Mahmood Ahmad. William E Ackerman, Sorin J Brull, Center for Pain Medicine, Univ of Arkansas for Medical Sciences, Little Rock, AR 72209, USA

To determine the various terms used to describe the specialty of Pain Management, we reviewed the classified sections of Anesthe-siology. Anesthesia & Analgesia, British Journal of Anaesthesia, Anaesthesia, Canadian Journal of Anaesthesia, and Acta Anaesthe-siologica Scandinavica for the period of July to December 1998. The terms that were used (n=5) included: Pain Management, Chronic Pain Management, Invasive Pain Management, Pain Medicine and Interventional Pain Medicine. The pain practitioner was described as: Pain Management Specialist, Pain Management Physician, Pain Management Fellowship Trained MD, Academic Pain Management Anesthesiologist, Anesthesiologist Pain Specialist, Pain Boarded Anesthesiologist, Pain Anesthesiologist, Interventional Anesthesiologist, Anesthesiologist with Pain Fellowship, Pain Boarded, Pain Board Certified, Board Certified Pain Specialist, Pain Trained, Pain Medicine Specialist, Pain attending and Pain Physician (n=16). There appears to be no consensus. The American Board ofAnesthesiology (ABA) awards Subspecialty Certification in Pain Management. The American Society of Regional Anesthesia (ASRA) renamed its Journal to Regional Anesthesia and Pain Medicine in 1998. The Australian and New Zealand College of Anaesthetists (ANZCA) renamed their "Certificate in Pain Management" to "Fellowship of the Faculty of Pain Medicine" in ANZCA. Pain Management may imply an emphasis only on the technical skills possessed by anesthesiologists. Similarly non-physicians also practice pain management. The American Academy of Pain Management certifies both physicians and non-physicians. The American Board of Pain Medicine is restricted to physicians from various specialties. The examination leading to the Subspecialty Certification in Pain Management by the ABA is not merely on the management aspect, but encompasses the entire discipline, including evaluation, investigation, diagnosis, interventional and non-interventional treatment of pain including prescription of therapy. In essence the practice is best descnbed by the term Pain Medicine.

Is it time to rename our specialty for the next millennium?


Bemardo C. Univ. ofSta. Marcelina, S. Joao das 2 Barras, 95 Itaquera 08270-080, Sao Paulo-SP, Brazil.

Aim of Investigation: To investigate the pain theme teaching situation in Nursing Graduation Courses in south eastern Brazil; to provide subsidies in order to discuss and propose a basic program comprising this theme in said courses.

Methods: The sample consisted of 37 schools which answered a questionnaire containing 8 questions concerning the pain theme teaching. The central axis of the analysis of contents was the Pain Core Curriculum for Basic Nursing Education-IASP highlighting the aspects which were close to or far away from this model.

Results: Most schools 97.3% reported the teaching of pain theme in their curricula. The area with the highest concentration of such theme was Nursing in Adult Health. The most taught theoretical and practical contents on pain was respectively Definitions, Types of Pain and Pain Assessment. The way of teaching, 81% of the schools reported that the classes are inserted as items of another clinical or surgical subject. The theoretical load varied from amin. of 1 hour to a max. of 130 hours.

Conclusions: This study enables us to outline a profile of the pain teaching in Nursing Graduation Courses in Southeastern Brazil and allows us to detect that the teaching has shortcomings that may reflect on the quality of the professional care, contributing to unnecessary suffering and degradation of quality of life.


Fntz Ernest Abude. Hetty Asare, Catherine Adiamah, Ghana Ports & Harbours Authority Clinic, Takoradi, Ghana.

Aims of Investigation: To investigate the effect and benefits of detailed prc-operative education for surgical patients on post- operative pain.

Method: Each patient is interviewed separately and asked to tell the team what they know about anaesthesia and post operative pain concerning the type of surgical operation they are to undergo. The team then tells the patient the "Fact and Fiction" about the type of pain expected and how it could be controlled.

Results: 84% of patients who have never undergone surgery have quite a different ideas about how intensive pain and inconveniences they would undergo during anaesthesia and post operative period. The discussion with each patient individually has disabused their minds and allay their fears about how intensive post operative pains would be. This experience is discussed by the individuals among friends and relatives with similar fears about anaesthesia and post operative pains during the reconvalecing period.

Conclusion: Education of each prospective surgical patient individually and taking time to explain the type of discomfort and pains which may occur during anaesthesia and post operative period is an important aspect of "treatment" which is generally taken lightly or ignored. This type of education is earned over indirectly to 10-15 individuals during the reconvalecing period, and also reduces the use of analgesics.


L. Bogatcheva. A. Vakhlakov*, N. Pocutnij*, S. Tchorbinskaya*. Polyclinic, Medical Center of the General Management Dept of the President of the Russian Federation, 26/28, Sivtsev Vrazhcc, 121002, Moscow, Russia

Aim of Investigation: Development and implementation of a program for training a family doctor to improve quality of the medical assistance provided to patients with non-specific pain syndromes (back pain, arthrodynia, tension headache).

Material and Methods: In general practice, non-specific pain syndromes occur in over 80% of patients. Recently new Outpatient Pain Clinic (OPC) were established in treating institution of the Medical Center to provide comprehensive treatment to these patients. However, training of the family doctors for management of such patients is still a current issue.

