Guidelines For Cancer Pain Management Research Articles

Evaluation of the adequacy of pain control using Opioid analgesics in palliative ward patients using Cancer Pain Management Guidelines

Evaluation of the adequacy of pain control using Opioid analgesics in palliative ward patients using Cancer Pain Management Guidelines

Comparison of Pain Management between before and after the Application of Guidelines in Cancer Emergency Room

Purpose: This study was to investigate the effect of the application of cancer pain management guidelines on pain management among patients in Cancer Emergency Room. Methods: This study was a retrospective descriptive study. Before application, data were col lected by analyzing the Electronic Medical Record in Cancer Emergency Room in September, 2011, and after application in February, 2012. The subjects of this study consisted of 231 patients (pre-application group 83, post-application group 148), who stayed over 24 hours and complained of pain higher than Numeric Rating Scale score 4. The post-test was conducted after educating the nurses about the application of the pain management guidelines in the Electronic Medical Record. Results: This survey showed that, as the cancer pain management guidelines were applied for cancer patients with above moderate pain, the pain intensity decreased, the number of patients reaching the treatment goal score increased. Furthermore, the estimated time to reach the treatment goal decreased signifi cantly. Conclusion: Pain intensity of the cancer patients was decreased through regular pain assessments by nurses and the medication of analgesics according to the cancer pain management guidelines. Therefore, it is necessary to develop the pain management program and to provide the physicians and nurses with intensive education about the pain management guidelines for systematic and effective pain management.

Reporting characteristics of cancer pain: A systematic review and quantitative analysis of research publications in palliative care journals

Objective:A common disorder requiring symptom palliation in palliative and end-of-life care is cancer. Cancer pain is recognized as a global health burden. This paper sought to systematically examine the extent to which there is an adequate scientific research base on cancer pain and its reporting characteristics in the palliative care journal literature.Materials and Methods:Search conducted in MEDLINE and CINAHL sought to locate all studies published in 19 palliative/ hospice/ supportive/ end-of-life care journals from 2009 to 2010. The journals included were: American Journal of Hospice and Palliative Care, BMC Palliative Care, Current Opinion in Supportive and Palliative Care, End of Life Care Journal, European Journal of Palliative Care, Hospice Management Advisor, Indian Journal of Palliative Care, International Journal of Palliative Nursing, Internet Journal of Pain Symptom Control and Palliative Care, Journal of Pain and Palliative Care Pharmacotherapy, Journal of Palliative Care, Journal of Palliative Medicine, Journal of Social Work in End-of-life and Palliative Care, Journal of Supportive Oncology, Palliative Medicine, Palliative and Supportive Care, and Supportive Care in Cancer. Journal contents were searched to identify studies that included cancer pain in abstract.Results:During the years 2009 and 2010, of the selected 1,569 articles published in the journals reviewed, only 5.86% (92 articles) were on cancer pain.Conclusion:While researchers in the field of palliative care have studied cancer pain, the total percentage for studies is still a low 5.86%. To move the field of palliative care forward so that appropriate guidelines for cancer pain management can be developed, it is critical that more research be reported upon which to base cancer pain therapy in an evidence-based palliative care model.

Challenges in managing cancer pain

Effective pain control is a key factor in cancer management, and is primarily achieved through drug therapy. Despite the World Health Organization (WHO) guidelines for cancer pain management, many cancer patients still do not receive adequate analgesia. Lack of knowledge and misconceptions about opioid treatment is a key contributing factor, along with shortcomings in the WHO guidelines themselves. Evidence shows that starting treatment with strong opioids can provide significantly greater benefits than being treated according to the WHO recommended ‘analgesic ladder’ – a sequential escalation of treatment. There is, therefore, a need for alternative treatment strategies that optimise drug selection, dose and methods of administration. Although widely used, drug delivery through the oral routes is not always acceptable for cancer patients with oral and gastrointestinal problems, and as such a range of administration routes, including transdermal, transmucosal and intranasal routes should be considered. Promising clinical outcomes with treatments such as transdermal fentanyl and intranasal fentanyl spray lend support to the opinion that strong opioids, used in appropriate formulations and doses, play an important role in the care of patients with severe pain.

Retrospective Assessment of Cancer Pain Management in an Outpatient Palliative Radiotherapy Clinic Using the Pain Management Index

The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain. The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI. All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors. One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable. Despite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy.

