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Hall EA, Hagemann TM, Shelton CM, Jasmin HM, Calvasina AN, Anghelescu DL. A Narrative Review of Pain in Pediatric Oncology: The Opioid Option. Paediatr Drugs 2024:10.1007/s40272-024-00640-y. [PMID: 38954225 DOI: 10.1007/s40272-024-00640-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/04/2024]
Abstract
Opioid therapy is the mainstay for managing pain in pediatric oncology. This narrative review describes the current literature regarding opioids for pediatric cancer pain. The review explores the multifaceted landscape of opioid utilization in this population, including the role of opioids in certain clinical circumstances, modalities of opioid delivery, unique opioids, outpatient and at-home pain management strategies, and other key concepts such as breakthrough pain. This review highlights the importance of individualized dosing and multimodal approaches to enhance efficacy and minimize adverse effects. Drawing from a wide range of evidence, this review offers insights to optimize pediatric oncology pain management.
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Affiliation(s)
- Elizabeth A Hall
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Tracy M Hagemann
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Nashville, TN, USA
| | - Chasity M Shelton
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hilary M Jasmin
- Health Sciences Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alexis N Calvasina
- College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Doralina L Anghelescu
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
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2
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Ing J, Wong S, Chan H, Hsu E. Opioid Therapy in Cancer Pain. Cancer Treat Res 2021; 182:87-95. [PMID: 34542877 DOI: 10.1007/978-3-030-81526-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cancer is a leading cause of morbidity and mortality, with up to 9.6 million cancer-related deaths worldwide in 2018 [1].
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Affiliation(s)
- Jakun Ing
- Department of Anesthesiology and Perioperative Medicine, UCLA, 757 Westwood Plaza #3325, Los Angeles, CA, 90095, USA.
| | - Samantha Wong
- Department of Anesthesiology and Perioperative Medicine, UCLA, Los Angeles, CA, USA
| | | | - Eric Hsu
- Department of Anesthesiology and Perioperative Medicine, UCLA, Los Angeles, CA, USA
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3
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Grossoehme DH, Brown M, Richner G, Zhou SM, Friebert S. A Retrospective Examination of Home PCA Use and Parental Satisfaction With Pediatric Palliative Care Patients. Am J Hosp Palliat Care 2021; 39:295-307. [PMID: 34293957 DOI: 10.1177/10499091211034421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Home Patient-Controlled Analgesia (PCA) is an effective and often preferred therapy for the treatment of chronic pain symptoms in the pediatric palliative care patient. There is little previous research of patient experience with Home PCA. The purpose of this study was to investigate use of home PCA devices in pediatric patients to inform palliative care providers considering an alternative management option for the treatment of end-of-life or chronic pain. METHODS A chart review was performed of patients prescribed home PCA. Surveys were sent to patients' guardians/caregivers. Questions referred to caregiver impression/satisfaction with information provided regarding use of the PCA machine, the medication used, the benefits and risks of PCA, monitoring of patient pain level and alertness, machine efficacy, and fears and concerns. RESULTS Thirty-four patients met inclusion criteria, and 18 patient families completed surveys. Demographic data showed that the majority were Caucasian and had a cancer diagnosis. Patient age and duration of home PCA use varied greatly. Overall, participants were satisfied with information received and felt positively about home PCA, albeit expressing concerns. The majority described the machine as easy to use and were satisfied with their child's pain management and level of alertness. CONCLUSION Responses indicated that home PCA is a manageable and effective alternative to traditional analgesic medications for management of chronic pain in the pediatric patient.