Results: Family doctor training program exists since 1991 and includes pathophysiological, clinical psycho-social aspects of pain, differential diagnostic algorithms of pain syndromes in different locations, diagnosing based on 1CD-10, mastering practical skills (vacuum manual massage, using distracting means; teaching patients how to move mildly, do breathing and relaxing exercises; using portable instruments of percutaneous neurostimulation, laser therapy, vibromassage, etc.). They are aimed at decreasing pain syndrome, understanding indications for additional methods of investigation and treatment in different Depts ofpolyclinic (OPC, physiotherapy, acupuncture, kinesitherapy) or hospital. Thanks to increased number of family doctors using modem diagnostic and treatment algorithms, the average disability during non-specific pain syndromes was decreased from 1991 to 1997, e.g. during acute cervicalgia by 4,8 days, cervicobrachialgia - by 3,4 days, thoracalgia-by 3,1 days, lumboishialgia-by 6,3 days (P<0,05).

Conclusions: Implementation of the program developed for family physicians enable to improve the quality of treatment and diagnosing patients with non-specific pain syndromes in general practice.


M Mclnemey, S Kerr, G Jastrzab, B Goodenough, Sydney Children's / Prince Of Wales Hospitals, Randwick NSW 2031, Australia

Aim of Investigation: To examine nurses' attribution of blame for suboptimal pain management in hospital settings, and the relationship between pain-specific knowledge and attitudes.

Methods. An anonymous questionnaire (comprising 20 multiple choice items on pain-specific knowledge, a 12 item attitude survey, and 11 demographic items) was distributed to registered nurses from three different hospitals in the South Eastern Sydney Area Health Service (Sydney Children's, Prince of Wales, Prince Henry).

Results: 458 questionnaires were returned (150 paediatric, 308 adult). Concerning reasons for suboptimal pain relief, the attribution of blame for the paediatric and adult samples respectively were: nursing colleagues (7% , 23%), medical staff (15%, 30%), the patient (13%, 43%), and side effects of medications (7%, 19%). Overall, the tendency to implicate medical staffer the patient, rather than nursing staff, was statistically significant for both hospital contexts, as were the relative differences between the adult and paediatric samples. There was little evidence for any relationship between the responses for attitude and knowledge items. Rather, the highest correlate for the knowledge scores was age, with younger nurses tending to achieve higher percent correct. Conclusions: Registered nurses were least likely to attribute blame toward their own profession for sub-optimal pain relief. Rather, nurses especially from the adult context, were more likely to implicate medical staff and the patient's themselves. As these attribution patterns showed little relationship to a formal measure of pain knowledge, education programmes may have little clinical impact unless underlying attitudes and personal heuristics of nurses can be significantly moderated.


Eloise Can". Eileen Mann*, Lisa Dawson*, Mary Pay*, Inst of Health & Community Services, Bournemouth Univ, Royal London House, Bournemouth, Dorset BH1 3LT.

Aim of the Project: To introduce an innovative strategy, incorporating evidence based practice, into education programmes for health care professionals to facilitate an improvement in pain management.

Methods: An educational video and booklet have been produced as a result of a collaborative effort by a team of clinicians led by a Senior Lecturer. The material included is based on the conclusions of research and following extensive audit. The project came about as the evidence, within contemporary literature, continues to indicate that despite advances in acute pain management, and increased scientific interest, some patients are continuing to experience unrelieved pain after surgery. Educational efforts appear to have been only relatively successful in bringing about change in practice (Lander 1990).

Results: The video explores the patients perspective to consider how health care professionals can actively contribute to reducing pain and suffering. During the video, icons appear to indicate a topic is expanded in the accompanying booklet using up to date references. Suggestions are made where current practice should be examined, where subtle barriers to pain relief exist and where possible changes to current practice may be made.

Conclusions: During trial showings of the video to both undergraduate and post-graduate students, this education strategy is able to identify issues in a powerful and visual format. By using this format to explore myths and misconceptions it would appear to be a valid and useful medium to promote dialogue that may change practice in the future.

Acknowledgments: Supported partly by a grant from Boehringer-Ingelheim.


Betty R. Ferrell. Rose Virani* and Marcia Grant, City of Hope National Medical Center, Duarte, CA 91010 USA.

Aim of Investigation: Recent events, such as the US Supreme Court ruling on assisted suicide, have brought attention to the problem of unrelieved pain and end of life care. Previous research has demonstrated that nursing education has not prepared nurses to provide optimum palliative care for terminally ill patients. Nursing, as a profession central to patient care, needs to be in the forefront of aggressive change in education. The aim of this project is to strengthen nursing education to improve pain management and end of life care by accomplishing three goals.

Methods: The goals are: Goal 1: To improve the content regarding pain and end of life care included in major textbooks used in nursing education; Goal 2: To insure the adequacy of content in pain and end of life care as tested by the national nursing examination, the NCLEX; and Goal 3: To support key nursing organizations -the National Council of State Boards of Nursing (NCSBN), the National League for Nursing Accrediting Commission (NLNAC), and the American Association of Colleges of Nursing (AACN) - in their efforts to promote nursing education and practice in pain management and end of life care. Methods include a national needs assessment survey of 725 nurse educators, a national survey of 2100 clinical nurses, and in depth analysis of nursing texts.

Results: This poster will present progress of major activities of the project to date. Findings will be shared including the survey results that identified major needs for improving nursing education and analysis of the review of fifty (50) textbooks used in nursing schools.

Conclusions: These sources have demonstrated the gaps in current nursing education and that improved care for patients is contingent upon adequate education of nurses.

