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Lakkad M, Martin B, Li C, Harrington S, Dayer L, Painter JT. The use of gabapentinoids and opioids and risk of developing opioid-induced respiratory depression among older breast cancer survivors with neuropathic pain. J Cancer Surviv 2024; 18:917-927. [PMID: 36753003 DOI: 10.1007/s11764-023-01338-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/17/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE To estimate the combined effect of gabapentinoid and opioid therapy compared to opioid monotherapy on the risk of developing opioid-induced respiratory depression among breast cancer survivors with neuropathic pain. METHOD A nested case-control study of Medicare female breast cancer survivors with neuropathic pain receiving both opioids and gabapentinoids, opioid monotherapy, gabapentinoid monotherapy, and none of these drugs was conducted using SEER-Medicare between 2007 and 2015. Cases were survivors with respiratory depression and were matched with controls on the event date (± 1 year), age at diagnosis (± 5 years), and stage at diagnosis. Exposure to opioids and gabapentinoids was assessed 120 days before the event date. Conditional logistic regression was used to assess the impact of exposure among cases and controls. RESULTS A total of 657 cases and 11,471 controls were identified. After matching, 656 cases and 5612 controls were retained, and cases were more likely to be diagnosed with mental health disorders (24.4% vs 10.5%, p < 0.0001) than controls. In the primary adjusted analysis, combined opioids and gabapentin use were associated with an increased risk of respiratory depression compared to opioid monotherapy (Adj. OR: 1.513; 95% CI: 1.473-2.350). Additionally, under secondary analysis, combined opioids and gabapentin use were associated with an increased risk of respiratory depression compared to receiving neither of these classes. (Adj. OR: 1.595; 95% CI: 1.050-2.421). CONCLUSION There is a need for dose titration strategies of gabapentinoids and caution when co-prescribing opioids and gabapentinoids in older cancer survivors.
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Affiliation(s)
- Mrinmayee Lakkad
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #622-4, Little Rock, AR, 72205, USA
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #622-4, Little Rock, AR, 72205, USA
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #622-4, Little Rock, AR, 72205, USA
| | - Sarah Harrington
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lindsey Dayer
- Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jacob T Painter
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, #622-4, Little Rock, AR, 72205, USA.
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Lawlor P, Cohen L, Adeli SR, Besserer E, Gratton V, Murphy R, Warmels G, Bruni A, Kabir M, Noel C, Heidinger B, Anderson K, Arsenault-Mehta K, Wooller K, Lapenskie J, Webber C, Bedard D, Enright P, Desjardins I, Bhimji K, Dyason C, Iyengar A, Bush SH, Isenberg S, Tanuseputro P, Vanderspank-Wright B, Downar J, Parsons H. Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada. BMJ Open 2023; 13:e075518. [PMID: 37669840 PMCID: PMC10481717 DOI: 10.1136/bmjopen-2023-075518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVE To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic. DESIGN In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents. SETTING Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs. RESULTS The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses. CONCLUSIONS COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.
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Affiliation(s)
- Peter Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Leila Cohen
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | | | - Ella Besserer
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Valérie Gratton
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Medicine, Hopital Monfort, Ottawa, Ontario, Canada
| | - Rebekah Murphy
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Grace Warmels
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Adrianna Bruni
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Monisha Kabir
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Chelsea Noel
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Brandon Heidinger
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Koby Anderson
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | | | - Krista Wooller
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel Bedard
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Paula Enright
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Isabelle Desjardins
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Khadija Bhimji
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Claire Dyason
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Akshai Iyengar
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Sarina Isenberg
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Brandi Vanderspank-Wright
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Henrique Parsons
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
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Watanabe A, Shimada N, Ishiki H, Fujiwara N, Nojima M, Tojo A. Differences in Fentanyl Requirements in Terminally Ill Cancer Patients. J Pain Palliat Care Pharmacother 2023; 37:26-33. [PMID: 36512675 DOI: 10.1080/15360288.2022.2149667] [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: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Aya Watanabe
- Aya Watanabe, MSc, Naoki Shimada, PhD and Noriko Fujiwara, MSc, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan. Masanori Nojima, PhD, Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Arinobu Tojo, PhD, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Naoki Shimada
- Aya Watanabe, MSc, Naoki Shimada, PhD and Noriko Fujiwara, MSc, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan. Masanori Nojima, PhD, Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Arinobu Tojo, PhD, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Hiroto Ishiki
- Aya Watanabe, MSc, Naoki Shimada, PhD and Noriko Fujiwara, MSc, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan. Masanori Nojima, PhD, Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Arinobu Tojo, PhD, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Noriko Fujiwara
- Aya Watanabe, MSc, Naoki Shimada, PhD and Noriko Fujiwara, MSc, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan. Masanori Nojima, PhD, Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Arinobu Tojo, PhD, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masanori Nojima
- Aya Watanabe, MSc, Naoki Shimada, PhD and Noriko Fujiwara, MSc, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan. Masanori Nojima, PhD, Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Arinobu Tojo, PhD, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- Aya Watanabe, MSc, Naoki Shimada, PhD and Noriko Fujiwara, MSc, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan. Masanori Nojima, PhD, Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan. Arinobu Tojo, PhD, Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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Ogawa Y, Kurihara T, Sakurai M, Momma M, Nakayama H, Higuchi H, Kogo M, Kiuchi Y. Predictors of Opioid Resistance: An Investigation in Cancer Pain. J Pain Palliat Care Pharmacother 2022; 36:79-87. [PMID: 35471183 DOI: 10.1080/15360288.2022.2064033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Appropriate use of opioid analgesics according to the World Health Organization pain relief ladder has provided pain relief to many patients with cancer pain. However, a proportion of patients fail to achieve sufficient pain relief and develop opioid resistance. Individual risk factors may relate to opioid resistance. Therefore, we conducted a historical cohort study to identify risk factors for opioid resistance and to construct an index to predict it. We investigated salient factors at the time of opioid initiation in the medical records of 233 patients. The outcome was the achievement of stable pain at 14 days after opioid introduction. We identified factors contributing to opioid resistance by multivariate analysis (p < 0.05). We created a resistance score from the regression equation of the identified factors to predict opioid resistance. Forty-nine (21.0%) patients were opioid resistant without achieving the outcome. Age, neuropathic pain, and alkaline phosphatase were extracted as significant factors for opioid resistance (p < 0.05). A resistance score was created from these factors and classified into binary values, the sensitivity was 80.6% and the negative predictive value was 91.6%. The findings suggest that the resistance score could be a sensitive predictor of opioid resistance before opioid initiation.