Patient-Related Barriers to Effective Cancer Pain Management

Barriers to optimal cancer pain management exist among clinicians and patients and within the healthcare system. This article examines patient barriers to effective management of cancer pain. Unrelieved pain remains a major problem for patients with cancer and other diseases. Recommendations and guidelines for effective cancer pain management are widely available; however, patients continue to hold misconceptions about the use and effects of drugs commonly used to manage cancer pain. Although interventions designed to raise the awareness of patients seem to help in controlled research studies, much still needs to be done to address this problem. Researchers have advocated that control of cancer pain can be improved through patient education by helping patients have more control over their pain and by improving the patients' adherence to the scheduling of pain medications. Limited research efforts have been directed toward developing or evaluating the effectiveness of pain education programs that focus on patient-related barriers to pain management for patients with cancer.

Oncology Nurses' Use of Nondrug Pain Interventions in Practice

Cancer pain management guidelines recommend nondrug interventions as adjuvants to analgesic medications. Although physicians typically are responsible for pharmacologic pain treatments, oncology staff nurses, who spend considerable time with patients, are largely responsible for identifying and implementing nondrug pain treatments. Oncology nurses' use of nondrug interventions, however, has not been well studied. The purpose of this study was to describe oncology nurses' use of four nondrug interventions (music, guided imagery, relaxation, distraction) and to identify factors that influence their use in practice. A national sample of 724 oncology staff nurses completed a mailed survey regarding use of the nondrug interventions in practice, beliefs about the interventions, and demographic characteristics. The percentages of nurses who reported administering the strategies in practice at least sometimes were 54% for music, 40% for guided imagery, 82% for relaxation, and 80% for distraction. Use of each nondrug intervention was predicted by a composite score on beliefs about effectiveness of the intervention (e.g., perceived benefit; P < 0.025) and a composite score on beliefs about support for carrying out the intervention (e.g., time; P < 0.025). In addition, use of guided imagery was predicted by a composite score on beliefs about characteristics of patients who may benefit from the intervention (e.g., cognitive ability; P < 0.05). Some nurse demographic, professional preparation, and practice environment characteristics also predicted use of individual nondrug interventions. Efforts to improve application of nondrug interventions should focus on innovative educational strategies, problem solving to secure support, and development and testing of new delivery methods that require less time from busy staff nurses.

Hazards for Pain Severity and Pain Interference with Daily Living, with Exploration of Brief Pain Inventory Cutpoints, Among Women with Metastatic Breast Cancer

Few longitudinal studies have assessed risk factors for pain outcomes in tumor-specific populations. Such studies are needed to improve clinical practice guidelines for cancer pain management over the course of treatment. Among patients with metastatic breast cancer, we assessed the impact of baseline clinical and demographic risk factors on patients reaching different pain severity and interference scores. We analyzed data originally collected in a clinical trial of two bisphosphonate therapies. Pain was measured by the Brief Pain Inventory (BPI) severity and interference with daily living 0–10 subscales. We fit univariate (per-cutpoint) and multivariate (cutpoints 3, 4, 5, 6, and 7 on the BPI) proportional hazards models to identify predictors of pain outcomes over 51 weeks among 1,124 women with metastatic breast cancer. Predictors included race, age, education, geographic region, performance status, chemotherapy versus hormonal therapy only, time from first bone metastasis to randomization, and previous skeletal-related event (SRE, e.g., fractures, spinal cord compression). Non-Caucasian women had greater hazards for reaching higher cutpoints (5 and above) on the severity scale than Caucasian women (hazard ratio [HR] for cutpoint 5 interaction term = 1.76; 95% confidence interval [CI] = 1.37–2.26). For the interference scale, these hazards were greater for those patients with restricted (versus active) baseline Eastern Cooperative Oncology Group (ECOG) performance status (HR for cutpoint 5 interaction term = 2.51; 95% CI = 2.01–3.13). In the multivariate severity model, other factors associated with higher pain severity were restricted baseline ECOG performance status, previous SRE, and not being employed full-time at baseline (HRs = 1.70, 1.23, and 1.33, respectively). Our findings that non-Caucasian race and restricted performance status were associated with greater pain hazards over time confirm previous cross-sectional findings that these characteristics are pain risk factors. Because we found that the most influential demographic and clinical baseline factors had predictive value for worsening outcomes as early as cutpoint 5, we recommend that pain management strategies use cutpoints informed by risk factors for worsening outcomes as cues for earlier intervention, thus delaying or preventing worst pain among women with metastatic disease who are at greatest risk.