Acknowledgments: This project is funded by the Robert Wood Johnson Foundation.


Figueiro JAB, Teixeira MJT, Mineko NM, Multidisciplinary Pain Center, Hospital das Clinicas ofUniv ofSao Paulo, Institute Central, 5 andar, sala 6011, CEP 05403-000, Sao Paulo, SP, Brazil.

In general, the Brazilian situation concerning pain management (diagnosis and treatment) and palliative care is a great disaster. Worried about this subject, the Brazilian Medical Association (AMB) created on May 5, 1997, a Continuous National Educational Program for Health Care Professionals, and Community Education for the General Population, about Pain and Palliative Care that was incorporated as a project of the Health Ministry, a Federal Governmental Health Organization in November 1998.

In order to promote an alteration in this panorama, we are elaborating courses, symposiums, lectures and other events that would be held at the AMB regional offices, universities, medical schools, hospitals, out-patient clinics and other scientific and health centers for the public and private populations. We will use three TV systems via satellite and cable, scientific Journals and magazines besides the informative material created and distributed by the program. This program reaches other health care providers such as nurses, psychologists, social workers, nutritionists, etc. as well as the general population.

All Brazilian Specialty Societies and Federal Councils for the Health Care Professions were invited to participate as consultants. This program was presented and approved by the National Health Council of the Health Ministry and now is an official governmental program for the Health Policies Secretary of the Health Ministry.

The Program's objectives are: 1) To develop a Continuous National Educational Program for Health Care Professionals, and Community Education for the General Population, about Pain and Palliative Care; 2) To include specialized teaching on pain and palliative care in the curriculum of health care colleges; 3) To alert governmental authorities about the need to change this Brazilian view on pain and palliative care management; 4) To follow faithfully the internationally recommended guidelines with the necessary regional and cultural adaptations. The main objective is to give better quality of life and assistance to thousands of people suffering unnecessary pain or needing palliative care. The program collaborate to help economize resources (financial and professional time) that are greatly wasted nowadays in the Brazilian medical practice.

This program is constituted by the Board of Directors, the Executive, the Administrative and the Consultant Commissions. The latter presenting two sub-commissions: the national and the international commissions.

The purpose of this presentation is to present a Brazilian experience on a national educational program on pain and palliative care supported by the Brazilian Medical Association and the Health Ministry.


Cynthia R Goh. Tan Chor Hiang*, Koh-Tai Bee Choo*, National Cancer Centre and Ministry of Health, Singapore 169854, Republic of Singapore

Aim of Investigation: To define the level of knowledge and attitudes of doctors and nurses in Singapore to cancer pain management.

Methods: The ECOG Physician Cancer Pain Survey questionnaire was adapted for the doctors' survey. Using a sampling frame of 4,361 doctors registered with the Singapore Medical Council and currently working, 550 were selected by stratified sampling. For nurses, an adaptation of the Cancer Information Survey questionnaire by McCaffery and Ferrell was used. From a sampling frame of 9,804 State Registered Nurses who are currently working, 500 were selected.

Results: A variety of knowledge and attitudinal deficits were found in both physicians and nurses. Sixty-five percent of physicians felt that the majority of patients with pain are undermedicated. Among the nurses, 69% correctly chose morphine as the drug of choice for treatment of prolonged moderate to severe pain, 36% correctly gave the oral route as the recommended route for administration of opioids. Only 10% of nurses gave the correct answer of<l% being the likelihood ofopioid addiction as a result of its use in pain relief

Conclusion: More education and training on cancer pain management is needed to improve the deficits in knowledge and attitudes in doctors and nurses.

Acknowledgment: This was an extension of a survey done in collaboration with Dr Fumikazu Takeda and was in part supported by a grant from the World Health Organisation. Dr Goh was Medical Director of Assist Home & Hospice when the work was carried out.


L E Jones. R D Hams and L E Tonkin, Univ of Sydney, Pain Management and Research Centre, Royal North Shore Hospital, Sydney, New South Wales 2065 AUSTRALIA

Aims of Investigation: 1) To discover opinions of Australian physiotherapy students on the appropriateness of their undergraduate education regarding pain. 2) To examine the 'Pain Curriculum for Students in Occupational Therapy or Physical Therapy' (Berde 1994) in terms of the above.

Method: A questionnaire was devised based on the IASP guidelines and objectives (Berde 1994), including a section from a questionnaire devised by Unruh (1995). Final year physiotherapy students were surveyed from six Australian universities.

Results: Response rate was >60 % (N = 386). Mean number of months before completion of degree was 4.5 (SD = 1.8). Data was grouped under headings suggested in the curriculum recommended by the IASP. Mean group scores corresponded to 2 or below on a Likert-type scale (i.e., students considered they had inadequately learned a topic in terms of their needs). However, mean scores indicated that respondents were confident of satisfying the IASP objectives after course completion.

Conclusions: Australian physiotherapy students considered they were not receiving satisfactory education about pain topics as outlined in the IASP document. However, in general, respondents expected to have a level of pain-related knowledge and skill, as described in the IASP course objectives, by the end of their course. While these conclusions suggest that Australian physiotherapy schools may need to review their pain education content and process, it is also appropriate that the IASP document (the basis of these conclusions) be reviewed for its relevance to current teaching formats, and its availability or exposure to curriculum makers.


