Opioid needs of terminal care patients: variations with age and primary site

Differences in Fentanyl Requirements in Terminally Ill Cancer Patients

Cancer pain is a significant issue in terminally ill cancer patients (TICPs). The fentanyl patch (FP) is used extensively for treating cancer pain, but FP requirements vary between patients. We aimed to identify determinants of FP requirements in TICPs and propose effective pain relief using a FP. In a retrospective chart review, we investigated cancer patients admitted to our hospital from April 2012 to July 2015 and used FP until death. The time course of FP use in TICPs until death was examined. The primary endpoint was the final dose of FP use (FDFP). In total, 79 patients were included the analysis. FDFP was inversely correlated with age (R= -0.262, p = 0.20; Spearman test). FDFP tended to be higher in males than in females and was significantly higher in patients with pancreatic cancer than in patients without pancreatic cancer (p = 0.017; Welch's test). FP adjustments were more frequent in the last 60 days of life in patients with pancreatic cancer than in patients with other malignancies (P for interaction = 0.002; mixed effect model). In conclusion, younger age, and pancreatic cancer were associated with higher FP requirements in TICPs. TICPs with pancreatic cancer required more frequent FP adjustment near death.

Opioid and benzodiazepine use in gynecologic oncology patients

OBJECTIVE

The goals of this study were to describe opioid and benzodiazepine prescribing practices in the gynecologic oncology patient population and determine risks for opioid misuse in these patients.

METHODS

Retrospective study of opioid and benzodiazepine prescriptions for patients treated for cervical, ovarian (including fallopian tube/primary peritoneal), and uterine cancers within a single healthcare system from January 2016 to August 2018.

RESULTS

A total of 7643 prescriptions for opioids and/or benzodiazepines were dispensed to 3252 patients over 5754 prescribing encounters for cervical (n=2602, 34.1%), ovarian (n=2468, 32.3%), and uterine (n=2572, 33.7%) cancer. Prescriptions were most often written in an outpatient setting (51.0%) compared with inpatient discharge (25.8%). Cervical cancer patients were more likely to have received a prescription in an emergency department or from a pain/palliative care specialist (p=0.0001). Cervical cancer patients were least likely to have prescriptions associated with surgery (6.1%) compared with ovarian cancer (15.1%) or uterine cancer (22.9%) patients. The morphine milligram equivalents prescribed were higher for patients with cervical cancer (62.6) compared with patients with ovarian and uterine cancer (46.0 and 45.7, respectively) (p=0.0001). Risk factors for opioid misuse were present in 25% of patients studied; cervical cancer patients were more likely to have at least one risk factor present during a prescribing encounter (p=0.0001). Cervical cancer was associated with a higher number of risk factors (p<0.001).

CONCLUSIONS

Opioid and benzodiazepine prescribing patterns differ for cervical, ovarian, and uterine cancer patients. Gynecologic oncology patients are overall at low risk for opioid misuse; however, patients with cervical cancer are more likely to have risk factors present for opioid misuse.

Predicting transdermal fentanyl delivery using physics-based simulations for tailored therapy based on the age

Transdermal fentanyl patches are an effective alternative to the sustained release of oral morphine for chronic pain management. Due to the narrow therapeutic range of fentanyl, the concentration of fentanyl in the blood needs to be carefully monitored. Only then can effective pain relief be achieved while avoiding adverse effects such as respiratory depression. This study developed a physics-based digital twin of a patient by implementing drug uptake, pharmacokinetics, and pharmacodynamics models. The twin was employed to predict the in-silico effect of conventional fentanyl transdermal in a 20–80-year-old virtual patient. The results show that, with increasing age, the maximum transdermal fentanyl flux and maximum concentration of fentanyl in the blood decreased by 11.4% and 7.0%, respectively. However, the results also show that as the patient's age increases, the pain relief increases by 45.2%. Furthermore, the digital twin was used to propose a tailored therapy based on the patient's age. This predesigned therapy customized the duration of applying the commercialized fentanyl patches. According to this therapy, a 20-year-old patient needs to change the patch 2.1 times more frequently than conventional therapy, which leads to 30% more pain relief and 315% more time without pain. In addition, the digital twin was updated by the patient's pain intensity feedback. Such therapy increased the patient's breathing rate while providing effective pain relief, so a safer treatment. We quantified the added value of a patient's physics-based digital twin and sketched the future roadmap for implementing such twin-assisted treatment into the clinics.