National multi-center epidemiological study on prevalence and treatment of cancer-related symptoms

17048 Background: This outcome measure of cancer-related symptoms was conducted in Russia in 2005–2006 to have a better understanding of the current status of symptom management among patients with advanced cancer. Specific aims of this study are to describe the prevalence of pain, fatigue, and other cancer-related symptoms among cancer patients being treated in multiple sites across Russia and to assess current symptom treatment and response to it across different centers. Methods: The sample size included 500 patients with advanced cancer from 10 cancer centers: male/female - 216/284, mean age 53.6. Symptom status was assessed using M.D. Anderson Symptom Inventory and Brief Pain Inventory at two time points. We used descriptive statistics to describe symptom prevalence and severity. Pain Management Index (PMI) was calculated for each patient to examine whether or not analgesics were prescribed to treat pain according to the World Health Organization's guidelines for cancer pain management. Results: The following distribution of patients according to the malignancies was observed: breast cancer (31%), hematological malignancies (30%), lung cancer (19%), gastrointestinal tumors (13%), gynecological tumors (8.4%), others (3%). As a result, the most severe symptom was fatigue (4.2) ranging from 1.5 to 5.0 across the centers. Its prevalence was 85 %. Other pronounced symptoms were pain (3.4; ranging from 0.9 to 7.0 across the centers), distress (3.0), sadness (2.9), and sleep disturbance (2.9) with their prevalence of 65.8%, 71.8%, 71.6%, and 70.0% respectively. Out of the total sample, 130 patients had only mild symptoms and 360 - at least one symptom as moderate-to-severe. Among them there were 136 patients who had 5 or more moderate- to-severe symptoms and 13 patients who had 10 or more such symptoms. Fatigue was treated only in 131 patients (26%, including blood transfusion and erythropoietin therapy); among them the decrease in fatigue level was achieved in 35% patients. Inadequate pain management was provided for 43% of patients. Conclusions: The results of this symptom outcome study provide the initial data on symptom control in Russia and allow establishing the framework for identifying the patients who experience poor symptom assessment and management. No significant financial relationships to disclose.

A Multidisciplinary Project to Improve the Quality of Cancer Pain Management in Italy

Pain afflicts most cancer patients, mainly in the advanced and metastatic phases of the disease. Despite the existence of several guidelines for cancer pain management that are based on the recommendations by the World Health Organization and the availability of effective treatments for 70% to 90% of cases, undertreatment is well documented and can involve up to 40% of patients. Undertreatment is usually attributed to an incorrect use of opioids for reasons often conceptualized in terms of barriers related to healthcare provider, patient, family, institution, and society. In Italy, opioid consumption rates are among the lowest in Europe despite some of recent efforts to improve the analgesic prescription and utilization. In the context of a wide project coordinated by the Mario Negri Institute, a non-for-profit private foundation located in Milan, Italy, 4 activities were launched: (1) a critical appraisal of information available on the Web, with the preparation and publication of a meta-site to facilitate the use of selected resources; (2) an evaluation of prescriptions of analgesic drugs in a cohort of cancer patients using a large administrative database; (3) a nationwide outcome research study to assess the epidemiology, quality, and effectiveness of different analgesic strategies; and (4) a multimodal, community-based intervention based on information, education, and training programs to change the knowledge, opinions, and attitude toward cancer pain treatment. Activities started in 2005. Some results and outputs are already available; others will be ready by the end of 2007.

(877): Cancer patients’ perceptions of pain relief with guided imagery and progressive muscle relaxation interventions

Cancer pain management is a major challenge for patients and healthcare providers alike. In the inpatient setting, where patients are hospitalized for symptom management and potentially painful treatments, the prevalence of pain is high, upwards of 79%. Guidelines for cancer pain management recommend combining pharmacologic and nondrug interventions to maximize pain relief. However, evidence regarding the effectiveness of nondrug interventions in this population is mixed. These findings may be related to how individual patients perceive and respond to specific nondrug interventions.