Meghan Kielty*. BSN, RN; Arthur Schuller, MD; Catherine Tom* BSN, RN; Kirn Hadden*, RN, MPA; Karen Alien*, MSN, CCRN; Judy Silvcrman*, MD; Cathy Lau*, PharmD, BCPS; Pain Management Program, St. Mary's Medical Center San Francisco, California, 94117, USA

Aim of Investigation: In 1994, St. Mary's Medical Center Pain Management Program was established to provide education to clinicians and the community on managing pain. Its goals emphasized improving patient outcomes. Resources were limited to those available in our community hospital, including clinical and community volunteers and, since 1997, one full-time employee.

Methods: Patient outcome data has been collected since 1996. A modified version of the Postoperative Pain Management Quality Assessment Survey (Abbott Laboratories, publication no. 93-3154/R 1) and-the Acute Pain Management Quality Assessment Survey (Abbott Laboratories, publication no. 96-4797-20-Mar., 97, TQPM version 4.49), have been used to measure patient satisfaction.

Results: Satisfaction with pain relief improved from 73% of patients reporting satisfaction during first quarter 1996 (n=99), to 92% during second quarter 1998 (n=71). The percentage of patients reporting timely receipt of pain medications (< 30 minutes) has increased from 70% during third quarter 1997 (n=34), to 90% during second quarter 1998 (n=71). However, average pain scores (using a 0 to 10 pain scale) during this time have increased for both reported "worst pain" [from 5.0 in third quarter 1997 (n=34) to 6.2 in second quarter 1998 (n=71)], and "least pain" [from 1.2 in third quarter 1997 (n=34)to 1.8 in first quarter 1998 (n=102)].

Conclusion: Despite the limited resources available in community hospitals, a successful pain management program can be developed, if driven by the energy and dedication of its volunteers and viewed as a long-term endeavor. Patient outcome data will continue to shape our educational programs, empowering clinicians to improve patient care.

Acknowledgments: The TQPM (Total Quality Pain Management) software program was supplied by Abbott Laboratories.


Kimberly Klassen. Jeanne Lamb*, (SPON: D. Hughes), Acute Pain Services, Calgary Regional Health Authority, Calgary, Alberta, Canada, T2T 5C7

Aim: 1) Promote consumer awareness about rights and responsibilities regarding pain management; 2) promote consumer awareness about pain management options; 3) promote active patient involvement in pain control; 4) promote public awareness of support groups within the community.

Methods: Health care agencies and community support groups were invited to participate in a daylong program of public education held in a large covered shopping mail. These agencies represented clients with various of types of pain and different approaches to treatment. Space was donated, free parking was available, and the mall location provided exposure to a wide cross-section of a large population. The "Pain Fair" was publicized via newspapers, radio, TV and flyers. The event was evaluated by questioning a random sample of consumers. Exhibitors were given an anonymous mail-back questionnaire.

Results: 11 different support groups, health care agencies and professional associations participated. The exact number of visitors to the display area was not recorded, however 250 consumer information brochures were distributed. 47 female and 16 male consumers were interviewed. The majority were 30-70 years. 96% liked the venue and 85% said the information provided would be useful. 75% of exhibitors felt the goals had been clearly defined. Most felt it met their expectations and the event was worthwhile. An unexpected benefit of the event was the opportunity for exchange of information and consultations amongst complementary providers in the health care system and the community.

Conclusion: A non-threatening consumer-oriented environment can be used to provide effective public education about resources for pain management.

Acknowledgments: Supported by the Calgary Pain Interest Group and the Calgary Regional Health Authority.


S. Loftus*, I. Taylor*, LR Harris, MJ Cousins (SPON: S. Walker) Univ of Sydney Pain Management & Research Centre, Royal North Shore Hospital, Sydney, NSW 2065, Australia

Aim: The aim is to provide a web-based course in multidisciplinary pain management to health care professionals from a variety of backgrounds, including doctors, dentists, nurses, psychologists and physiotherapists.

Background: The Graduate Diploma/Master's degree in Pain Management is offered on a part-time basis, both as a residential course since 1996 and a distance course commencing in 1999 by the Univ of Sydney. The residential course was the first of its kind in the world. The first cohort of students has now completed their degrees. The residential course has always been heavily oversubscribed, and students have been willing to travel great distances to Sydney from out of state to attend residential weekends. To meet the demand for higher training in this growing field, the degree has been designed for distance education.

Methods: The distance course is managed from a secure World Wide Web site and integrates a number of educational technologies. Study guides are provided and supplemented by online interactive quizzes and CBL programs. Students take part in online discussion groups. Tutors take on the role of mentors and facilita-tors rather than teachers. An online patient simulator allows students to role-play the assessment and treatment planning of a patient in a multidisciplinary centre. In addition, a series of case studies and lectures by internationally acknowledged experts is provided on videotapes.

Evaluation: The outcome of first semester will be reported on in the poster presentation


Jacques Meynadier. Andre Muller, Philippe Poulam, Alain Serrie, Bernard Serrie, Claude Thurel, Centre Oscar Lambret, B.P. 307, 59020 Lille cedex, France.

Aim: To teach the teachers.

