I have a middle aged woman with advanced vulvar cancer on my caseload. Co-morbs of HTN, smoking. She has significant pelvic/perineal tumor burden which is the source of her pain. It is mixed nociceptic and neurpathic. She came to me using Percocets at her max with continuous pain 7-9/10. She has remains on that same dosage today, it is her safety blanket. We have moved her through morphine, to methadone which was somewhat more effective with the neuro pain. She has now, unfortunately started having some visual hallucenations and I fear that the methadone has exceeded its risk/benefit ratio. She was too sedated on Neurontin and had a systemic allergic reaction to Elavil. Her pain control is currently averaging 4-5/10 with exacerbations. It is the neuropathic pain that is most difficult for her. She lives independently and is very cognitively approp for age. She is sleeping reasonably well with pharma help. She uses Ativan periodically but not routinely. Safety at home with good pain control are her immediate goals. I believe that the best palliative options for this woman are in the arena of intrathecal, epidural, nerve block. Obviously, these are expensive options...so I need to advocate an intelligent and informed plan of action which ends (soon I hope) in good pain control for this woman. I do not think that simply switching from methadone to say...dilaudid...will solve this problem as the neuro pain is key to her quality of life. Any suggestions for a next step?