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Affiliation(s)
- Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, 1079Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, 1079Akron Children's Hospital, Akron, OH, USA
| | - Miraides Brown
- Rebecca D. Considine Research Institute, 1079Akron Children's Hospital, Akron, OH, USA
| | - Gwendolyn Richner
- Haslinger Family Pediatric Palliative Care Center, 1079Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, 1079Akron Children's Hospital, Akron, OH, USA
| | - Sarah M Zhou
- Haslinger Family Pediatric Palliative Care Center, 1079Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, 1079Akron Children's Hospital, Akron, OH, USA
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, 1079Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, 1079Akron Children's Hospital, Akron, OH, USA
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Piette V, Beernaert K, Cohen J, Pauwels NS, Scherrens AL, van der Werff Ten Bosch J, Deliens L. Healthcare interventions improving and reducing quality of life in children at the end of life: a systematic review. Pediatr Res 2021; 89:1065-1077. [PMID: 32645707 DOI: 10.1038/s41390-020-1036-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/15/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Children with serious illness suffer from symptoms at the end of life that often fail to be relieved. An overview is required of healthcare interventions improving and decreasing quality of life (QOL) for children with serious illness at the end of life. METHODS A systematic review was performed in five databases, January 2000 to July 2018 without language limit. Reviewers selected quantitative studies with a healthcare intervention, for example, medication or treatment, and QOL outcomes or QOL-related measures, for example, symptoms, for children aged 1-17 years with serious illness. One author assessed outcomes with the QualSyst and GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) Framework; two authors checked a 25% sample. QOL improvement or reduction was categorized. RESULTS Thirty-six studies met the eligibility criteria studying 20 unique interventions. Designs included 1 randomized controlled trial, 1 cross-sectional study, and 34 cohort studies. Patient-reported symptom monitoring increased QOL significantly in cancer patients in a randomized controlled trial. Dexmedetomidine, methadone, ventilation, pleurodesis, and palliative care were significantly associated with improved QOL, and chemotherapy, stem cell transplant, and hospitalization with reduced QOL, in cohort studies. CONCLUSIONS Use of patient-controlled symptom feedback, multidisciplinary palliative care teams with full-time practical support, inhalation therapy, and off-label sedative medication may improve QOL. Curative therapy may reduce QOL. IMPACT QOL for children at the end of life may be improved with patient-controlled symptom feedback, multidisciplinary palliative care teams with full-time practical support, inhalation therapy, and off-label sedative medication. QOL for children at the end of life may be reduced with therapy with a curative intent, such as curative chemotherapy or stem cell transplant. A comprehensive overview of current evidence to elevate currently often-failing QOL management for children at the end of life. New paradigm-level indicators for appropriate and inappropriate QOL management in children at the end of life. New hypotheses for future research, guided by the current knowledge within the field. Various healthcare interventions (as described above) could or might be employed as tools to provide relief in QOL management for children with serious illness, such as cancer, at the end of life, and therefore could be discussed in pediatrician end-of-life training to limit the often-failed QOL management in this population, cave the one-size-fits-all approach for individual cases. Multidisciplinary team efforts and 24/7 presence, especially practical support for parents, might characterize effective palliative care team interventions for children with serious illness at the end of life, suggesting a co-regulating link between well-being of the child partly to that of the parents Hypothesis-oriented research is needed, especially for children with nonmalignant disorders, such as genetic or neurological disorders at the end of life, as well as QOL outcomes for intervention research and psychosocial or spiritual outcomes.
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Affiliation(s)
- Veerle Piette
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels Health Campus-Building K Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Public Health and Primary Care, Universitair Ziekenhuis Gent, Ghent University, Entrance 42 (K3), 6th floor, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels Health Campus-Building K Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Universitair Ziekenhuis Gent, Ghent University, Entrance 42 (K3), 6th floor, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels Health Campus-Building K Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Universitair Ziekenhuis Gent, Ghent University, Entrance 42 (K3), 6th floor, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Nele S Pauwels
- Knowledge Centre for Health Ghent, Universitair Ziekenhuis Gent, Ghent University, Entrance 42 (K3), 1st floor Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Anne-Lore Scherrens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels Health Campus-Building K Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Universitair Ziekenhuis Gent, Ghent University, Entrance 42 (K3), 6th floor, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Jutte van der Werff Ten Bosch
- Department of Paediatrics, KidZ Health Castle Children's Hospital, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Dikke-Beuklaan 128, 1090, Brussels, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels Health Campus-Building K Laarbeeklaan 103, 1090, Brussels, Belgium.,Department of Public Health and Primary Care, Universitair Ziekenhuis Gent, Ghent University, Entrance 42 (K3), 6th floor, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Alleviating Terminal Pediatric Cancer Pain. CHILDREN-BASEL 2021; 8:children8030239. [PMID: 33808534 PMCID: PMC8003275 DOI: 10.3390/children8030239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 12/30/2022]
Abstract
Terminal cancer pain remains one of the most distressing aspects of pediatric oncology practice. Opioids are the cornerstone of cancer pain management at end-of-life and fortunately, most pain at end-of-life can be managed successfully. This article presents a practical step-by-step approach to alleviating pediatric terminal cancer pain, which can be delivered across settings.