Methods: Forty medical practitioners from the Univ Medical School of Maputo are trained to detect and diagnose pain in patients and a twice two years Univ program on pain management (1997-1998 & 1999-2000), totally integrated in the Univ medical teaching programs has been set up. Four times a year, DSF recruited professor for giving during two weeks, lectures extended to cover the main public health care concern cancer, AIDS, postoperative pain, pain in special populations (children, elderly, malnourished and handicapped people). DSF teachers try, each time it is necessary, to adapt their lectures to the local situation and needs. DSF also organizes targeted training to primary care post-graduate doctors and secondary care doctors of public hospitals in Maputo. The teaching is intended for certified doctors at the Maputo Univ Hospital (chief physicians, school of medicine' professors) and second cycle medical students. It consists in a 8 modules representing 4 teaching sessions (2 weeks) per year, that is a 2 year program that will be renewed once (full program : 4 years). This teaching is validated by an examination at the end of the first year and also at the end of the second year. The first course of two years was ended in 1998 and the second part of the courses will resume at the beginning of 1999 (March).

Conclusion: It is a DSF philosophy to pass the reins as soon as possible as local situation have reached all the conditions for such a transfer of responsibility.


Andre Muller. Alain Seme, Jacques Meynadier, Philippe Poulain, Bernard Seme*. Claude Thurel, DSF; hopital Lariboisiere, 2 rue Ambroise Pare, 75475 Paris.

Aim of Investigation: Our association is a non profit-making, nongovernmental organization (NGO) with a strictly humanitarian calling. To fight against pain: this is our fundamental mission; for all patients including those for whom conditions of life and health are more precarious; all over the world: whatever the reasons for countries misfortune.

Methods and results: DSF organization:

1. Basic principles: 1) the fundamental aim is humanitarian action providing medical care, either directly or by training future care personnel. 2) The structure should allow an optimization of the team's efficiency in the field.

2. The structure: 1) the geographical structure: Six officers are in charge of our main intervention countries, Angola, Cambodia and Mozambique. They co-ordinates assignments, whatever their nature is. They are assisted by a local permanent officer. 2) the technical structure : DSF medical care, which prepares all pain treatment projects: pain in amputees, in AIDS and cancer, post-operative pain, and in special populations, etc...DSF Education and Training, which establishes teaching programmes, procedures, relations with universities and ensures high-quality professors recruitment. DSF global organization, which deals with problems linked to multidisciplinary interventions.

3. The general administration, composed of five pain specialists and one engineer, motivated by a passion that they communicate to all DSF members and interventions teams: to fight against is part of humanitarian action.

4. Financial resources: They are come from: Physicians who accepted and still accept to work and give time to the structure without being paid (75 per year), drugs and medical equipment companies which bore the cost of the basic devices, the French government through its ministries and generous private donations.

Conclusions: DSF is not a NGO like others, DSF is the only organisation in the specific field of pain. DSF requires highly qualified doctors. DSF directs a large proportion of its resources to training at the highest level.


Irimar de Paula Posso. Maria Belen Salazar Posso, Univ of Sao Paulo School of Medicine, Sao Paulo, Brazil.

Aim of Investigation: To evaluate the knowledge of the abdominal surgeons about the patients' right of not feeling pain after upper abdominal surgery and their ability to manage the postoperative pain.

Methods: A hundred surgeons were interviewed, males and females, working for 10 or more years with abdominal surgery. They answered the two following questions: 1- Do you think that it is a right of the patient not to feel postoperative pain? 2- How do you manage the pain after an upper abdominal surgery?

Results: All the surgeons believed that it is a right of the patient not to feel pain after any surgery. Only 11% of them proposed an appropriate therapeutic plan, to manage this kind of postoperative pain, based in the assessment of pain, the use of various analgesic modalities, adjustment of dosage to achieve the necessary effect in any individual case. The other 89% surgeons proposed a plan, but they did assess the intensity of the pain and they did not adjust the therapeutic model to the intensity of the pain.

Conclusions: All the interviewed surgeons recognize that it is a right of the patients not to feel available pain, but only 11% are really interested in assessing and managing the postoperative pain, of their patients.


Deborah Rochman. Penelope Herbert*, Tufts Univ, Boston School of Occupational Therapy, Medford, MA 02155 and *Spaulding Rehabilitation Hospital, Boston, MA 02114-1198, USA

Aim of Investigation: Our aims were to: 1) develop a flexible, interdisciplinary survey with established content validity; and 2) use the survey to measure pain knowledge and attitudes of a sample of occupational and physical therapists in different clinical settings.

Methods: Development of the survey instrument began with an occupational and physical therapist submitting an established nurses' knowledge and attitudes survey to eight rehabilitation clinical experts in pain management (four from each discipline). The experts were asked to select questions from the nurses' survey which they felt would be appropriate to include in a rehabilitation survey. The questions that were selected had > 70% agreement. Three case studies were adapted and one developed; ten original questions were created or adapted from other sources. Survey items addressed the following: physiology, assessment and measurement, developmental issues, pharmacology, cognitive-behavioral methods, and pain beliefs. The survey was then resubmitted for editing to the eight clinical experts and the chairs of the American Pain Society Committee on Educating and Training Pain Clinicians. The survey is currently being administered to 100 physical therapists and 100 occupational therapists across the United States.

Results:The survey and results of this preliminary study will be presented. The investigators anticipate that there will be differences in scores and knowledge related to years of clinical experience, different clinical settings and between disciplines.

Conclusions: There is evidence in the occupational and physical therapy literature that deficiencies in pain knowledge and attitudes exist among practitioners and within educational curricula The findings of this study may support the need for efforts to standardize pain education by identifying specific areas of deficiencies among occupational and physical therapy professionals.


Alain Seme. Joel Menard*, Edouard Couty*, Direction Generate de la Sante, Direction des Hopitaux, Secretariat d'Etat a la Sante et a 1'Action Sociale, 8 Ave de Segur, 75350 Paris 07 SP.

