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Loosen SH, Schwartz J, Grewe S, Krieg S, Krieg A, Luedde T, Batzler YN, Kostev K, Neukirchen M, Roderburg C. Drug landscape in patients receiving general outpatient palliative care in Germany: results from a retrospective analysis of 10,464 patients. BMC Palliat Care 2023; 22:118. [PMID: 37596590 PMCID: PMC10439623 DOI: 10.1186/s12904-023-01231-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 07/19/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND According to § 27 and § 87 1b of the German Social Code, Book V, general outpatient palliative care (GOPC) aims to promote, maintain, and improve the quality of life and self-determination of seriously ill people. It should enable them to live in dignity until death in their preferred environment. Instead of a curative approach GOPC treatment focuses on the multiprofessional objective of alleviating symptoms and suffering on a case-by-case basis using medication or other measures, as well as the management of an individual treatment plan. The aim of this study was therefore to investigate to what extent medication differs from 12 months prior GOPC treatment within 12 months following GOPC treatment. METHODS A retrospective database cross sectional study based on the IQVIA Disease Analyzer (DA) was performed, including adult patients with cancer diagnosis and at least one documentation of palliative support between January 1st, 2018 and December 31st, 2021, in 805 general practices (GP). RESULTS The results of this study show, that in the context of general general outpatient palliative care, there is a significant increase in the prescription of opioids (18.3% vs. 37.7%), sedatives (7.8% vs. 16.2%) and antiemetics (5.3% vs. 9.7%), as well as a significant reduction in other medications such as statins (21.4% vs. 11.5%), proton pump inhibitors (PPI) (41.2% vs. 35.3%), or antihypertensives (57.5% vs. 46.6%). CONCLUSIONS Our results support the role of GOPC as an important element in improving pharmacological symptom control and deprescription to improve quality of life of patients at the end of their life.
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Affiliation(s)
- Sven H Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
| | - Jacqueline Schwartz
- Interdisciplinary Center for Palliative Medicine, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Duesseldorf, Germany
| | - Steven Grewe
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Sarah Krieg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Andreas Krieg
- Department of Surgery (A), Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine- University Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Yann-Nicolas Batzler
- Interdisciplinary Center for Palliative Medicine, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Duesseldorf, Germany
| | | | - Martin Neukirchen
- Interdisciplinary Center for Palliative Medicine, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Duesseldorf, Germany
- Department of Anesthesiology, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of Heinrich, University Hospital Duesseldorf, Heine University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
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Borders JR, Letvak S, Amirehsani KA, Ross R, Phifer N. Opioid epidemic and prescribing in hospice and palliative care: a review of the literature. Int J Palliat Nurs 2021; 27:255-261. [PMID: 34292770 DOI: 10.12968/ijpn.2021.27.5.255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Rising rates of opioid abuse worldwide have led to the implementation of policies to curb opioid prescribing. It is unknown what impact these policies have on prescribing within the setting of hospice and palliative care. OBJECTIVES To determine the current state of the science of opioid prescribing in hospice and palliative care in relation to the opioid epidemic and associated policies. METHODS A systematic integrative literature review was conducted using the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest Central and SCOPUS. RESULTS Most of the existing literature examines physician perspectives related to opioid prescribing in primary care settings. Ample evidence exists that policies can and do affect rates of opioid prescribing in specialties outside of hospice and palliative care. There is limited evidence to suggest how these policies affect opioid prescribing in hospice and palliative care. However, the available evidence suggests that opioids are necessary in hospice and palliative care in order to manage pain. CONCLUSION Further research is necessary to examine the possible negative impact of the opioid epidemic on opioid prescribing in hospice and palliative care.