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Oostendorp LJM, Rajapakse D, Kelly P, Crocker J, Dinsdale A, Fraser L, Bluebond-Langner M. Documentation of breakthrough pain in narrative clinical records of children with life-limiting conditions: Feasibility of a retrospective review. J Child Health Care 2019; 23:564-578. [PMID: 30463428 PMCID: PMC7323830 DOI: 10.1177/1367493518807312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This study explored the feasibility of generating reliable information on the frequency, nature and management of breakthrough pain (BTP) in children with life-limiting conditions and life-threatening illnesses (LTIs) from narrative clinical records. In the absence of standardized ways for documenting BTP, we conducted a consensus exercise to develop a glossary of terms that could denote BTP in the records. Thirteen clinicians who contributed to the records reached consensus on 45 terms which could denote BTP, while emphasizing the importance of contextual information. The results of this approach together with guidance for improving the reliability of retrospective reviews informed a data extraction instrument. A pilot test of this instrument showed poor agreement between raters. Given the challenges encountered, we do not recommend a retrospective review of BTP using narrative records. This study highlighted challenges of data extraction for complex symptoms such as BTP from narrative clinical records. For both clinical and research purposes, the recording of complex symptoms such as BTP would benefit from clear criteria for applying definitions, a more structured format and the inclusion of validated assessment tools. This study also showed the value of consensus exercises in improving understanding and interpretation of clinical notes within a service.
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Affiliation(s)
- Linda JM Oostendorp
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, University College London, London, UK
| | - Dilini Rajapakse
- Louis Dundas Centre for Oncology Outreach and Children’s Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Paula Kelly
- Louis Dundas Centre for Oncology Outreach and Children’s Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Joanna Crocker
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, University College London, London, UK,Health Experiences Institute, University of Oxford, London, UK
| | - Andrew Dinsdale
- Louis Dundas Centre for Oncology Outreach and Children’s Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, University College London, London, UK,Myra Bluebond-Langner, UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, Louis Dundas Centre for Children’s Palliative Care, 30 Guilford Street, London WC1N 1EH, UK.
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Donado C, Solodiuk J, Rangel SJ, Nelson CP, Heeney MM, Mahan ST, Ullrich C, Tsegaye B, Berde CB. Patient- and Nurse-Controlled Analgesia: 22-Year Experience in a Pediatric Hospital. Hosp Pediatr 2019; 9:129-133. [PMID: 30655310 DOI: 10.1542/hpeds.2018-0179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Pediatric pain management has rapidly changed over the last 2 decades. In this study, we describe the changing practices and adverse events (AEs) related to patient-controlled analgesia (PCA) and/or nurse-controlled analgesia (NCA) over a 22-year period. METHODS After institutional review board approval, retrospective data from a single tertiary-care pediatric hospital were collected between 1994 and 2016. Subgroup analyses were done for surgical and medical case patients. We reported the number of times that PCA and/or NCA was ordered annually, the median and interquartile ranges for age, PCA and/or NCA duration and length of stay, and AE frequencies. RESULTS Over 22 years, 32 338 PCAs and/or NCAs were ordered in this institution. Morphine and hydromorphone were used most commonly. Between 1994 and 2006, initial orders for PCA and/or NCA increased 2.5-fold. After 2007, initial orders for PCA and/or NCA rapidly decreased; after 2013, the decrease continued at a slower rate, with a total of 1007 orders in 2016. This decrease occurred despite increased hospital admissions and surgeries. Between 2007 and 2012, peripheral nerve blocks rapidly increased (10-fold). After 2002, 146 AEs were reported (1.0%). Of those, 50.5% were nonintercepted, and 20.6% were intercepted AEs; 5.5% and 6.2% were preventable and nonpreventable AEs, respectively. CONCLUSIONS PCA and/or NCA usage continues to be common in pediatric patients, although usage has declined and stabilized in the setting of other emerging methods of analgesia and increases in the number of minimally invasive surgical procedures. The overall rate of AEs was extremely low. However, improvements to eliminate all errors are needed, especially with medications with a great risk of harm (such as opioids).
