Care of the dying: is pain control compromised or enhanced by continuation of the fentanyl transdermal patch in the dying phase?

Current management of cancer pain in Italy: Expert opinion paper

Introduction

Chronic pain and breakthrough cancer pain (BTcP) have a high prevalence in all cancer types and cancer stages, combined with a significant physical, psychological, and economic burden. Despite efforts to improve appropriate management of cancer pain, a poor assessment and guilty undertreatment are still reported in many countries. The purpose of this expert opinion paper is to contribute to reduce and clarify these issues with a multidisciplinary perspective in order to share virtuous paths of care.

Methods

Common questions about cancer pain assessment and treatment were submitted to a multidisciplinary pool of Italian clinicians and the results were subsequently discussed and compared with the findings of the published literature.

Conclusion

Despite a dedicated law in Italy and effective treatments available, a low percentage of specialists assess pain and BTcP, defining the intensity with validated tools. Moreover, in accordance with the findings of the literature in many countries, the undertreatment of cancer pain is still prevalent. A multidisciplinary approach, more training programs for clinicians, personalised therapy drug formulations, and virtuous care pathways will be essential to improve cancer pain management.

Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life-A Systematic Literature Review

CONTEXT

Dying patients commonly experience potentially distressing symptoms. Palliative care guidelines recommend opioids, anticholinergics, antipsychotics, and benzodiazepines for symptom relief.

OBJECTIVES

The objective of this study was to systematically review the effectiveness and safety of palliative drug treatment in the last days of life of adult patients, focusing on the management of pain, dyspnea, anxiety, restlessness, and death rattle.

METHODS

A systematic search of the literature was published before December 2016 in PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Cochrane, ClinicalTrials.gov, and SveMed+. Studies on safety or effectiveness of drug therapy in dying adults with at least one outcome on symptom control, adverse effects, or survival were included. Data for included studies were extracted. Study quality was assessed using the Effective Public Health Practice Quality assessment tool for quantitative studies.

RESULTS

Of the 5940 unique titles identified, 12 studies met the inclusion criteria. Five studies assessed anticholinergics for death rattle, providing no evidence that scopolamine hydrobromide and atropine were superior to placebo. Five studies examined drugs for dyspnea, anxiety, or terminal restlessness, providing some evidence supporting the use of morphine and midazolam. Two studies examined opioids for pain, providing some support for morphine, diamorphine, and fentanyl. Eight studies included safety outcomes, revealing no important differences in adverse effects between the interventions and no evidence for midazolam shortening survival.

CONCLUSION

There is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients, and the reviewed evidence provides limited guidance for clinicians to assist in a distinct and significant phase of life.

Systematic review of the role of alternative application routes for opioid treatment for moderate to severe cancer pain: an EPCRC opioid guidelines project

The European Palliative Care Research Collaboration is updating the EAPC recommendations on opioids in cancer pain management. A systematic literature search on Medline on the use of alternative routes for opioid application identified 242 papers, with 72 publications included in the final evaluation. Two or more alternative routes of opioid application were compared in 18 papers with a total of 674 patients. The best evidence base was available for the subcutaneous route. A comparison of subcutaneous and intravenous routes found no differences, confirming both routes as feasible, effective and safe. Efficacy and safety of the rectal route was comparable to the parenteral route. The side effect profile seemed to be very similar for the subcutaneous, intravenous, rectal or transdermal routes. Local side effects were reported for rectal application as well as for subcutaneous and transdermal administration. In conclusion, the systematic review found good evidence that subcutaneous administration of morphine or other opioids is an effective alternative for cancer patients if oral treatment is not possible. However, for a number of patients intravenous, rectal or transdermal therapy will offer a good alternative to the subcutaneous route. The review found no significant differences in efficacy or side effects between the alternative application routes.

End-of-life care pathways

PURPOSE OF REVIEW

To summarize recent research findings about the use and effects of integrated care pathways for end-of-life care.

RECENT FINDINGS

Integrated care pathways designed for patients at the end of life include the Liverpool Care Pathway, used widely in the UK, and Palliative Care for Advanced Disease, developed in the USA. There is general consensus in the current literature that integrated care pathways improve standardization, continuity and collaboration among the interdisciplinary team. Although recent studies on integrated care pathways for dying patients have been predominantly descriptive, previous studies demonstrate improved symptom assessment, documentation of care goals, compliance with standardized guidelines and pain control.

