN. Timothy Moynihan, Mayo Clinic, Rochester, MN. (All speakers have disclosed no relevant financial relationships.)

Pain is often inadequately treated. To evaluate a common method of assessing pain and to identify some barriers to improving pain control, 50 hospitalized patients in pain, their nurses, and their physicians were interviewed about the pain experienced by the patients. The patients' "pain behavior" was assessed and literature was reviewed to identify the risk for developing iatrogenic drug addiction in patients with no prior history of drug abuse. Doctors and nurses tended to assess pain intensity as less than the patients' assessments. The doctor's and nurse's assessment of the same patient correlated poorly (r = 0.21). Pain behavior correlated weakly (rs = 0.36) with patients' pain scores. Twenty-one patients wanted more pain medicine but often staff would not give more. A common reason was fear of addiction, notwithstanding a literature that iatrogenic addiction hardly ever occurs in usual hospitalized patients. Barriers to better pain control in acutely hospitalized patients include: (1) exaggerated fear of iatrogenic addiction, (2) an attitude among staff that patients exaggerate the intensity of their pain, (3) poor correlation between pain behavior and pain intensity that can mislead staff who rely on pain behavior to assess pain intensity, and (4) a lack of agreement between doctor and nurse in estimating the intensity of a patient's pain. A new way of thinking about patients in pain, assessing pain as either present or absent, is proposed for evaluation. If pain is present, one should attempt to ameliorate it in a manner consistent with the desire of the patient and the acceptability of adverse effects.

This study tested the feasibility of standardized pain assessment instruments in a population of patients with far advanced cancer at the time of admission to a specialty hospital. As pain is a symptom, pain control must be based on patients' self-report. Cognitive impairment and severe physical illness, however, limited the ability to use these tools. Almost one-half (44.8%) of the patients were unable to use the McGill-Melzack Pain Questionnaire, the Memorial Pain Assessment Card, or the Faces Pain Rating Scale. Patients with far advanced cancer fall into three groups: those who report pain, those who report no pain, and those who are unable to state whether or not they have pain. This study demonstrates the need to undertake pain assessment while the patient is able to respond and to monitor behaviors that could be indicative of changes in pain.

population and the potential uses of interventional pain management techniques. Appropriate candidates for interventional therapy will be identified. Neuraxial drug delivery systems (epidural and intrathecal) for pain management will be discussed, as well as peripheral and autonomic nerve blockade for palliative care. The use of spinal cord stimulation, neuroablative techniques, and neurosurgical techniques for pain control will be discussed. Review of the literature, recommendations, and guidelines by professional organizations and governmental agencies, and consensus of experts will guide the palliative care practitioner in formulating a strategy for consideration of these techniques in patients. The efficacy, potential adverse effects, and complications associated with these techniques will be discussed.

Home care is greatly expanding because of the savings it offers by avoiding unnecessary hospitalization and also because patients benefit from being in their own home environments. Since 1988, Societa Assistenza Malato Oncologico Terminale (SAMOT) has organized a pain relief and home palliative care unit for terminal cancer patients. Objectives, difficulties, protocols, and achievements of 4 years of experience were examined, and the findings of the various years were compared. Our results suggest that considerable progress has been made in home palliative care. There are still social and cultural difficulties to overcome, however.

We treat cancer pain patients at their homes, in collaboration with their relatives and primary physician. Assistance is free. Our team is monodisciplinary and trained volunteers are the liaison between team and patients. In 118 patients treated with our model between October 1987 and December 1988, we assessed the symptoms that moved them to seek assistance, their previous therapies, and the effectiveness of our intervention. The data obtained suggest that (a) in our country, the majority of cancer patients do not obtain effective pain and symptom control; (b) our model yields satisfactory pain control and improvement in quality of life; and (c) there is a need for centers that teach and practice terminal care; our model may be useful as a working outline for such centers.

Analgesia has been reported as a potential effect of systemically administered local anesthetics for over four decades. Interest in the use of these drugs as analgesics has been stimulated by the advent of oral formulations and the findings of several controlled studies that suggest efficacy of these preparations in neuropathic pain syndromes. We review the pharmacology of local anesthetics and critically evaluate the medical literature describing the analgesic consequences of systemic administration. The data extant support their analgesic effect in selected pain syndromes.

We reviewed the charts of 48 consecutive patients treated by our Palliative Care Team (PCT) during 1984 and compared these results with 50 consecutive patients treated during 1987. The composition of the PCT did not change between 1984 and 1987. The median equivalent daily dose of parenteral morphine (MEDD) before referral, after initial treatment by the PCT, and at the maximum prescribed by the PCT were 43 mg, 48 mg, and 96 mg in 1984, respectively, versus 60 mg (p less than 0.03), 60 mg (p less than 0.03), and 120 mg (p less than 0.12) in 1987, respectively. Seventeen of 43 patients were receiving mild narcotics in 1984 versus 7 of 48 patients in 1987 (p less than 0.01). Parenteral narcotics were used initially in 2% of patients in 1984 versus 46% of patients in 1987 (p less than 0.001). Poor pain control after the initial treatment was observed in 42% of patients in 1984 versus 26% in 1987 (p less than 0.01). Our results suggest that patients are being treated more aggressively by their physicians before referral to the PCT in 1987, that our PCT is using more aggressive initial treatment than in 1984, and that, notwithstanding these changes, there is still a significant proportion of patients in whom pain cannot be controlled before death. These results suggest that more research is necessary to better define intractable pain syndromes and develop adequate treatments for them.