Management of pain, a constant preoccupation of care givers has become a health care priority clearly defined by the Health Ministry. To date the management of those patients was inadequate, particularly for post-operative and chronic pain, but also children, elderly and patients with cancer and AIDS. Nowadays, the delay in our country should be resolved by organization and reglementary aspects. Health providers have to follow the regulations to take in charge pain and suffering as given in the law (article L 710.3.1. du code de la sante publique).

We enter now in the first phase ofatri-year plan 1998-2000 that was announced by the Health State Secretary B. Kouchner. Pain management policy is focused in 4 ways. • Developing patient education: A “Pain booklet ” will be handed to each hospitalized patient. All caregivers will receive a tool for pain assessment: a visual analogic scale. Legislation for controlled substances such as opioids will be modified.

Developing pain management in medical Depts: more 150 qualified pain structures have been identified. This list is available on the web: http// 1000 Patient Controlled Analgesia will be given in 1999. CLUD (comite de lutte centre la douleur) local committee against pain are devoted to introduce a “ pain culture ” in hospitals and clinics. The management of pain is included in the accreditation procedures, and will be materialized in agreements between Regional Hospitalization Agencies and medical services.

Developing physician education: pain is integrated into medical and nurse school curriculum. Pain has become a priority topic for the continuing medical education.

Developing public information: The aim is to recognize pain and suffering as therapeutics objects and restore the relationship between patient and physician.


Maureen J. Simmonds. Rhonda J. Scudds', Roger A. Scudds', Dei-dra D. Crow.* School of Physical Therapy, Texas Woman's Univ, Houston, TX , USA, 77030. ' Hong Kong Polytechnic Univ, Hong Kong.

Aim of Investigation: Practitioners' knowledge of pain and attitudes towards patients with pain has been shown to influence the effectiveness of pain management. At present it is unclear how much time is spent and what pain-related content is taught within entry level training of physical therapists. The aim of this study was to determine: 1) faculty interest and expertise in pain, 2) instructional time devoted to pain; 3) pain related topics taught, and, 4) faculty perceptions regarding students preparedness to assess and manage patients with pain.

Methods: Program Directors or their designates from all PT programs in North America (NA), United Kingdom (UK), Australia, New Zealand, Middle East, Asia, and South Africa were surveyed. This analysis is limited to the results from NA and the UK. The survey form was designed by the authors, reviewed by experts, revised, piloted to several programs and revised a second time.

Results: Surveys were sent to 169 PT programs in NA, and 28 programs in the UK. The response rate was 63% from NA (n=106) and 64% from the UK (n=l 8). Key results were as follows. In NA 18% of respondents had a specific interest in pain, 7% were members of a pain association and 21% conducted pain research. This compares to 95%, 44% and 67% respectively, in the UK. Pain was most commonly taught within a modalities course. The modal time devoted to pain in this course was 4 hours in NA (range 2-39) and 2 hours in the UK (range 1-36). Approximately half the respondents (NA 55% and UK 45%) thought that enough time was devoted to pain. The majority of respondents in NA and the UK, thought that students were adequately prepared to assess (83% in NA and the UK) and manage (91% in NA and 78% in the UK) patients with acute pain. But only half expressed the same level of confidence in students' preparedness to assess and manage chronic pain.

Conclusions: Faculty in NA are less interested in pain than their UK counterparts. Within the context of the overall PT curriculum, very little time is spent on pain. However, this is generally perceived to be adequate.


Bemadette Wouters: (SPON. JL Scholtes) Centre de Perfectionne-ment en Soins Infirmiers, 1200 Bruxelles, Belgium.

Aim: To implement the Core curriculum for professional education in pain -IASP.

Programme: 95 hours devoted to anatomy, epidemiology, drug and non drug treatments, evaluation, structures, specific types of pain ( cancer, post operative, children, neurology...), psychology, ethic, prevention, final test.

Teachers: Physicians, nurses, psychologists, physiotherapists, occupational therapist, ethician, chosen for their experience in pain management.

Students 1998-1999: 37 RNs + 1 physiotherapist. 28 RNs have obtained from 1 to 5 more diplomas; 13 have a certificate in Palliative Care (only those have specific knowledge on pain), 7 are trained as senior nurses, 4 have a Univ degree. 28 come from 16 hospitals, 51/2 work in nursing homes and 11 are "managers". 26 of them were working in many different settings and have experience with all kinds of patients and pains. By now 9 of them are working with post operative patients, while 25 meet mostly chronic pain patients. The drugs used in their wards are the well known analgesics and A1NS, the neuroleptics are only mentioned twice, the clonazepam and local anesthetics only one. As non pharmaceutical approach they mention physiotherapy, massages, psychological support, relaxation, TENS. The scope of pain problems is far more extended than the scope of available treatment, this indicates the need for such training.


P. Langkafel*, H. Hagmeister, U. Arnold*, Humboldt-Univ, Berlin 13353, Germany

Aim of Investigation: To investigate and evaluate the possibilities of problem based learning via internet in pain management.

Methods: We integrated the concept of Problem Based Learning (PBL) in an electronic environment, This helped to create the first step of a course of Pain Management for medical students and young doctors from four European universities (Germany, France, Sweden, Hungary). PBL is a learning method for small groups. The course took place for one month in May. The aim is to create an environment of active discussion about a given problem and to derive precise questions and then solutions from the problems experienced. At the end of the two virtual/multimedia cases there was an online session with the professor to ask specific questions. Results: The online evaluation was performed three times (start, middle, end of the course). We investigated four dimensions

- learning with new technologies (Computer, Email, chat...)

