S Hofer Inselspital, Bern, Switzerland

Introduction
In our system, the role of the Clinical Nurse Specialist depends on her position within the clinic In the Department of Visceral and Transplantation Surgery, I am engaged about 50% of my total working hours on the wards, which means, that I am in daily contact with the nurses On this day to day basis, problems regarding pain can be discussed and solved directly
The nurse plays a central role in the postoperative pain management Her main responsibility is to prevent the patient from suffering unnecessary pain The nursing staff is responsible for detecting signs of pain, evaluating pain and initiating prescribed therapySForthergill Bourbonnais 92) as well as other means of pain relief

An abundant literature indicates, that postoperative pain therapy is still far from sufficient in many places (P. Ford, H. Owen, K. Seers). Seen from the nurses point of view, there are several reasons for this : insufficient knowledge of the pathophysiology of pain and of how analgesics work, fear of side effects as well as lack of communication between nurse and patient. This lack of knowledge together with the fear of side effects leads to an anxiety of nurses unfamiliar with modalities of pain treatment. (E. Carr) A nurse who is insecure will transmit her anxiety to the patient.

Postoperative pain management
"Pain is whatever the experiencing person says it is, existing whenever he says it does" (Me Caffery). This short but very accurate definition of pain by Me Caffery leads us in our pain treatment.
For most patients, acute pain is extremely unpleasant, and rapid and efficient relief of this suffering is expected. In order to be able to relieve pain, we must learn to listen to the patient: pain is a very subjective matter, only the patient can tell us about the character and intensity of the pain and the response to therapeutical interventions.
A thorough evaluation of pain is mandatory in postoperative pain treatment. In the first postoperative hours, it is particularly important to determine the intensity and quality of pain in order to adjust the therapy to the rapidly changing patient needs.

The evaluation should be regularly and systematically performed and the intensity of pain estimated, preferably using a verbal or visual analogue scale Furthermore, the following questions about pain therapy have to be discussed and answered : What kind of drug will most promptly and efficiently help this particular patient ? How should it be applied ?
In order to optimise the postoperative pain therapy it is important to pay attention to the following : the pain intensity should never be allowed to reach an extreme level. Pain medication should be given in short intervals. The patient must be comfortable and able to breath deeply and to move. The patients should be told, that inadequate pain therapy will have a negative influence on their recovery or, in other words : "it does not pay to suffer".
Later, in a less acute stage, additional therapeutical interventions might be useful, like physical or cognitive behavioural therapy.
The patient must be informed about the various kinds of therapy available, know the pro's and con's and be able to give his opinion. His preferences should of course - whenever possible - be respected. But, to be able to make an informed decision, the patient must be advised and informed by the nurse. That means, he needs a good knowledge about pharmacological as well as non-pharmacological therapies
A dialogue with the patient is as important as any other method in pain therapy. Anxiety, stress and uncertainty all tend to increase pain.
It is also important to know whether the patient is satisfied with his therapy. Is it sufficient, is he comfortable ? Does the patient have any questions, uncertainties, or is there anything else that worries him ?
The evaluation of pain therapy and side effects including the entry into a monitoring protocol should be performed regularly and systematically and never appear to the patient as a formal check-up.
Side effects have to be taken into account. The safety of the patient is our most important aim. Regardless of what kind of therapy the patient receives, he should be monitored continuously for side effects like nausea and vomiting, respiratory depression or vertigo.

Training and Education
To provide a high quality in postoperative pain treatment, all nurses in the department are instructed on the following aspects of pain and pain therapy : Assessment of pain, different methods of pain relief, pharmacology of the most important analgesic dmgs and management of the technical devices used in the hospital for pain therapy, a short instruction of the pumps used in pain management. This instruction is repeated about four times a year.
On each ward, there is one nurse, who is responsible for pain management. That means, she is the first contact for the nursing team, when there are problems in pain management. These nurses have a wider knowledge and they meet at least once a year at the "pain meeting".
I got involved in a hospital-wide post-operative pain management programme together with the acute pain team (Dept. of Anaesthesiology).
An extensive teaching programme with a theoretical and a practical Part has been applied in Bern with particular emphasis on the use of PCA, patient controlled analgesia and EDA ,epidural analgesia. This course is repeated on a regular basis, enabling all nurses to attend. For example, in 1999 80 nurses had gone through the course.
Also on a day to day basis a close co-operation between the acute pain team and the nurses on the wards is absolutely essential, to keep a high standard in post-operative pain management.