SUMMARY

The use of integrated care pathways for dying patients has the potential to improve care by promoting best practice and standardizing care. In addition, these pathways may improve documentation and provide a mechanism for measuring patient outcomes. Although recent studies on the use of these integrated care pathways are descriptive, some publications have demonstrated improved patient outcomes and processes of care. As their use expands, more studies on the effects and outcomes of these care pathways are anticipated.

Caring for the Patient and the Family in the Last Hours of Life

Recognition of the signs and symptoms that are common in the final hours of life and a basic understanding of how to manage these signs and symptoms are important to helping the patient and family experience a good death in the home setting. The most common signs and symptoms, including pain, dyspnea, and terminal restlessness or delirium, and their management are discussed. Also addressed are other signs and symptoms, such as cardiovascular signs and symptoms including cold extremities, mottling, and changes in vital signs; respiratory signs and symptoms such as changes in breathing pattern, noisy breathing, and mandibular breathing; and neurological signs and symptoms such as disorientation, sensory changes, and semicomatose state. Changes in metabolism such as fatigue, surge of energy, and increased temperature are presented, along with decreased intake, excretion, and communication changes.

Clinical experience with transdermal and orally administered opioids in palliative care patients--a retrospective study

BACKGROUND

Transdermal fentanyl is a widely used opioid for the treatment of cancer pain. Simplicity of use and high patient compliance are the main advantages of this opioid. However, based on our clinical experience, transdermal fentanyl is often not efficacious in terminally ill palliative care patients. We thus retrospectively examined the pain management and need for opioid switching in cancer patients admitted to our palliative care unit.

METHODS

Of 354 patients admitted to our palliative care unit from 2004 through 2005, 81 patients were pre-treated with transdermal fentanyl. Demographic and cancer-related data (diagnosis, symptoms, pain score on a numeric rating scale (NRS)), analgesic dose at admission and discharge were compared.

STATISTICS

mean +/- SD, ANOVA, Wilcoxon's test was used for inter-group comparisons, significance P < 0.05, adjusted for multiple testing. Pain scores are given in median (range).

RESULTS

Mean transdermal fentanyl dose at admission was 81.0 +/- 55.8 microg/h. In 79 patients transdermal fentanyl treatment was discontinued. In two patients, analgesic treatment according to WHO I provided sufficient pain relief. The other 77 patients were switched to other opioids: 33 patients to oral morphine and 44 to oral hydromorphone. In patients switched to morphine the dose at discharge (104.7 +/- 89.0 mg) was lower than at admission (165.5 mg morphine equivalence). In patients switched to hydromorphone the dose of 277.8 +/- 255.0 mg morphine equivalent was higher at discharge than at admission (218.2 +/- 131.4 mg morphine equivalence--considering an equianalgesic conversion ratio morphine: hydromorphone = 7.5: 1). Pain scores decreased significantly after opioid rotation (NRS at rest/on exertion: 4 (0-10)/7 (2-10) versus 1 (0-3)/2 (0-5); P < 0.001).

CONCLUSIONS

In the patient group switched to morphine, sufficient pain relief was achieved by lower equianalgesic morphine doses, compared with the doses at admission. In the patient group switched to hydromorphone, higher equianalgesic morphine doses were needed at discharge, considering an equianalgesic conversion ratio of morphine: hydromorphone = 7.5: 1. Patients with far advanced cancer often suffer from sweating and cachexia, which may have negative effects on the absorption of transdermal fentanyl. Opioid switching to oral morphine or hydromorphone was well tolerated and proved to be an efficacious option for cancer pain treatment.

[The last phase in the progressive neoplasic disease: care at the end-of-life, refractory symptoms and sedation]

End-of-life is one of the most stressful phases during course of a neoplasic disease. Frequently, death of patients with cancer comes after a continuous and progressive physical impairment. As death approaches, the medical team might redefine outcomes and treat as priority symptoms and relief suffering. That care encompasses the physical, psychological, social, spiritual, and existential needs of patients and their families. However, symptoms are frequently observed that are intolerable for the patient and which do not respond to usual palliative measures. The intolerable nature and being refractory to treatment indicates to the health-care team, on many occasions, the need for sedation of the patient. The medical team can take comfort in the knowledge that they did their best to provide safe passage to all their patients and that, although they did not always cure them, the patients often were healed.