- learning with a modem method (problem-based learning)

- learning new contents (pain management)

- improve the language skills (the complete course was in English).

Conclusions: The need for a special course of Pain Management for Students and young doctors is highly relevant. Especially because there is a lack of adequate contents in general curricula of medical education. Learning via internet with Multimedia/Virtual Cases seems to be a good possibility to improve this situation. The students mentioned especially the advantages ofsynchron and asynchrom time planning and the independence of the geographic situation of this oped distance learning module.


V. Piguet'. C. Cedraschi', W. Fischer*2, J. Desmeules', A.F. Al-laz', M. Kondo*', B. Roche*3, P. Dayer', "Multidisciplinary Pain Center & Depts of Psychiatry, 'Surgery, Univ Hospital, CH-1211 Geneva 14.

Aim of Investigation: To examine the representations ofantide-pressants (AD) in chronic pain patients (CPP), as compliance with these drugs is restricted.

Methods: 60 standardized semi-structured interviews were conducted with CPP referred to a pain center and matched pain-free controls (C).

Results: More CPP than C had already received AD (66% vs 16% p<0.01), essentially for depression, and in CPP only, for chronic pain (9%) and both indications (13%). CPP considered depression (74%) and relaxation (40%) as the main AD indications; C cited depression (84%) and mood change (44%). Only CPP (26%) spontaneously proposed pain (C 0%, p<0.01). More C (60%) than CPP (30%, P=0.02) described AD as a help but not a way to solve problems; C (32%) also more often cited the need for other concomitant therapies (CPP 3%, p<0.01). CPP (56%) mentioned somatic side effects (SE) as the main risk associated with AD intake, whereas C mentioned "dependence" (72%, pO.01). Only CPP (21%) cited an aggravation of depression as a risk of AD. SE in general were a predominant problem in CPP and were the cause of stopping a medication in 93% CPP (C 50%, p<0.01).

Conclusions: Pain as an indication for AD is widely unknown even in chronic pain patients. The somatic effects of AD are emphasized, whether positive or negative, by chronic pain patients. AD prescription in these patients should take these characteristics into account.


C. Cedraschi'. V. Piguet', W. Fischer*, A.F. Allaz', J. Des-meules', P. Dayer', 'Multidisciplinary Pain Center & "^ept of Psychiatry, Univ Hospital, CH-1211 Geneva 14. Antidepressants (AD) exert a clear-cut analgesic effect but compliance with AD is poor.

Aim of Investigation: To examine where lay people get information about the medication they use; and whether this information may contribute to explain compliance problems when prescribing AD to chronic pain patients (CPP) referred to a pain center.

Methods: 60 standardized semi-structured interviews were conducted with CPP and matched pain-free controls (C). Patient information leaflets (PIL) of 16 AD were analyzed.

Results: More than 90% of the CPP and C said they always or almost always read the instruction leaflet which was their most common source of information about medication, ahead of any other, including physicians. They mainly looked for indications (67% vs 60%) and side effects (SE) (50% vs 52%). Out of the 16 PIL, 15 referred to the treatment of depression. Further indications included obsessive compulsive disorders, bulimia and social phobia. Only 5 evoked pain as a possible indication, directly or indirectly, among which 3 mentioned physical symptoms with no organic cause or linked to depression. Analysis ofSE (n=55) showed that 82% were somatic and 18% psychological.

Conclusion: AD leaflets point to indications which have a strong psychiatric connotation, confirming both groups representations of AD*. The predominance of somatic SE may further contribute to lower compliance in patients already experiencing many physical symptoms. Prescription of AD for pain is non-congruent with PIL and patients representations. *see Abstract Piguet et al.


Philippe Poulain. Jacques Meynadier, Andre Muller, Alain Seme, Bernard Serrie, Claude Thurel, “ Douleurs Sans Frontieres ”, In-stitut Gustave Roussy, 94805 Villejuif, FRANCE

Aim: To develop pain education and promote pain therapy in Cambodia.

Methods and results: Since 1996, a total of 605 amputated patients have been treated (385 with TENS, 58 by neuroma alcoholization). We organised a training plan in 3 prosthesis and rehabilitation centres and we now delegate the responsibility to the local team of passing on the technique. Our second aim is pain education and we provided an 80 hours pain training program over two years for anaesthetists in collaboration with the Faculty of Medicine of Phnom Penh. Another 60 hours are individualised and targeted for training specialists in gynaecology, surgery, paediatrics and internal medicine. Frequently, DSF physicians are asked by various institutions or NGOs, (Veteran International, Handicap International, Medecins Sans Frontieres...) to provide courses in various fields of pain (cancer and AIDS pain and symptom management, post-operative pain, pain in rehabilitation...). A big part of our job is on- site training (at the patient's bedside); teach how to recognise the main signs of pain in patients who do not complain of pain because ofKhmer and religious tradition. AIDS will become the major public health concern within the next 10 years in Cambodia, therefore DSF has taken a large part in the guidelines for the evaluation and treatment of pain and related symptoms of a nationwide program. DSF opened its first pain clinic in Phnom Penh military hospital 3 months ago. An average of 10 to 25 patients are treated every day by 2 K-hmer doctors trained and appointed by DSF.