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Affiliation(s)
- Carolina Donado
- Departments of Anesthesiology, Critical Care, Pain Medicine.,Departments of Anesthesia and
| | - Jean Solodiuk
- Departments of Anesthesiology, Critical Care, Pain Medicine.,Departments of Anesthesia and
| | | | | | - Matthew M Heeney
- Cancer and Blood Disorders Center and.,Cancer and Blood Disorders Center, and.,Department of Cancer and Blood Disorders Center, and
| | - Susan T Mahan
- Orthopedic Surgery.,Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts; and
| | - Christina Ullrich
- Department of Cancer and Blood Disorders Center, and.,Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Binyam Tsegaye
- Anesthesiology Information Technology, Boston Children's Hospital, Boston, Massachusetts
| | - Charles B Berde
- Departments of Anesthesiology, Critical Care, Pain Medicine, .,Departments of Anesthesia and
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Nijland L, Schmidt P, Frosch M, Wager J, Hübner-Möhler B, Drake R, Zernikow B. Subcutaneous or intravenous opioid administration by patient-controlled analgesia in cancer pain: a systematic literature review. Support Care Cancer 2018; 27:33-42. [PMID: 30056529 DOI: 10.1007/s00520-018-4368-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT Opioids administered by various routes are a mainstay of tumour-related pain management. Subcutaneous or intravenous patient-controlled analgesia (PCA) with opioids is an appropriate and safe form of treatment for postoperative pain but studies on this form of administration are sparse in the setting of cancer pain despite widespread use. OBJECTIVE To evaluate the published studies on opioids administered by subcutaneous and intravenous patient-controlled analgesia for patients with cancer pain. METHODS Articles were identified from the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 7, 2016), PubMed (Medline; 1975 to 2016) and EMBASE (1974 to 2016). Additional reports were identified from the reference lists of retrieved papers. Studies based on original data with a focus on intravenous or subcutaneous PCA administration of opioids in patients suffering from cancer-related pain were selected. The language was restricted to Dutch, English or German. Predefined information was extracted depending on the topic. RESULTS Fifty studies published since 1980 met the inclusion criteria. A wide range of study designs, study quality and research objectives were observed. The studies indicated use of standard or by proxy PCA in the inpatient and outpatient setting were safe and useful while significant adverse effects were rarely observed. CONCLUSION This systematic review of the current evidence suggests PCA can be appropriately used in a wide range of clinical situations.
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Affiliation(s)
- Lisa Nijland
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany
| | - Pia Schmidt
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany
| | - Michael Frosch
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany
| | - Julia Wager
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany
| | - Bettina Hübner-Möhler
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany
| | - Ross Drake
- Starship Children's Health, Auckland, New Zealand
| | - Boris Zernikow
- Department of Children's Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany.