Respiratory Tract Secretions in the Dying Patient: A Comparison between Glycopyrronium and Hyoscine Hydrobromide

The evidence for the management of respiratory tract secretions (RTS) in dying patients with antimuscarinic drugs remains inconclusive. This study investigated the effectiveness of glycopyrronium versus hyoscine hydrobromide in controlling RTS using the Liverpool Care of the Dying Pathway (LCP) in 72 patients matched for age, diagnosis, and gender who died on a 30-bed specialist palliative care unit. All patients in the glycoypyrronium group had some response to glycopyrronium, whereas 22% of patients in the hyoscine group had no response to hyoscine hydrobromide. There was a significant difference in overall response between the two groups (p < 0.01). Twenty-eight percent of patients in the glycopyrronium and 42% of patients in the hyoscine group died with RTS present. There was no statistically significant difference in the levels of agitation following administration of either drug. This study provides further evidence that the LCP can be a useful tool in the evaluation of new drugs for symptom control in dying patients and suggests that glycopyrronium may be at least as effective in controlling RTS in dying patients as hyoscine hydrobromide.

A comparison of the resources used in advanced cancer care between two different strong opioids: an analysis of naturalistic practice in the UK

OBJECTIVE

To assess the resource implications of using strong opioids in patients with advanced cancer in the UK, based on naturalistic practice, in order to develop the evidence base supporting better management.

DESIGN AND SETTING

A modelling study performed from the perspective of the UK's National Health Service (NHS). Study participants and interventions: A data set was created from the DIN-link database comprising 986 patients with advanced cancer who were prescribed either 12-hourly sustained release morphine (SR morphine; MST Continuous) ( n = 784) or transdermal fentanyl (Durogesic) (n = 202) as their first strong opioid between 1st January 1998 and 30th September 2000 and died during that period.

METHODS

Palliative care-related resource use data were obtained from the DIN-link database. Unit costs at 2000/2001 prices were applied to the resource use values to determine the mean NHS cost of palliative care from the start of treatment until death.

RESULTS

Patients initially treated with transdermal fentanyl started their strong opioid regime 8.5 years after diagnosis compared to 6.4 years after diagnosis in those who started SR morphine. This equates to an overall survival period from diagnosis of 8.8 years and 7.4 years respectively. Nevertheless, the total NHS cost of palliative care was similar between treatment groups, ranging from a mean 3087-3462 pounds per patient. Hospitalisation accounted for up to 71% of the total cost and opioids accounted for up to a further 17%. Less than one-third of patients received 4-hourly morphine as part of their initial opioid treatment despite UK guidelines recommending that moderate-to-severe pain should always be managed initially with an immediate-release preparation. Additionally, patients who received transdermal fentanyl as part of their initial treatment received significantly more laxative prescriptions than patients who started with SR morphine.

CONCLUSIONS

SR morphine and transdermal fentanyl seem to be used in different situations. The results also confirm previous findings that pain management in cancer patients is often sub-optimal. The low contribution of opioids to the overall costs indicates that this should not be an obstacle to starting this aspect of palliative care earlier in disease progression. This characterisation of the resource implications of using SR morphine and transdermal fentanyl should enable purchasers and providers to optimise the availability of strong opioids for cancer patients on medical, economic and humanitarian grounds.

Opioid switch in palliative care, opioid choice by clinical need and opioid availability

Availability of different WHO-step 3 opioids has encouraged the discussion on their value and led to the concepts of opioid rotation. Rotation is suggested, when other measures fail to achieve optimal analgesia and tolerability in cancer pain treatment. Opioid use was assessed in a prospective cohort study of 412 palliative care patients from 14 inpatient and outpatient palliative care facilities in Germany. The most frequently used opioids at baseline were morphine and fentanyl. The most frequent changes in medication (N=106) occurred from oral to parenteral morphine. Only in 49 cases true switches to other long acting opioids were recorded. This is far less than expected from other reports. True switches and adverse side effects were found to occur more frequently in inpatients, while efficacy problems were more frequently recorded in outpatients. There was no correlation between the opioid used at baseline and switch frequency, but numbers of cases receiving other opioids than fentanyl or morphine were low. Reasons for and frequencies of changes in medication were found to be largely shaped by the setting reflecting patients' needs and clinical necessities. Recommendation of first line therapy and availability of opioid formulations define the frequency of opioid use. This impedes evaluation of specific differences between the opioids.