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Tatokoro M, Matsuo N. The Impact of Aging on Symptom Prevalence and Management in Terminally ill Patients With Cancer. J Pain Symptom Manage 2022; 63:251-259. [PMID: 34508818 DOI: 10.1016/j.jpainsymman.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/19/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Abstract
CONTEXT With global population aging, the number of older patients with cancer is increasing. However, few data are available on palliative care for these patients. OBJECTIVES To evaluate differences in symptom prevalence and the need for medical interventions among patients of different ages in a palliative care unit. METHODS In this retrospective analysis, a consecutive sample of 1032 terminally ill patients with cancer were categorized into the following age ranges: <70, 70-79, 80-89, and ≥90 years. We evaluated symptom prevalence, the need for palliative medicines, opioid dose on the day before death, and the need for palliative sedation. Trend tests were used to examine whether the prevalence of findings increased or decreased with age. RESULTS As age increased, significant decreasing trends were observed in the prevalence of pain, dyspnea, fatigue, constipation, nausea, drowsiness, difficulty sleeping, anxiety, and dysuria but not in appetite loss, edema, sputum production, or delirium. As age increased, significant decreasing trends were also observed in the need for opioids, benzodiazepines, antiemetics, and anticholinergics. The median opioid doses in the <70, 70-79, 80-89, and ≥90 years age groups were 118, 72, 48, and 48 mg oral morphine equivalents/day, respectively (P < 0.0001). The need for palliative sedation showed a significant decreasing trend as age increased (P < 0.0001). CONCLUSION We found age to be inversely related to symptom prevalence and medical interventions among terminally ill patients with cancer, contributing to the understanding of the experience of older patients with cancer.
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Affiliation(s)
| | - Naoki Matsuo
- Hospice (M.T., N.M.), Sotoasahikawa Hospital, Akita, Japan
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Arai YCP, Nishihara M, Ikemoto T, Mori N, Maeda K, Yasunaga C, Toda M, Kondo M, Ejiri M, Kato R. Thoracic Paravertebral Neurolysis for the Treatment of Intractable Chest Wall Pain Caused by Neoplasms: A Case Series. PAIN MEDICINE 2021; 22:2133-2135. [PMID: 34270749 DOI: 10.1093/pm/pnaa462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Young-Chang P Arai
- Multidisciplinary Pain Center, School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Makoto Nishihara
- Multidisciplinary Pain Center, School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Tatsunori Ikemoto
- Multidisciplinary Pain Center, School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Naoharu Mori
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Keisuke Maeda
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Chiharu Yasunaga
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | | | - Miki Kondo
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masayuki Ejiri
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Ryoko Kato
- Department of Palliative and Supportive Medicine, Graduate School of Medicine, Aichi Medical University, Nagakute, Aichi, Japan
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Effects of age and gender in patients receiving doses of opioids for breakthrough pain proportional to background opioid doses. Support Care Cancer 2019; 28:3813-3818. [PMID: 31832823 DOI: 10.1007/s00520-019-05227-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
AIM To identify the role of age and gender in analgesic and adverse effects after administering fentanyl products for breakthrough pain (BT), given in doses proportional to opioid doses given for background pain. METHODS Data from nine studies, in which patients with BP were given fentanyl products in doses proportional to their basal opioid regimen, were analyzed. RESULTS A total 462 patients presenting 1905 episodes of BP were included in this analysis. In older patients, the decrease in pain intensity was more pronounced 15 min after administration of a BP medication. No gender differences were found. No significant differences in frequency and intensity of adverse effects for age and gender were found. CONCLUSION Fentanyl products given for BP in doses proportional to background opioid regimen were more effective in older patients without adding risks of adverse effects. Gender did not influence analgesia and adverse effects of fentanyl products.