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Madden K, Park M, Liu D, Bruera E. Practices, Attitudes, and Beliefs of Palliative Care Physicians Regarding the Use of Methadone and Other Long-Acting Opioids in Children with Advanced Cancer. J Palliat Med 2018; 21:1408-1413. [PMID: 29893627 DOI: 10.1089/jpm.2017.0670] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND Palliative care physicians often assist with pain management in children with cancer, but little is known about how they use long-acting opioids for chronic pain with these patients. OBJECTIVE To determine the practices, attitudes, and beliefs of palliative care physicians toward the use of long-acting opioids in children with advanced cancer. DESIGN An electronic survey was sent to all members of The American Academy of Pediatrics (AAP) Section of Hospice and Palliative Medicine (SOHPM) and those identified as physicians who provide palliative care to children on the AAP SOHPM LISTSERV®. RESULTS The response rate to the survey was 62% (116/188). A majority (66% [77/116]) of physicians are board certified in both pediatrics and hospice and palliative medicine. This represents 28% of all board-certified pediatric palliative care physicians. Most palliative care physicians report comfort in using long-acting opioids in children (84-94%), with the exception of long-acting hydromorphone (37%). Physicians perceived methadone as least costly (3%) but associated it with a higher perceived family resistance (51%). As compared with pediatric palliative care fellowship-trained physicians, nonpediatric fellowship-trained physicians perceived titration of oxycodone ER and morphine ER to be easier (p = 0.06, p = 0.07) and less likely to agree that the main reason for starting methadone is that the existing formulations of other long-acting opioids are unsuitable for children (p = 0.05). CONCLUSIONS Most physicians who provide palliative care to children are comfortable using opioids but there is significant variation in the level of comfort with different opioids. This information will be helpful in developing targeted education for palliative care providers.
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Affiliation(s)
- Kevin Madden
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
| | - Minjeong Park
- 2 Department of Biostatistics, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
| | - Diane Liu
- 2 Department of Biostatistics, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas , M.D. Anderson Cancer Center, Houston, Texas
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10
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Thomas R, Phillips M, Hamilton RJ. Pain Management in the Pediatric Palliative Care Population. J Nurs Scholarsh 2018; 50:375-382. [PMID: 29729653 DOI: 10.1111/jnu.12389] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this integrative review was to identify, review, synthesize, and analyze the current literature related to pain management in the pediatric palliative care population from infancy through adolescence. METHODS The literature was searched for the terms palliative, pediatric, and pain in PubMed, PsycINFO, Cumulative Index to Nursing and Allied HeALTH LITERATUre (CINAHL) Complete, and Google Scholar. The search was limited to papers in English that had been published from January 1, 2005, to December 31, 2016. RESULTS These searches resulted in 918 articles, of which 29 met inclusion criteria. These 29 articles were reviewed and reported. Four broad themes emerged: patient and family experience, pain assessment, pharmacological pain management, and nonpharmaceutical interventions. CONCLUSIONS Gaps in current research have been identified, such as investigating pediatric pain scales for the palliative care population and new complementary and alternative medical therapy and other interventions. More research is needed to bring innovative pain management interventions to the attention of pediatric caregivers. CLINICAL RELEVANCE A better understanding of current research on pain in the pediatric palliative care population can improve patient care and lead to better research in this specialty field.
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Affiliation(s)
- Rene Thomas
- Doctoral Student, Rush University College of Nursing, Chicago, IL, USA
| | - Marcia Phillips
- Assistant Professor, Department of Adult Health and Gerontological Nursing, Rush University College of Nursing, Chicago, IL, USA
| | - Rebekah J Hamilton
- Professor, Department of Women, Children, and Family Nursing, Rush University College of Nursing, Chicago, IL, USA
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11
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Faerber J, Zhong W, Dai D, Baehr A, Maxwell LG, Kraemer FW, Feudtner C. Comparative Safety of Morphine Delivered via Intravenous Route vs. Patient-Controlled Analgesia Device for Pediatric Inpatients. J Pain Symptom Manage 2017; 53:842-850. [PMID: 28062336 DOI: 10.1016/j.jpainsymman.2016.12.328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 11/18/2016] [Accepted: 12/23/2016] [Indexed: 11/18/2022]
Abstract
CONTEXT Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. OBJECTIVES This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database. METHODS We assembled a retrospective cohort of pediatric inpatients between five and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System database. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and nonsurgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to two days after drug administration. RESULTS Surgical and nonsurgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to two days after PCA exposure, although these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20%-44% lower odds of same day CPR in both surgical and nonsurgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients. CONCLUSION In this large pediatric inpatient population, morphine administered via PCA device for surgical and nonsurgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.