What has been reached in the Department an the hospital?

• The nurses have a good, sound knowledge of pain management.
• The patients feel safe and well cared for. They express their satisfaction with pain therapy.
• PCA and EDA are well established.
• The co-operation between the acute pain team and the nursing team is constructive.

An optimal pain therapy requires time, staff an dedication. Especially in this time of very short financial as well as personal resources, this fact must not be underestimated. On the other hand good postoperative pain management is cost effective, the patients have less complications an leave the hospital earlier.

References:
Ferell BR, McCaffery M, Ropchan R. Pain Management as a Clinical Challenge for Nursing Administration Nursing Outlook. November 1992
Fothergill Bourbonnais F, Wilson-Bamett J.
A comparative study of intensive therapy unit and hospice nurses' knowledge on pain management
Journal of Advanced Nursing, 1992
Hofer S Postoperative Schmerztherapie mittels patientenkontrollierter Analgesic
Pflege, No. 1, Februar 1993

PAIN AND PATIENTHOOD
Willem J Meijier. Groningen, The Netherlands.

People who have learned to live with their pain and, therefore, do not depend on the healthcare system for an alleviation of their pain (non-consumers) may serve as a reference group for treatment efficacy. Studying such a group may have consequences for the treatment strategy of multidisciplinary pain centres.
In our study a group of non-consumers was contrasted with referrals to a multidisciplinary pain centre and with patients who went through a pain management program.
Analysis of the non-consumer data revealed that this group did split into two subgroups. One subgroup did differ with both patient groups in a negative sense, e. g. were more depressed, showed more pain related distress en where less active. The second subgroup, showing a more effective coping style, did differ in a more positive way, e. g. less depressed, less pain related distress, more active and less catastrophizing thoughts.
Although the latter group differed in a number of ways with patients asking for help, differences between the groups did not reach clinical significance. Therefore, a role of reference can be questioned for this group.
Alternatives are discussed.

THE McGILL PAIN QUESTIONNAIRE: A PRACTITIONER PERSPECTIVE AND CURRENT RESEARCH IN THE COMMUNITY
(1) Jane Latham. Visiting Lecturer, City University, St. Bartholomew School of Nursing and Midwifery, London El EA, England
(2) Professor Bryn Davis, Nursing Consultant, Cardiff, Wales

Aim of investigation: To examine life-style disability, resource usage and pain profiles of chronic pain patients and other patients in the community.

Methods: Development and utilisation of the McGill Pain Questionnaire will be reviewed from a practitioner perspective. The current study pre-identified criteria for one chronic pain and two "non pain" groups (n = 120) selected at random from general practices in the U.K. At interview, an additional cohort of unrecognised chronic pain patients were subsequently identified from the two "non-pain" groups (n = 16). The interview schedule included the McGill Pain Questionnaire, the Sickness Impact Profile and a Resources Questionnaire.

Results: With reference to the McGill Pain Questionnaire, Group 1 with previously identified chronic pain have consistently higher scores across all dimensions and the overall profile score when compared to those in Group 4 with previously unidentified chronic pain. Sickness Impact Profile data also reflects such findings, with both pain groups scoring higher disability profile scores than other "non-pain" diagnostic groups in the community.

Conclusions: Whilst this is a small exploratory study, findings indicate the need for further more large-scale studies. In view of legislative changes in the UK, which affect the primary and secondary health/social care interface, priority should be placed on addressing education and training needs of health care professionals in relation to screening and treatment programmes for long-term chronic pain management in the community.

HOW TO FACILITATE TRANSMURAL INTERDISCIPLINARY CHRONIC PAIN TREATMENT IN AN ACADEMIC PAIN - CENTER: THE NIJMEGEN MODEL
Han Samwel. Quinne Anderegg, Ben J.P. Cml
Academic Pain Center University Medical Center
St. Radboud
P.O. Box 9101, 6500 HB Nijmegen Netherlands

Aim of the project: to create a transmural organization of pain treatment for chronic pain in which first echelon pain care is able to perform pain treatment for patients who have been diagnosed in the academic paid center. Primary goals are to 1/ increase the number of chronic pain treatment possibilities in the first echelon pain care and 2/ establish a sohd treatment collaboration between the second and first echelon pain care.