Cancer Pain Management Guidelines Issued for Children; Adult Guidelines Updated

Cancer Pain Management Guidelines Issued for Children; Adult Guidelines Updated

Palliative care resource (PCR) utilization associated with cancer pain management background

8077 Background: Resources required for cancer pain management are not well documented. We monitored the use of PCR, including medications, consultations, imaging needs and hospitalizations in patients (pts) undergoing management of cancer pain by Hematology/Oncology palliative care program at a VA Medical Center. Methods: 99 inpts and 96 outpts with worst pain \(\underline{\mathrm{{>}}}\) 4/10 completed the Brief Pain Inventory at baseline and 1 week (wk). Pain management followed the Agency Health Care Policy Research Cancer Pain Management Guidelines. PCR were obtained prospectively. Results: The median (M) age was 69.2 yrs (range 44.3–87.6). Pts had metastatic cancer of the prostate (29.2%), lung (26.7%), head and neck (9.2%), colorectal (7.7%), pancreas (5.1%), and advanced lymphoma (5.1%) and multiple myeloma (4.6%). Pain pathophysiology included somatic (56.9%), neuropathic (32.8%) and visceral pain (10.3%) By wk 1, worst pain severity (mean 8.4 vs 6.1,p<0.0001), pain relief (40.8% vs 70.9%,p<0.0001) and pain interference scores (38.1 vs 19.9,p<0.0001) improved significantly. PCR by category included: (A) Medications: 71% of pts changed opioids. The M morphine equivalent daily dose (MEDD) was 20 mg orally (0–3,120mg) on day 1 and 90mg (0–3,200mg) at wk 1 (p<0.0001). Adjuvant analgesics included steroids (27%), anticonvulsants (16%) and NSAIDs (8%). Opioid-related side effect treatments included laxatives (72%), antiemetics (19%), anxiolytics (8%), psychostimulants (7%) and neuroleptics (3%). (B) Consultation referrals included radiation (26%), neurology (14%), psychiatry (9%), surgery (14%) and physical therapy (13%); 30 pts (15%) were started on radiation therapy. (C) Imaging studies included 234 plain films, 135 CT scans, 86 MRIs, 54 bone scans, 27 ultrasounds; pain specific imaging needs were identified. (D) Hospitalization: 58 pts (29.7%) were admitted for pain management and the M length of stay was 7 days (1–21). Conclusions: These identifiable costs for effective cancer pain management in a VA population provide a basis for cost effectiveness evaluation and comparison to the private sector (VAHSR&D PCC 98–068). No significant financial relationships to disclose.

Palliative care resource (PCR) utilization associated with cancer pain management background

8077 Background: Resources required for cancer pain management are not well documented. We monitored the use of PCR, including medications, consultations, imaging needs and hospitalizations in patients (pts) undergoing management of cancer pain by Hematology/Oncology palliative care program at a VA Medical Center. Methods: 99 inpts and 96 outpts with worst pain \(\underline{\mathrm{{>}}}\) 4/10 completed the Brief Pain Inventory at baseline and 1 week (wk). Pain management followed the Agency Health Care Policy Research Cancer Pain Management Guidelines. PCR were obtained prospectively. Results: The median (M) age was 69.2 yrs (range 44.3–87.6). Pts had metastatic cancer of the prostate (29.2%), lung (26.7%), head and neck (9.2%), colorectal (7.7%), pancreas (5.1%), and advanced lymphoma (5.1%) and multiple myeloma (4.6%). Pain pathophysiology included somatic (56.9%), neuropathic (32.8%) and visceral pain (10.3%) By wk 1, worst pain severity (mean 8.4 vs 6.1,p<0.0001), pain relief (40.8% vs 70.9%,p<0.0001) and pain interference scores (38.1 vs 19.9,p<0.0001) improved significantly. PCR by category included: (A) Medications: 71% of pts changed opioids. The M morphine equivalent daily dose (MEDD) was 20 mg orally (0–3,120mg) on day 1 and 90mg (0–3,200mg) at wk 1 (p<0.0001). Adjuvant analgesics included steroids (27%), anticonvulsants (16%) and NSAIDs (8%). Opioid-related side effect treatments included laxatives (72%), antiemetics (19%), anxiolytics (8%), psychostimulants (7%) and neuroleptics (3%). (B) Consultation referrals included radiation (26%), neurology (14%), psychiatry (9%), surgery (14%) and physical therapy (13%); 30 pts (15%) were started on radiation therapy. (C) Imaging studies included 234 plain films, 135 CT scans, 86 MRIs, 54 bone scans, 27 ultrasounds; pain specific imaging needs were identified. (D) Hospitalization: 58 pts (29.7%) were admitted for pain management and the M length of stay was 7 days (1–21). Conclusions: These identifiable costs for effective cancer pain management in a VA population provide a basis for cost effectiveness evaluation and comparison to the private sector (VAHSR&D PCC 98–068). No significant financial relationships to disclose.