A systematic review of the risk factors for clinical response to opioids for all-age patients with cancer-related pain and presentation of the paediatric STOP pain study

BACKGROUND

Inter-patient variability in response to opioids is well known but a comprehensive definition of its pathophysiological mechanism is still lacking and, more importantly, no studies have focused on children. The STOP Pain project aimed to evaluate the risk factors that contribute to clinical response and adverse drug reactions to opioids by means of a systematic review and a clinical investigation on paediatric oncological patients.

METHODS

We conducted a systematic literature search in EMBASE and PubMed up to the 24th of November 2016 following Cochrane Handbook and PRISMA guidelines. Two independent reviewers screened titles and abstracts along with full-text papers; disagreements were resolved by discussion with two other independent reviewers. We used a data extraction form to provide details of the included studies, and conducted quality assessment using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

Young age, lung or gastrointestinal cancer, neuropathic or breakthrough pain and anxiety or sleep disturbance were associated to a worse response to opioid analgesia. No clear association was identified in literature regarding gender, ethnicity, weight, presence of metastases, biochemical or hematological factors. Studies in children were lacking. Between June 2011 and April 2014, the Italian STOP Pain project enrolled 87 paediatric cancer patients under treatment with opioids (morphine, codeine, oxycodone, fentanyl and tramadol).

CONCLUSIONS

Future studies on cancer pain should be designed with consideration for the highlighted factors to enhance our understanding of opioid non-response and safety. Studies in children are mandatory.

TRIAL REGISTRATION

CRD42017057740 .

Pattern of symptoms and symptomatic treatment in adults and the aged population: a retrospective analysis of advanced cancer patients followed at home

Context Data regarding symptom burden and symptomatic drugs in palliative population in different classes of age are lacking. Objective The aim of this retrospective study was to assess the symptom burden, and the profile of symptomatic drugs in the last four weeks of life in adults and older cancer patients followed at home. Methods Charts of 412 patients were retrospectively analyzed by using a backward analysis. Patients were divided into three groups: adults (<65 years, A), old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Results At -4W Karnofsky status was significantly lower for older people (p = 0.03). No significant effect of age on the vector of symptoms was found (p = 0.07). A significant decrease in intensity of pain and nausea, and an increase in intensity of all other symptoms was found through the four weeks of the study (p = 0.00). No differences of drug pattern among the age categories were found. The use of symptomatic drugs decreased over time, except for opioids. Age statistically affected NSAID use, neuroleptic use, and antiemetics over time. Conclusion The burden of symptoms worsened in the last four weeks of life, except for pain and nausea, but did not differ among the age subgroups. The use of NSAIDs, neuroleptics, and antiemetics changed, while the frequency of opioid use was unchanged until death.

Morphine-methadone opioid rotation in cancer patients: analysis of dose ratio predicting factors

The dose ratio that is effective when switching opioid therapy from morphine to methadone in cancer patients varies widely. There are no conclusive data explaining the source of this variability. We analyzed 54 cancer patients undergoing opioid rotation to clarify those factors that influenced the morphine/methadone dose ratio (MMEDR) at Day 10 after the switch. Reasons for switching were uncontrolled pain (10 patients) or side effects (with or without pain, 44 patients). Initial MMEDR was 5:1 or 10:1 (82% or 18% of patients, respectively). Multivariate regression analysis was used to identify the demographic, cancer-related, and treatment-related variables that were potential predictors of MMEDR. Median previous morphine dose for the entire sample was 220 mg/day (range: 30-1000 mg/day). The stable MMEDR median was 5:1 (range: 2:1-15:1). In the univariate analysis, reasons for opioid rotation, age, and previous morphine doses were associated with MMEDR. Multiple linear regression analysis showed that only the reason for switching (pain vs. side effects; P<0.001) and previous morphine doses (lower vs. upper to 300 mg/day; P<0.001) were associated with MMEDR. From this analysis, the MMEDRs for patients rotated for side effects at 300 mg/day or more or less than 300 mg/day of morphine were 9.1:1 or 5.6:1, respectively, and the MMEDRs for those switched for pain at 300 mg/day or more or less than 300 mg/day of morphine were 4.9:1 or 3:1, respectively. Both the reasons for opioid rotation and previous morphine doses are predictive factors and should be used to select the MMEDR more accurately.