Strategy: as a first step treatment protocols were developed for psychological and TENS treatment. As a second step courses were developed to educate psychologists and physiotherapists in the first echelon health care how to treat patients with chronic pain in accordance with the treatment protocols developed. As a third step periodical supervision was provided in order to strengthen the collaboration.

Results: In 1998 and 1999 24 psychologists and over 100 physiotherapists were trained and were included in a regional network. In 1999 350 patients with chronic pain were diagnosed in the academic Pain Center. 240 patients were diagnosed to receive a physiotherapeutic and/or psychological treatment. In all patients the treatment proposed was started within 4-6 weeks in the first echelon. The psychologists and physiotherapists judged the training and supervision as very practical and contributing to their abibty to treat chrome pain patients. A pilot study showed that referrers (general practitioners) were very satisfied with the care for their patients (20 referrers gave a mean 7.5 score on a 0-10 satisfaction rate)

Conclusion: The transmural organization of interdisciplinary chrome pain treatment is very promising and creates a new way of collaboration between second and first echelon health care for chronic pain treatment. A major study is under way in order to study the effects of this new way of organizing chronic pain care.

HET NUMEEGS MODEL I Pain Centre Nijmegen
Quirine Anderegg. Han Samwel, Ben J.P. Crul Academic Pain Center University Medical Centre St. Radboud. P.O. Box 9101, 6500 HB Nijmegen Netherlands.

Introduction: The main problem was the long time between the first visit of the patient with chronic pain to the outpatient clinic and the outlining of the treatment strategy. This resulted in unsatisfied patients and reference physicians. Due to the fact that the anaesthesiologist decided about the involvement of other disciplines there were multiple consultations needed. As a consequence patients had to return several times (average in 1993: 3,8).

Aim of the project in 1993: To develop an efficient method and high quality treatment strategy for patients as well as reference physicians. Participating disciplines are anaesthesiology, psychology and physical therapy.

Conditions:

• Diagnoses of patients are based on diagnostic imaging.
• A patient-tailored treatment design is based on the specific needs of a particular patient and the reference physicians.
• Every discipline is involved in each treatment decision

The set up: Since 1995 a questionnaire was sent to patients before their first visit. Each discipline determines the need of a consultation on the basis of the questionnaire and medical data. The patient visits the outpatient clinic only once. Each discipline in question offers its treatment options. The final treatment strategy will be determined on a basis of consensus. This proposal is offered to the patient, who will be asked whether he/she agrees. The reference physicians will be informed and involved in performing the treatment.

Results:

1. During the first visit the patient is clearly informed about the (im)possibilities and sequence of treatment.
2. The number of visits of the patient decreased between 1993 and 1998 (average in 1993-1995: 2,6 in 1996-1998: 1,6p<0.05).
3. Reference physicians were very satisfied with the care for their patients (20 referrers gave a mean 7.5 score on a 0-10 satisfaction rate).

Conclusion: This method has been successful.

IS PMOR KNOWLEDGE HELPFUL? A SURVEY OF PATIENTS UNDERGOING TREATMENT FOR CHRONIC PAIN
M Sobczyszvn. P. A. van Raders, W.J. Gallagher, R. M. Langford. St Bartholomew's Hospital, London, EC1A 7BE, United Kingdom.

Aims of Investigation:

1. To investigate patients' knowledge of their proposed treatments in the Day Surgery Unit (DSU).
2. To explore their perceived experiences of attending the DSU.

Methods: A semi structured interview was conducted with 40 first time patients. They were asked to state the name of their proposed procedure and to describe it in their own words. Their expectations and experiences of the actual procedure and recovery period were elicited. The first 20 patients questioned were asked if preparation by a specialist nurse would have been helpful, and the second 20 were asked if they would have liked to be sent a leaflet prior to attending.