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Affiliation(s)
- Jennifer Faerber
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wenjun Zhong
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Dingwei Dai
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Avi Baehr
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis Wickham Kraemer
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Abstract
Pain is a common and highly distressing symptom in pediatric patients with advanced malignancies. Prompt recognition, assessment, and treatment of pain are necessary, especially at the end of life. Opioid medications remain the mainstay of treatment of malignant pain in children at the end of life and the amount of opioids required for adequate pain control in patients is highly variable. Nonpharmacological approaches including behavioral and physical approaches in addition to non-opioid pain medications should be used when possible to augment pain control. Identification and treatment of any underlying pathology is important and use of adjuvant medications based on pathophysiology and source of pain should be considered. In cases where adequate pain control is not achieved through these multiple modalities, an interdisciplinary approach including potential interventional techniques and alternative treatments is required. This multimodal approach to pain management is best provided by interdisciplinary teams, as these teams can best address the complex causes of pain and associated distress that occurs in patients and within families.
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13
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Montgomery K, Sawin KJ, Hendricks-Ferguson VL. Experiences of Pediatric Oncology Patients and Their Parents at End of Life. J Pediatr Oncol Nurs 2015. [DOI: 10.1177/1043454215589715] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Improvement in pediatric palliative and end-of-life care has been identified as an ongoing research priority. The child and parent experience provides valuable information to guide how health care professionals can improve the transition to end of life and the care provided to children and families during the vulnerable period. The purpose of this systematic review was to describe the experience of pediatric oncology patients and their parents during end of life, and identify gaps to be addressed with interventions. A literature search was completed using multiple databases, including CINAHL, PubMed, and PsycInfo. A total of 43 articles were included in the review. The analysis of the evidence revealed 5 themes: symptom prevalence and symptom management, parent and child perspectives of care, patterns of care, decision making, and parent and child outcomes of care. Guidelines for quality end-of-life care are needed. More research is needed to address methodological gaps that include the pediatric patient and their sibling’s experience.
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Affiliation(s)
| | - Kathleen J. Sawin
- University of Wisconsin–Milwaukee, Milwaukee, WI, USA
- Children’s Hospital of Wisconsin, Milwaukee, WI, USA
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Anghelescu DL, Snaman JM, Trujillo L, Sykes AD, Yuan Y, Baker JN. Patient-controlled analgesia at the end of life at a pediatric oncology institution. Pediatr Blood Cancer 2015; 62:1237-44. [PMID: 25820345 PMCID: PMC4433603 DOI: 10.1002/pbc.25493] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 02/03/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patient controlled anesthesia (PCA) is increasingly used to manage pain in pediatric cancer patients and is important in the treatment of escalating pain at the end of life. The description of the use of opioid PCA in this population has been limited. PROCEDURE This retrospective chart review of the last 2 weeks of life addressed the following objectives: (1) to describe the patient population treated with opioid PCA; (2) to describe the morphine-equivalent doses (MED) (mg/kg/day); and (3) to describe the pain scores (PS). RESULTS Twenty-eight percent of inpatients used opioid PCA for pain control during the last 2 weeks of life. The mean MED (mg/kg/day) (SD) at 2 weeks prior and the day of death were 10.7 (17.9) and 19 (25.8). The mean MED increased over the last 2 weeks of life for all patients and across age groups and cancer diagnoses (all P < 0.05). The mean MED was significantly higher in the younger age group (age <13 vs. age ≥ 13) on the day of death (P < 0.04). There was a significant change in mean PS over the last 2 weeks of life (P < 0.001), with the highest PS on the day before death. The most frequently used concurrent medications were benzodiazepines (91%). CONCLUSIONS Children and young adults with cancer experience high opioid requirements and significant dose increases during the last 2 weeks of life. Additionally, PS increase toward the end of life. Opioid rotation and addition of adjuvant medications merit consideration in the context of escalating opioid requirements.