[Influence of body weight, age, and primary tumor site on opioid dose in advanced cancer pain patients]

AIM

The aim of this study was to evaluate the relationship between maximum opioid dose and body weight, age, and primary site in terminal cancer patients in a palliative care unit.

METHODS

Medical records of 152 terminal cancer patients were reviewed retrospectively. Body weight, primary tumor site, age, and analgesic state were used as independent variables, and the maximum opioid dose was used as a dependent variable.

RESULTS

There was no correlation between body weight and maximum opioid requirement. Selected independent variables were age and location of the primary lesion in the lower gastrointestinal tract. Maximum opioid dose was negatively correlated with age (P < or =0.0001). Opioid needs of age <65 was 344.2 mg/day oral morphine equivalent, but age 65-74 was 168.5, and age > or =75 was 116.9 mg/day.

CONCLUSION

Elderly cancer patients required a lower amount of opioid analgesia than younger adults. The ratio for age <65, 65-74, and > or =75 was about 1:1/2:1/3.

Pharmacological Management of Cancer Pain in the Elderly

Existing studies indicate a high prevalence rate and poor management of cancer pain in the elderly. Pain is often considered an expected concomitant of aging, and older patients are considered more sensitive to opioids. Despite the well known pharmacokinetic changes in the elderly, the complex network of factors involved in the opioid response make the evaluation of a single element, such as age, more difficult. Notwithstanding such difficulties, appropriate analgesic treatment is able to control cancer pain in the elderly in most cases. Skills necessary to optimise pain control in older cancer patients include the ability to objectively assess functional age (not necessarily related to chronological age since the rate of decline is variable), understand the impact of coexisting conditions, carefully manage the numbers and types of drugs taken at the same time and adequately communicate with patients and relatives. The most common treatment of cancer pain consists of the use of regularly given oral analgesics. The elderly are at increased risk of developing toxicity from NSAIDs, and the overall safety of these drugs in frail elderly patients should be considered. When older patients have clear contraindications to NSAIDs, manifest signs of toxicity from these agents, or find that pain is no longer controlled with this class of drugs, opioids should be started. A variety of opioids are available, and they differ widely with respect to analgesic potency and adverse effects among the elderly. Although the aged population requires lower doses of opioids, only careful titration based on individual response can ensure the appropriate response to clinical demand. Elderly patients are potentially more likely to be affected by opioid toxicity because of the physiological changes associated with aging. Nevertheless, appropriate dosage and administration may limit these risks. Cancer patients with pain who do not respond to increasing doses of opioids because they develop adverse effects before achieving acceptable analgesia may be switched to alternative opioids. Despite the favourable effects reported with opioid switching, monitoring is crucial, particularly in the elderly or patients who are switched from high doses of opioids. Adjuvant analgesics, including antidepressants, antiepileptics, corticosteroids and bisphosphonates may help in the treatment of certain types of chronic pain. With an appropriate and careful approach, it should be possible to reduce or eliminate unrelieved cancer pain in most elderly patients and, consequently, to enhance their quality of life. Older patients with cancer should be continuously assessed for cancer pain, both before and after analgesic treatment.

The use of benzodiazepines in palliative care

BACKGROUND

Benzodiazepines are widely used in palliative care, but few studies have attempted to study their use.

AIM

To determine the frequency and nature of benzodiazepine prescribing in a palliative care setting.

METHOD

The notes of a consecutive series of 100 patients who had died or been discharged from the hospice were studied. Demographic, illness and prescription data were noted. The indication for the administration of benzodiazepines, their effectiveness and any adverse effects were recorded.

RESULTS

Notes were found on 93 patients. Some 54 (58%) were prescribed benzodiazepines either by the hospice or their General Practitioner. Younger patients and those on opioids or antipsychotics were more likely to be prescribed benzodiazepines. Most administration of benzodiazepines occurred within the last three weeks of life in response to symptoms of anxiety or less specific distress.

CONCLUSIONS

A relatively high proportion of patients was prescribed benzodiazepines. The role of benzodiazepines at different stages of palliative care merits further study.

The terminal cancer patient: effects of age, gender, and primary tumor site on opioid dose

OBJECTIVE

The objective of the current study is to describe correlations between age, gender, and primary cancer site and sustained-release opioid doses prescribed for hospice patients at the end of life.

PATIENTS AND SETTING

This study included all 7,201 hospice patients referred to a North American palliative care specialty pharmacy with the primary diagnosis of cancer and who were prescribed transdermal fentanyl, sustained-release oral morphine, or sustained-release oxycodone.