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Affiliation(s)
- Joshua R Borders
- Lecturer, School of Nursing, University of North Carolina at Greensboro
| | - Susan Letvak
- Professor, School of Nursing, University of North Carolina at Greensboro
| | - Karen A Amirehsani
- Assistant Professor, School of Nursing, University of North Carolina at Greensboro
| | - Ratchneewan Ross
- Professor, School of Nursing, University of North Carolina at Greensboro
| | - Nancy Phifer
- Palliative Care Physician, University of North Carolina at Greensboro
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Coons LM, Gardea Hart J, White A, Summers S. Naloxone Prescribing and Education in Outpatient Pain Management and Palliative Care. J Pain Palliat Care Pharmacother 2021; 35:100-105. [PMID: 33844624 DOI: 10.1080/15360288.2020.1843587] [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: 10/21/2022]
Abstract
Over the past two decades, opioid use and overdose have increased substantially. Naloxone, an opioid overdose reversal agent, has been one of many risk mitigation strategies for preventing mortality due to overdose. Most literature describing naloxone utilization has been about populations of illicit drug users and patients in hospitals, primary care, and pharmacies. There is limited information regarding naloxone prescribing and training for opioid users in specialty pain management clinics. Furthermore, there are no known publications concerning patients receiving palliative care services and overdose prevention. Pain and palliative care patients are commonly at risk of opioid overdose. In an interdisciplinary outpatient pain and palliative care clinic, pharmacists implemented naloxone prescribing and education. Eleven patients at increased risk for overdose were prescribed naloxone and educated on overdose risk factors, recognition, and management. Seven patients reported picking up their naloxone prescription from the pharmacy, and none reported using it within two weeks of the initial education. This intervention was deemed successful within the clinic, but small sample size and the pharmacist role may not be replicable within other pain and palliative care settings. It encourages further research of overdose risk and prevention in pain management and palliative care.
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Al-Shahri MZ, Abdullah A, Alansari A, Sroor M. Opioid Prescribing Patterns Before and After an Inpatient Palliative Care Consultation. Am J Hosp Palliat Care 2019; 37:738-742. [PMID: 31876160 DOI: 10.1177/1049909119897260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND To the best of our knowledge, the change in opioid prescription patterns upon referral to a palliative care team (PCT) was not previously investigated in the Middle East. OBJECTIVE This study aimed to explore the change in the pattern of opioid prescription and the pain scores before and after referring inpatients to a PCT. METHODS We conducted a retrospective review of patients' records including all inpatients ≥15 years newly referred to the PCT over a period of 21 months at King Faisal Specialist Hospital and Research Center, Riyadh. RESULTS Of 631 patients, 52.3% were females, the median age was 54 years, and 96.7% had cancer. The proportion of patients on opioids before referral (83.4%) increased to 93.3% in the postreferral period, P < .0001. Patients receiving opioids on a regular basis increased from 31.9% before referral to 49.9% after referral to the PCT, P < .0001. Morphine was the most commonly prescribed opioid on a regular basis pre- and postreferral. Upon referral, the administration of opioids through the subcutaneous route increased from 3.7% to 10.9%, P < .0001. On average, pain scores were reduced by 1 point on a 0 to 10 numeric scale within 48 hours of seeing a patient by the PCT, P < .0001. CONCLUSION Patients referred to a PCT are likely to get their opioid prescription optimized and pain scores improved shortly after the PCT involvement. Patients with cancer-related pain requiring opioids should be referred to a PCT as early as possible.
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Affiliation(s)
| | | | - Ameena Alansari
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mahmoud Sroor
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Finlay E, Rabow MW, Buss MK. Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution. Am Soc Clin Oncol Educ Book 2018; 38:111-121. [PMID: 30231351 DOI: 10.1200/edbk_200775] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.
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Affiliation(s)
- Esme Finlay
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael W Rabow
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mary K Buss
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Carmichael AN, Morgan L, Del Fabbro E. Identifying and assessing the risk of opioid abuse in patients with cancer: an integrative review. Subst Abuse Rehabil 2016; 7:71-9. [PMID: 27330340 PMCID: PMC4898427 DOI: 10.2147/sar.s85409] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The misuse and abuse of opioid medications in many developed nations is a health crisis, leading to increased health-system utilization, emergency department visits, and overdose deaths. There are also increasing concerns about opioid abuse and diversion in patients with cancer, even at the end of life. Aims To evaluate the current literature on opioid misuse and abuse, and more specifically the identification and assessment of opioid-abuse risk in patients with cancer. Our secondary aim is to offer the most current evidence of best clinical practice and suggest future directions for research. Materials and methods Our integrative review included a literature search using the key terms “identification and assessment of opioid abuse in cancer”, “advanced cancer and opioid abuse”, “hospice and opioid abuse”, and “palliative care and opioid abuse”. PubMed, PsycInfo, and Embase were supplemented by a manual search. Results We found 691 articles and eliminated 657, because they were predominantly non cancer populations or specifically excluded cancer patients. A total of 34 articles met our criteria, including case studies, case series, retrospective observational studies, and narrative reviews. The studies were categorized into screening questionnaires for opioid abuse or alcohol, urine drug screens to identify opioid misuse or abuse, prescription drug-monitoring programs, and the use of universal precautions. Conclusion Screening questionnaires and urine drug screens indicated at least one in five patients with cancer may be at risk of opioid-use disorder. Several studies demonstrated associations between high-risk patients and clinical outcomes, such as aberrant behavior, prolonged opioid use, higher morphine-equivalent daily dose, greater health care utilization, and symptom burden.