Neuroadenoylysis of the pituitary (NALP) has been found to be an effective technique in relieving pain of malignant origin. This paper describes a modified technique using a single small needle through a needle. This modified technique was used on 15 consecutive patients with intractable diffuse painof malignant origin whose pain was not controlled by conventional treatment modalities. Nine of 15 patients (60%) experienced excellent pain relief, defined as the need for no narcotic analgesics to control their pain. Five of 15 patients (33%) reported good pain relief, defined as complete pain control with adjunctive oral narcotic analgesics given on an around-the-clock basis. One patient (7%) had poor relief of pain, defined as incomplete pain control despite use of narcotic analgesics. No permanent complications were observed. It appears that this modified approach to NALP provides a safe effective means of relievingpain of malignant origin with a decreased incidence of side effects.

This study investigated the contribution of pain to psychiatric symptoms in 43 hospitalized children and adolescents referred for psychiatric evaluation in a pediatric cancer center during a 1-yr period. Procedures included determination of the primary reason for referral, child and parent diagnostic interviews assessing pain history and psychiatric symptoms, and recommendations for improved pain control or other types of intervention and followup. Across the four referral categories (for symptoms of depression, cognitive/perceptual disturbance, anxiety, or disruptive behavior), approximately 20% of all consultations resulted in a primary recommendation for improved pain control. The findings suggest that pediatric cancer pain may go untreated when its manifestations are psychiatric. Implications for staff education, consultation-liaison psychiatry, and psychiatric nosology are discussed.

Acupuncture, dating back some 4,000 )'ears, is a major method of treatment for more than one-third of the world's populationJ Although associated with China, acupuncture is practiced in Japan, Africa, India, Indonesia and other parts of the Asian world for diagnosis and treatment of body disorders as well as pain control. 2 In the West, its use was first recognized by Sir William Osler in 1892, who proposed that threeto four-inch needles inserted into lumbar muscles and left in place for 5 to 10 minutes were an effective treatment for lumbago; 3 Osier also noted that applying constant electrical current to these needles was sometimes beneficial for the patient. 3 Despite this lengthy histor); western physicians view the therapeutic effects of acupuncture with skepticism. 4 Response differences between Oriental and Occidental cultures may be related to patient selection, duration of pain, psychological readiness and expectations for pain relief of the individual selected for this therapy. In hospitals throughout the People's Republic of Ctfina, scientific and traditional medicine coexist. 5 Often acupuncture is prescribed early in the treatment of painful conditions. To benefit from this procedure, the patient must be emotionally stable, physically receptive and psychologically prepared. In low back pain patients for example, surgical intervention is often considered only if acupuncture fails to provide pain relief. In the West, acupuncture treatment is usually prescribed after medical and surgical therapies fail to control pain. Used in this manner, Addison 6 places acupuncture with other "vogue therapies" that work only 15% to 20% of the

Much recent attention has focused on the development and refinement of pain measures, as well as on the use of more effective pain control methods for infants, children, and adolescents. This article reviews the primary categories of pediatric pain measures, with a specific focus on the selection of the most appropriate behavioral, physiologic, or subjective method for assessing a child's pain. The optimum pain measure depends on the age and cognitive level of a child, the type of pain experienced, and the situation in which the pain occurs. While no single measure is adequate for all children for all types of acute, recurrent, and chronic pain, it is possible to choose practical, valid, and reliable methods for evaluating any child's pain experience.

This is the first case report documenting the use of a neurolytic celiac plexus block for relieving chronic noncancer pain in a pediatric patient. The child was a 4-yr-old male with an unknown form of inflammatory bowel disease since 1 yr of age. Chronic abdominal pain became a problem at 3 yr of age, following multiple bowel resections; continuous intravenous narcotic administration was implemented for pain control. The patient's pain became refractory to high-dose morphine administration (maximum dose, 267 mg/kg/day, iv), and, for that reason, a CT-guided neurolytic celiac plexus block was performed. This procedure resulted in improved pain control along with a major reduction in narcotic use to 7 mg/kg/day of morphine.

Depression and psychological distress appear to be greater in patients with pancreatic cancer, compared to other equally ill patients with cancer, including those with other abnormal neoplasms. The several hypotheses regarding etiology are unproven, but the possibility of a tumor-related paraneoplastic syndrome which promotes the production of a false neurotransmitter capable of altering mood appears most logical at present. However, patients with pancreatic cancer have tumors with known poor prognosis and they often have pain. Both factors contribute to depression. Management of depression depends upon attention to adequate pain control, use of antidepressants and psychological support. Depression in pancreatic cancer raises challenging questions, both about its cause and treatment. Further research study of its psychological and biological components is important in oncology.