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Affiliation(s)
- Doralina L. Anghelescu
- Pediatric Medicine, Division of Anesthesiology; Director, Pain Management Service, St. Jude Children's Research Hospital
| | | | - Luis Trujillo
- Pediatric Medicine, Division of Anesthesiology, St. Jude Children's Research Hospital
| | - April D. Sykes
- Department of Biostatistics, St. Jude Children's Research Hospital
| | - Y Yuan
- Department of Biostatistics, St. Jude Children's Research Hospital
| | - Justin N. Baker
- Department of Oncology, St. Jude Children's Research Hospital
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The Safety and Effectiveness of Patient-controlled Analgesia in Outpatient Children and Young Adults With Cancer: A Retrospective Study. J Pediatr Hematol Oncol 2015; 37:378-82. [PMID: 26018808 PMCID: PMC4683407 DOI: 10.1097/mph.0000000000000354] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient-controlled analgesia (PCA) is safe and effective in hospitalized children; however, data regarding its use for outpatients are limited. The aims of the study are to determine the safety of outpatient PCA and to compare the standard and proxy PCA groups. METHODS All patients receiving outpatient PCA over 54 months were included in this retrospective study. Data regarding age, sex, diagnosis, PCA initiation/discontinuation circumstances, patient versus proxy-authorized PCA type, opioid doses, pain scores, and complications were collected. Nonparametric tests (Wilcoxon-Mann-Whitney test for comparing 2 groups or Kruskal-Wallis rank-sum test for comparing >2 groups) were used to compare duration of PCA use, opioid doses, pain scores, and circumstances of initiation and discontinuation of outpatient PCA. RESULTS Forty-five patients used 69 outpatient PCAs. The complication rate was 0.36%. The starting mean MED (mg/kg/d) was 1.67 when initiation was for an outpatient and 4.04 for those discharged from the hospital with PCA; this difference was not statistically significant (P=0.13). The analysis of mean opioid doses in relationship to the circumstances for the discontinuation of the outpatient PCA revealed a significantly higher dose (mg/kg/d) in the group of patients who died (19.54) than in the group with a change of status to inpatient or transfer to another hospital or hospice (3.70) and in the group in which PCA was discontinued because pain management no longer required a PCA (1.19). The mean opioid daily doses and pain scores were significantly higher at the end of life (P<0.0001). CONCLUSIONS Outpatient PCA use for children and young adults with cancer is safe.
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Mherekumombe MF, Collins JJ. Patient-controlled analgesia for children at home. J Pain Symptom Manage 2015; 49:923-7. [PMID: 25546288 DOI: 10.1016/j.jpainsymman.2014.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 10/15/2014] [Accepted: 10/22/2014] [Indexed: 11/18/2022]
Abstract
CONTEXT Pain is a common and significant symptom experienced by children with advanced malignant disease. There is limited research on pain management of these children at home. OBJECTIVES To describe and review the indications for using patient-controlled analgesia (PCA) in the form of a Computerized Ambulatory Drug Delivery device (CADD(®)) in the home setting. METHODS A retrospective chart review was conducted in children discharged home with opioid infusions using a CADD. Charts from January 2008 to February 2012 were surveyed. RESULTS Thirty-seven CADDs were dispensed during the study period, and of these, 33 were prescribed for patients with cancer-related pain. A third of the CADDs were commenced at home and almost all PCA CADDs were used for end-of-life care. Hydromorphone was the most commonly prescribed opioid. Patients remained at home and pain control was achieved by either increasing the opioid dose or switching the opioid and using adjuvant therapy. Sixteen patients were readmitted to hospital from home and three admissions were related to pain. The median duration on a PCA CADD at home was 33.7 days (range, 1-150 days), and the mean morphine equivalent dose was 2.13 mg/kg/day. CONCLUSION PCA with a CADD can be used to manage pain in the home setting. Dose adjustments and opioid switches were performed with no adverse incidents.