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Affiliation(s)
- Ashley-Nicole Carmichael
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura Morgan
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
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Krashin D, Murinova N, Jumelle P, Ballantyne J. Opioid risk assessment in palliative medicine. Expert Opin Drug Saf 2016; 14:1023-33. [PMID: 26084635 DOI: 10.1517/14740338.2015.1041915] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Pain management with opioids is a fundamental element of palliative medicine. Since the risks of chronic opioid therapy have emerged, a reassessment of these risks in the setting of palliative care is warranted. AREAS COVERED This article presents information about opioid-related risks including i) sedation, cognitive impairment and falls; ii) constipation; iii) addiction to opioids and associated aberrant behavior; and iv) death due to respiratory depression. For this article, the medical literature was searched using PubMed and Web of Science for appropriate terms including 'palliative care' and 'opioid risk.' Medical subject headings were used to identify suitable articles including 'Analgesics, Opioid', 'Pain/drug therapy,' 'Palliative Care' and 'Hospice Care.' Further sources were identified by following cross-references within the literature and with the help of the University of Washington library staff. EXPERT OPINION Palliation of severe pain at the end of life is probably the most widely accepted indication for chronic opioid therapy. At increased doses, adverse effects of opioids may limit or interfere with the benefits of treatment. Careful screening and follow-up will allow risk factors to be recognized and addressed when possible. The use of adjunctive treatments for pain may reduce opioid requirements and yield better outcomes.
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Affiliation(s)
- Daniel Krashin
- University of Washington, Department of Psychiatry , Box 359896, 325 Ninth Ave, Seattle, WA 98104 , USA
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Scheffey C, Kestenbaum MG, Wachterman MW, Connor SR, Fine PG, Davis MS, Muir JC. Clinic-based outpatient palliative care before hospice is associated with longer hospice length of service. J Pain Symptom Manage 2014; 48:532-9. [PMID: 24680626 DOI: 10.1016/j.jpainsymman.2013.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 10/17/2013] [Accepted: 10/30/2013] [Indexed: 12/25/2022]
Abstract
CONTEXT Outpatient nonhospice palliative care has been shown to provide many benefits to patients facing advanced illness, but such services remain uncommon in the U.S. Little is known about the association between clinic-based outpatient palliative care consultation and the timing of hospice enrollment. OBJECTIVES To determine whether there are differences in hospice length of service (LOS) between patients who were seen vs. patients who were not seen in an outpatient palliative care clinic before enrollment in hospice. METHODS Using a retrospective study of medical records, a "prior palliative care clinic" group was formed of those hospice patients who had had a nonhospice clinic-based outpatient palliative care consult before hospice admission (n = 354). For those patients, "control" hospice patients without prior clinic-based palliative care were chosen who were matched by age, gender, median income of their zip code, and diagnostic group. Both groups were restricted to patients who died while enrolled in hospice. LOS for these two groups was compared using standard statistical methods of survival analysis. RESULTS Prior palliative care clinic patients had a median LOS of 24 days, whereas control patients had a median LOS of 15 days (95% CI for difference between the medians 5-13 days). The difference between the LOS distribution curves was statistically significant by the log-rank test (P < 0.001). CONCLUSION Hospice patients who had clinic-based outpatient palliative consults before hospice enrollment tended, on average, to have a longer LOS in hospice than patients who did not.
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Affiliation(s)
| | | | - Melissa W Wachterman
- Capital Caring, Falls Church, Virginia, USA; Veterans Affairs Healthcare System, Boston, Massachusetts, USA
| | | | - Perry G Fine
- Pain Research Center, University of Utah School of Medicine, Salt Lake City, Utah, USA
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