June L. Dahl. PhD & Patricia H. Berry, PhD, RN, CRNH*, & Mary M. Skemp, BBA*, Univ of Wisconsin-Madison Medical School, Madison, WI, USA; Carole H. Patterson, MN, RN* & John M. Wuest, MS*, Dept of Standards, Joint Commission on Accreditation ofHealthcare Organizations, Oakbrook Terrace, IL, USA

Unrelieved pain is a major - yet avoidable public health problem. Despite 20 years of work by many and the publication of clinical practice guidelines, there have been at best modest improvements in pain management practices. While health care professionals and patients may create significant impediments to effective pain control, traditional patterns of professional practice are the most formidable barriers. The failure to routinely assess and document pain, lack of access to practical treatment protocols and the view pain is an expected and insignificant symptom continue to impede progress. Health care organizations must address the barriers in their practice settings to ensure all patients receive quality pain management. We are in collaboration to integrate pain assessment and treatment for all patients into the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) standards and survey processes, a rare opportunity to improve pain management in hospitals and other health care facilities. The proposed revisions are completed and approved for field evaluation by the JCAHO advisory groups and a committee of the JCAHO Board of Commissioners. We are conducting an evaluation of the impact of the revisions and will assist with their introduction to the surveyors and the health care field for implementation, a process we estimate will take until August 2000. Our poster presentation outlines the process we have followed and provides updates on our progress. We anticipate the field evaluation, pretest of the impact of the revisions, and the standards to be finalized at the time of the IASP meeting.

Acknowledgments: Supported by a grant from the Robert Wood Johnson Foundation.


Leesa Van Niekerk and Frances Martin*, School of Psychology, Univ of Tasmania, Hobart, 7000, Australia.

Aim of Investigation: To examine the ethical dilemmas and perceived barriers to pain management ofTasmanian Registered Nurses in relation to pain management issues such as addiction, use of analgesics, and assessment of pain. To date, these clinical practice issues have not been addressed using a sample of Australian nurses.

Methods: A total of 1009 registered nurses completed a 63-item survey examining knowledge and beliefs about pain management and satisfaction with pain management practices.

Results: Preliminary results indicate that nurse's perceive doctor's knowledge and perceptions of pain, patient cooperation in taking medication, inadequate prescribing of pain relief medications, and patient to nurse ratio to have a negative impact on their ability to provide optimal pain management. The most commonly cited ethical dilemmas experienced by nurses were concerns about use of medication, addiction, and adequacy of pain relief obtained by patients during hospitalisation.

Conclusions: The preliminary results of this study shows that the role of the nurse in pain management involves making significant decisions about patient pain management, with these decisions often resulting in the experience of ethical dilemmas. The results support the need for continuing education sessions for nurses, and the need for hospital guidelines that aid the decision making process. Education regarding effective pain management in a hospital setting needs to target pain management staff as well as the patient,


Eun-Ok Lee. Nursing school, Seoul National Univ; Soon-Ja Kirn, Dept of Nursing, Korea Univ

Aims of Investigation: The purpose of this study was to evaluate the effects of patient and medical personnel education on levels of pain, and patient's concerns for reporting pain and taking analgesics.

Methods: Seventy-five mpatients with cancer pain were selected from four major institutions of South Korea in which medical personnel education on cancer pain management finished. Pain intensity with a numerical scale and patient's concern with barriers questionnaire were measured before and after patient education.

Results: The pain scores from before to after the patient education significantly changed from 7 to 5.26 in the worst pain, 3.81 to 2.81 in the average pain, and 1.51 to 1.31 in the least pain during the last 24 hours. Total mean score of patient's concerns changed significantly from 25.74 to 18.37 in which fear of addiction from 3.68 to 2.36, desire to be a good patient from 3.32 to 2.12, and meaning of pain as disease progression from 4.16 to 3.75.

Conclusions: The results suggest that educational program for medical personnel and patients improve cancer pain management.

Acknowledgments: Supported in part by Oncology Nursing Foundation and the Janssen Korea LTD.


In-Gak Kwon* (SPON: Kirn SH), Director, Dept of Oncology Nursing, Samsung Medical Center; Eun-Ok Lee, Professor, College of Nursing, Seoul National Univ; Soon-Ja Kim, Professor,

Dept of Nursing, Korea Univ; Sister Park Teresia, Director, Hospice Dept, St. Mary's Hospital.

Aims of Investigation: This survey was designed to evaluate degree of cancer pain management of physicians and nurses in South Korea and to compare physicians' knowledge with nurses'.

Methods: Study subjects were 99 physicians and 152 nurses working at four major institutions in South Korea. The maximum score of the knowledge about cancer pain was 30 points with true and false answers in 4 categories such as pain assessment (6 items), action ofopioids (8 items), opioids classification (11 items), and administration ofopioids (5 items).

Results: Total mean score of physicians was 21.40, which was significantly higher than 20.87 of nurses. Rates of the correct answer were less than 40% in both physicians and nurses. In each category, physicians showed 3.11, 5.40, 9.52, and 3.37, while nurses 3.51, 4.97, 8.85, and 3.48. Nurses were higher in pain assessment and administration ofopioids than physicians.

Conclusions: Since physicians and nurses couldn't effectively manage the cancer pain because of inappropriate knowledge, it is important to provide aggressive education to physicians and nurses about cancer pain management.

Acknowledgments: Supported in part by Oncology Nursing Foundation and the Janssen Korea LTD.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.466 - 473