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Affiliation(s)
| | - John J Collins
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Sousa AM, de Santana Neto J, Guimaraes GMN, Cascudo GM, Neto JOB, Ashmawi HA. Safety profile of intravenous patient-controlled analgesia for breakthrough pain in cancer patients: a case series study. Support Care Cancer 2013; 22:795-801. [DOI: 10.1007/s00520-013-2036-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Accepted: 10/28/2013] [Indexed: 11/27/2022]
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Schiessl C, Schestag I, Sittl R, Drake R, Zernikow B. Rhythmic pattern of PCA opioid demand in adults with cancer pain. Eur J Pain 2012; 14:372-9. [DOI: 10.1016/j.ejpain.2009.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 06/23/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
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Zernikow B, Michel E, Craig F, Anderson BJ. Pediatric palliative care: use of opioids for the management of pain. Paediatr Drugs 2009; 11:129-51. [PMID: 19301934 DOI: 10.2165/00148581-200911020-00004] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pediatric palliative care (PPC) is provided to children experiencing life-limiting diseases (LLD) or life-threatening diseases (LTD). Sixty to 90% of children with LLD/LTD undergoing PPC receive opioids at the end of life. Analgesia is often insufficient. Reasons include a lack of knowledge concerning opioid prescribing and adjustment of opioid dose to changing requirements. The choice of first-line opioid is based on scientific evidence, pain pathophysiology, and available administration modes. Doses are calculated on a bodyweight basis up to a maximum absolute starting dose. Morphine remains the gold standard starting opioid in PPC. Long-term opioid choice and dose administration is determined by the pathology, analgesic effectiveness, and adverse effect profile. Slow-release oral morphine remains the dominant formulation for long-term use in PPC with hydromorphone slow-release preparations being the first rotation opioid when morphine shows severe adverse effects. The recently introduced fentanyl transdermal therapeutic system with a drug-release rate of 12.5 microg/hour matches the lower dose requirements of pediatric cancer pain control. Its use may be associated with less constipation compared with morphine use. Though oral transmucosal fentanyl citrate has reduced bioavailability (25%), it inherits potential for breakthrough pain management. However, the gold standard breakthrough opioid remains immediate-release morphine. Buprenorphine is of special clinical interest as a result of its different administration routes, long duration of action, and metabolism largely independent of renal function. Antihyperalgesic effects, induced through antagonism at the kappa-receptor, may contribute to its effectiveness in neuropathic pain. Methadone also has a long elimination half-life (19 [SD 14] hours) and NMDA receptor activity although dose administration is complicated by highly variable morphine equianalgesic equivalence (1 : 2.5-20). Opioid rotation to methadone requires special protocols that take this into account. Strategies to minimize adverse effects of long-term opioid treatment include dose reduction, symptomatic therapy, opioid rotation, and administration route change. Patient- or nurse-controlled analgesia devices are useful when pain is rapidly changing, or in terminal care where analgesic requirements may escalate. In this article, we present detailed pediatric pharmacokinetic and pharmacodynamic data for opioids, their indications and contraindications, as well as dose-administration regimens that include practical strategies for opioid switching and dose reduction. Additionally, we discuss the problem of hyperalgesia and the use of adjuvant drugs to support opioid therapy.
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Affiliation(s)
- Boris Zernikow
- Children's Hospital, Witten/Herdecke University, Vodafone Foundation Institute for Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.
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Zirkadianer Rhythmus des PCA-gesteuerten Opioidverbrauchs bei Kindern mit chemotherapiebedingter Mukositis. Schmerz 2008; 23:7-19. [DOI: 10.1007/s00482-008-0734-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Zernikow B. [Special pediatric care for dying children. IMPaCCT determines the standards for pediatric palliative care in Germany]. Schmerz 2008; 22:399-400. [PMID: 18629547 DOI: 10.1007/s00482-008-0663-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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