Cancer breakthrough pain characteristics and responses to treatment at a VA medical center

The purpose of this study is to analyze cancer breakthrough pain (BP) characteristics and how BP responds to conventional cancer pain management. Seventy-four cancer pain patients with worst pain severity ≥4 out of 10 completed the Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale-Short Form, Functional Assessment Cancer Therapy and Breakthrough Pain Questionnaires (BPQ) at an initial interview. Agency for Health Care Policy and Research (AHCPR) cancer pain management guidelines were followed. Pain syndromes and morphine equivalent daily dose (MEDD) orally were determined. One-week follow-up assessments were obtained in 66 patients with BPI and BPQ. The BP characteristics were similar at both time points. On day 1, 52 patients (70%) had BP, and the BP was unpredictable in 30 patients (58%). The median time to worst BP severity was 3 min. Patients with BP had significantly higher worst pain ( P<0.001). At week 1, the median MEDD doubled from 60 to 120 mg orally, and the number of patients who received adjuvant analgesics doubled from 31.1% (23 patients) on day 1 to 62.2% (41 patients). At week 1, 21 patients (32%) remained without BP, 21 patients (32%) were classified as BP responders and 24 patients (36%) were BP non-responders. The mean pain relief was similar for all three subgroups, i.e. around 80%. Compared to BP responders, BP non-responders had significantly higher worst pain ( P<0.0001), average pain ( P<0.004), and higher BPI interference parameters and shorter time to worst pain severity. The study confirmed the applicability of the BPQ to an US veteran population, and that pain management following the AHCPR guidelines is effective for a group of patients with cancer related BP. Underlying pain syndromes and the BP location may influence the response of BP to treatment. Patients with bone pain located in the spine, back, and pelvis may be at risk for resistant BP.

Longitudinal Documentation of Cancer Pain Management Outcomes: A Pilot Study at a VA Medical Center

We measured pain outcomes in a cohort of patients with cancer pain in a general hematology/oncology setting at a Veterans Administration Medical center (VA). The outcomes included pain relief, pain severity, changes in pain severity, interference scores, symptom distress, quality of life (QOL), and satisfaction. Seventy-four (74) consecutive patients with worst cancer-related pain equal to or greater than 4/10 were recruited. Cancer pain diagnoses were made and the cancer pain management guidelines of the United States Agency for Health Care Policy and Research were followed. Patients were followed weekly using the Brief Pain Inventory (BPI), medication diary, satisfaction questionnaire, visual analogue quality of life scale (VASQOL) and record of side effects for 3 weeks. The Functional Assessment of Cancer Therapy (FACT-G) and Memorial Symptom Assessment Scale Short Form (MSAS-SF) were used at initial and final interviews. The mean initial worst pain severity was 8.3 (range 4–10) and mean pain relief was 40% (range 0–100). By week 1, the majority of patients achieved pain relief of ≥80%, with a corresponding decrease in worst pain severity and pain interference scores. Pain continued to decrease over three weeks. At week 3, there was a significant improvement in the MSAS-SF psychological symptom distress subscale ( P = 0.02). The average number of opioid-related side effects was 5 and remained steady over time. Most patients felt “quite a bit” or “very much” satisfied at all weeks. There was a significant improvement in VASQOL ( P < 0.005) and in FACTG SUMQOL scores ( P = 0.007). This experience demonstrates that cancer pain management can result in measurable and significant changes in pain relief, pain severity, pain interference scores, psychological symptom distress, and QOL scores.

United States: Overview of Cancer Pain and Palliative Care

The growth of the palliative care movement in the United States will have enormous impact on pain specialty in terms of the increasing need for the skills of its professional work force and demand for improved symptom management from our sickest and most vulnerable patients. In this paper, we review the need for palliative care, recent developments in this new field and implications for specialists in pain management.