DESIGN

This is a retrospective analysis of the final sustained-release morphine, oxycodone, or transdermal fentanyl doses prescribed to cancer patients, according to pharmacy records. Comparisons between sex and age group were performed with chi-square tests. Mann-Whitney U tests were used to compare mean doses between the sexes. Analyses of covariance (ANCOVA) were used to compare opioid doses between genders and among primary cancer sites while controlling for age.

RESULTS

The inverse association between age group and dose was highly significant. For example, final opioid doses </=120 mg/day oral morphine equivalent were prescribed for only 46.4% of patients between 40 and 49 years of age compared with 86.4% of patients 90 years of age and older. An ANCOVA on the largest non-sex-related diagnoses found primary tumor site and patient age, but not gender, to be associated with sustained-release opioid dose.

CONCLUSIONS

Both primary tumor site and patient age were associated with final opioid dose. Further investigation is warranted to determine which primary tumor sites are associated with unusually high opioid doses and may highlight the need to optimize adjuvant medication therapy if neuropathic and/or inflammatory pain mechanisms are involved and to refer to pain specialists when appropriate.

Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatmentm

OBJECTIVES

To evaluate the pain experience of seriously ill hospitalized patients and their satisfaction with control of pain during hospitalization. To understand the relationship of level of pain and dissatisfaction with pain control to demographic, psychological, and illness-related variables.

DESIGN

Prospective, cohort study.

SETTING

Five teaching hospitals.

PATIENTS

Patients for whom interviews were available about pain (n = 5,176) from a total of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were interviewed after study enrollment about their experiences with pain. When patients could not be interviewed due to illness, we used surrogate (usually a family member) responses calibrated to patient responses (from the subset of interviews with both patient and surrogate responses). Ordinal logistic regression was used to study the association of variables with level of pain and satisfaction with its control. Nearly 50% of patients reported pain. Nearly 15% reported extremely severe pain or moderately severe pain occurring at least half of the time, and nearly 15% of those patients with pain were dissatisfied with its control. After adjustment for confounding variables, older and sicker patients reported less pain, while patients with more dependencies in activities of daily living, more comorbid conditions, more depression, more anxiety, and poor quality of life reported more pain. Patients with colon cancer reported more pain than patients in other disease categories. Levels of reported pain varied among the five hospitals and also by physician specialty. After adjustment for confounding variables, dissatisfaction with pain control was more likely among patients with more severe pain, greater anxiety, depression, and alteration of mental status, and lower reported income; dissatisfaction with pain control also varied among study hospitals and by physician specialty.

CONCLUSIONS

Pain is common among severely ill hospitalized patients. The most important variables associated with pain and satisfaction with pain control were patient demographics and those variables that reflected the acute illness. Pain and satisfaction with pain control varied significantly among study sites, even after adjustment for many potential confounders. Better pain management strategies are needed for patients with the serious and common illnesses studied in SUPPORT.

Dose changes in long- and medium-term intrathecal morphine therapy of cancer pain

Intrathecal morphine analgesia for the treatment of cancer pain was administered using implanted ports and drug delivery systems (DDS) in 79 patients. Effective control of the pain was achieved in nearly all patients; in only two patients was the use of the DDS discarded because of relative ineffectiveness. Fifty-three manual drug release systems (41 lumbar, 12 ventricular) and 26 lumbar ports were used. Forty patients survived more than 2 months; the maximum survival time was 560 days (mean survival time, 80 days with a port system, 100 days with a manual DDS). Patients still alive at the time of this study, i.e., with unknown survival time, were excluded. The initial mean daily dose was 8.5 mg in lumbar ports, 2.75 mg in lumbar DDS, and 0.2 mg with intraventricular application. Dose change patterns disclosed no alteration of the initial dose in 18 of 26 port patients, an initial increase in 4, a preterminal increase in 3, and a single intermittent increase in 1 patient. Of 40 lumbar DDS patients, 13 showed a constant dose, 9 an initial, 3 a preterminal, and 5 an intermittent increase. Three patients with less than 2 months' survival time had a rather continuous increase. All long-time survivors (i.e., with more than 2 months' survival time) reached a plateau and remained there until a preterminal if any increase occurred. These findings suggest the morphine dosage to be indicative of the progress of the disease rather than of a drug tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)