Results: 91% of patients did not know the name of their procedure and 53% were not able to describe it. Perceptions of the experience were generally positive. When asked about provision of information, 67% thought they had enough information, only 20% thought talking to a specialist nurse would be helpful, but 71% were in favour of receiving a leaflet.

Conclusion: Despite feeling that they had enough information, patients in this group demonstrated a very poor knowledge of their proposed treatment. This raises issues of comprehension and retention of information, and potentially with regard to obtaining informed consent. A greater interest in receiving a leaflet, than talking to a specialist nurse was shown. These two findings merit further investigation.

PAIN MANAGEMENT IN A FRENCH COUNTY : PICARDIE
E. SERRA, Pain Unit, Centre Hospitaller Universitaire, 80054 AMIENS, FRANCE and M. CSASZAR-GOUTCHKOFF, D.R.A.S.S. de Picardie, rue Daire, 80000 AMIENS, FRANCE.

Aim of the study: The authors study the organization of pain management and his history in a county called Picardie, situated at north of France.

Materials ans Methods: Methodology consists in presentation of Picardie county, of french laws and guidelines and of local use and history.

Results: Results are regional realizations : Multidis-ciplinary Pain Committees, Pain Consultations, opinion polls among health care professionals, quality assurance assessments, opiods use, research, professionnal education, regional organization in chronic pain and in cancer pain.

Conclusions: Changing practices on pain management are discussed according to main results. Further evolutions are required in comparison with other french counties and european countries.

THE USE OF STRONG OPIOIDS IN MURES DISTRICT, FOR TREATING PAIN IN CANCER
Romansa Lupsa, Csongor Csiki, Radu Demian Oncology Chair, Medical Faculty, Tg. Mures, str. Gh. Marinescu, nr. 3, Romania.

Aim of investigation: The use of strong opioids in cancer pain is an important indicative of pain management.

Methods: The assessment vas made on all cancer patients treated in Mures district in the last 7 years (1992-1999).

Results: Morphine prescriptions enhanced from 77 in 1997 to 323 in 1999. Daily doses increased from 60-80 mg in 1992 (most cases) to 80-120 mg in 1999 (most cases). There was prescribed 50 treatments with control released oral morphine from October 1999. After a previous increase, the pethidine consumption decreased to the level of 1992.

Conclusions: According to the WHO guidelines, morphine becomes the most used strong opioid for cancer pain, in our district. Immediate release morphine vas administered by the clock, to prevent pain. When the oral morphine becomes available, it was preferred to subcutaneous morphine. The use of higher doses indicates the decrease of fair concerning the adverse effects of morphine. Evaluation of use of strong opioids in cancer pain is an important way to increase the quality of life of cancer patients. Education of medical on the use of strong opioids, and the benefits of the treatment are essential for a better pain control in the future.

OPTIMISATION OF ANTI-PAIN MEDICAL ASSISTANCE IN RUSSIA
S S Pavlenko. G I Fomin A D Nekrasov Regional Pain Medical Center, Novosibirsk, 630087 Russia

Aim of investigation: To investigate the requirements for providing specialized anti pain medical assistance and prospects for its organization in Russia

Methods: Epidemiological study of prevalence of pain and analysis of activity of existing anti-pain medical institutions

Results: Epidemiological study of prevalence of pain syndromes has been performed in a randomized sample of 565 persons over 18 years old from population of Novosibirsk The pain prevalence accounted for 92,4% whereas chronic pains did 44,1% It was found that 57% of respondents considered ineffective the medical assistance and tried to relieve pain on their own The main difficulties in organizing the specialized anti-pain medical assistance lie in the following:

1. Strict regulation of medical institutions by the state public health system
2. Organization of public health service according to the nosology principle
3. Dogmatic views of medical doctors on vertebrogenic origin of most chronic pain syndromes
4. Lack of methods of behavioral and cognitive behavioral therapy in somatic clinics
5. Mentality of population connected with an aspiration for social guardianship and rental orientations

Conclusions: The structure of specialized interdisciplinary anti pain medical assistance should comply with the system of staged medical assistance existing in Russia It is necessary to reorganize the available structural subdivisions and to combine them with new forms of property in public health institutions It is also essential to provide a training for specialists in the field of pain curing

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 253, 255, 256, 365, 366, 368.