Germany: Cancer Pain and Palliative Care—Current Situation

Guidelines of the World Health Organization (WHO) for cancer pain management have been adopted by several German medical societies. 1,2 In 1996, the drug commission of the German Medical Board produced guidelines on cancer pain management that follow the WHO recommendations closely. A second edition was published in 2000, also including an evaluation of the medical evidence behind these recommendations. 3 The Agency for Quality in Medicine, a central non-governmental organization supported by health insurance and German Medical Board, started a guideline evaluation program in 1998 and has chosen cancer pain as the second topic for this guideline clearinghouse. 4 The report produced in 2001 evaluated 13 guidelines for cancer pain management, including three published by German authors, and rated development, form and practicability with standardized scores. The guidelines of the German Medical Board received the highest ranking, with 33 of 40 points, closely followed by the guidelines of the Agency for Health Care Policy and Research (AHCPR) with the same score. The WHO recommendations were placed on rank 9 with a score of 25. The guideline clearing report also suggested areas and topics that should be included in cancer pain guidelines and gave examples from the existing guidelines for these areas. A catalogue of measures is currently in preparation. Although pain management, including cancer pain management, is not a specialty, it has been introduced as a subspecialty by the medical boards in most German states, with the exception of Bavaria, Brandenburg and Hessen. Despite these advances, the common practice of cancer pain treatment still shows serious deficiencies. In a recent survey among physicians not specializing in pain management, the majority reported knowledge of the WHO recommendations, though more than 15% rated transdermal fentanyl as a weak opioid or even a nonopioid analgesic. 5 In a representative survey from 1200 physicians in Lower Saxony, only 33.1% said that they know the analgesic ladder of the WHO. 6 Medical education also shows major deficits in pain management, which implies that no change will be achievable in near time. In a survey among medical students in the final term from six German universities, only 65% reported that they knew the analgesic ladder of the WHO, and onethird of these students did not even know the correct number of steps on this ladder. 7

The development of use of oral morphine within the last 10 years in Japan

Japan's national cancer relief programme was initiated with a field-test of the WHO guidelines for cancer pain management in 1982. It revealed in an excellent result that 87% of 156 cancer patients could be completely relieved of their persistent pain, but this result were ignored by most Japanese health professionals, because of their lack of interest in cancer pain relief. The WHO guidelines were published in 1986 and made quite an impact on those health professionals in Japan. In 1987, a special research team appointed by the Ministry of Health and Welfare of Japan (MOHW) initiated discussion on the philosophy of palliative care in Japan. According to the recommendations made by this research team, the MOHW established a new policy on palliative care, edited manuals on palliative care for terminally ill cancer patients which included guidelines on cancer pain management, and revised narcotics control measures by 1992 in order to much improve the accessibility of opioid analgesics to cancer patients who need them for effective pain relief. The annual consumption of morphine for medical purposes was only 65kg in 1986 in Japan, but it rose to 973kg in 1999. Currently, morphine is mostly given by mouth and two-thirds of morphine preparations consumed are MS Contin Tablets. However, the current morphine consumption per capita in Japan is still less than one-sixth of the consumption in the United States.In order to achieve further improvement, educational effort should be much emphasized. In the 1990s, approximately 70% of medical and nursing schools in Japan have initiated their educational curriculum for cancer pain relief and palliative care. There have been government-sponsored, medical, nursing and pharmaceutical societies-sponsored seminar courses on appropriate morphine use in cancer pain management, palliative care and opioid availability, all of which have increasingly strengthened postgraduate education.

Orthopedics (70)

Applying the American Pain Society's QA standards to evaluate the quality of pain management among surgical, oncology, and hospice inpatients in Taiwan. (Taipei Medical College, Taipei, Taiwan) Pain 2000;87:43–49.The purpose of this study was two‐fold: first, to apply the American Pain Society (APS) outcome questionnaire to examine and compare the quality of pain management provided in surgical, oncology, and hospice inpatient units in the Taipei area of Taiwan, and second, to provide baseline data of pain management quality in advance of the implementation of national guidelines for cancer pain management. Data revealed that hospice patients reported that they received pain medication within 15 min after they complained of pain. However, a large number of patients never asked for pain medication during hospitalization. Moreover, most patients never requested medication changes even when their perception was that their medication was not effective. The findings of this study may provide support for the effectiveness of hospices in Taiwan in pain management and provide information on the validity of the APS quality standards.