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Chen L, Chubak J, Yu O, Pocobelli G, Ziebell RA, Aiello Bowles EJ, Fujii MM, Sterrett AT, Boggs JM, Burnett-Hartman AN, Ritzwoller DP, Hubbard RA, Boudreau DM. Changes in use of opioid therapy after colon cancer diagnosis: a population-based study. Cancer Causes Control 2019; 30:1341-1350. [PMID: 31667710 DOI: 10.1007/s10552-019-01236-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe patterns of opioid use in cancer survivors. METHODS In a cohort study of colon cancer patients diagnosed during 1995-2014 and enrolled at two Kaiser Permanente regions, we constructed quarterly measures of opioid use from 1 year before cancer diagnosis through 5 years after diagnosis to examine changes in use. Measures included any use, incident use, regular use (use ≥ 45 days in a 91-day quarter), and average daily dose (converted to morphine milligram equivalent, MME). We also assessed temporal trends of opioid use. RESULTS Of 2,039 colon cancer patients, 11-15% received opioids in the four pre-diagnosis quarters, 68% in the first quarter after diagnosis, and 15-17% in each subsequent 19 quarters. Regular opioid use increased from 3 to 5% pre-diagnosis to 5-7% post diagnosis. Average dose increased from 15 to 17 MME/day pre-diagnosis to 14-22 MME/day post diagnosis (excluding the quarter in which cancer was diagnosed). Among post-diagnosis opioid users, 73-95% were on a low dose (< 20 MME/day). Over years, regular use of opioids increased in survivorship with no change in dosage. CONCLUSION Opioid use slightly increased following a colon cancer diagnosis, but high-dose use was rare. Research is needed to differentiate under- versus over-treatment of cancer pain.
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Affiliation(s)
- Lu Chen
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Gaia Pocobelli
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Rebecca A Ziebell
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Erin J Aiello Bowles
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Monica M Fujii
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Andrew T Sterrett
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
| | - Jennifer M Boggs
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
| | | | - Debra P Ritzwoller
- Kaiser Permanente Colorado Institute for Health Research, Denver, CO, USA
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA.,Department of Pharmacy, University of Washington, Seattle, WA, USA
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9
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Kawashima H, Ariizumi T, Yamagishi T, Ogose A, Ikoma M, Hotta T, Endo N. Symptom Burden and End-of-Life Palliative Treatments during the Last Two Weeks of Life in Patients with Advanced Musculoskeletal Sarcoma. J Palliat Med 2019; 22:908-914. [PMID: 30762454 DOI: 10.1089/jpm.2018.0415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Musculoskeletal sarcomas (MSSs) are rare cancers and often aggressive tumors that originate from mesenchymal tissue. Patients with advanced MSS often report difficulties with symptom burden, which can reduce their health-related quality-of-life. Objective: The aim of this study was to describe the patterns of the physical symptoms of MSS patients in the palliative setting and to detail the palliative treatment used in the last two weeks of life. Design: Retrospective study using the electronic patient records from a single institution. Setting/Subjects: A retrospective study was carried out in a sample of 46 consecutive MSS patients with locally advanced/metastatic disease, who were hospitalized and died in our department. The median age of these patients was 56 years at death. Measurements: Symptom burden and medical intervention during the last two weeks of life were collected. Results: The most frequent physical symptoms were pain and dyspnea in 93% and 78% of patients, respectively, while only 17% of patients suffered from nausea. A total of 98% of patients required opioids, and most patients were treated with morphine through either subcutaneous or intravenous continuous injection. Nonsteroidal anti-inflammatory drugs and acetaminophen were administered to 79% of patients. Corticosteroids were administered for the relief of dyspnea to 83% of patients. Of the patients, 46% received palliative chemotherapy within the last two weeks of life, and the oral treatment was continued until a median of 5.6 days before death. In addition, 39% of patients received a sedative treatment during the last two weeks of life for uncontrolled refractory symptoms. Conclusions: The symptom burden experienced by advanced MSS patients is profound at the end of life for all palliative approaches. Therefore, palliative medicine is an important and even crucial component of the continuum of care, allowing for aggressive symptom management with a variety of medical interventions, including palliative sedation.
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Affiliation(s)
- Hiroyuki Kawashima
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.,2Palliative Care Team, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takashi Ariizumi
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuro Yamagishi
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akira Ogose
- 3Department of Orthopedic Surgery, Uonuma Kikan Hospital, Niigata, Japan
| | - Miho Ikoma
- 2Palliative Care Team, Niigata University Medical and Dental Hospital, Niigata, Japan.,4Division of Palliative Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuo Hotta
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Naoto Endo
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Lucenteforte E, Vagnoli L, Pugi A, Crescioli G, Lombardi N, Bonaiuti R, Aricò M, Giglio S, Messeri A, Mugelli A, Vannacci A, Maggini V. 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. BMC Cancer 2018; 18:568. [PMID: 29776346 PMCID: PMC5960169 DOI: 10.1186/s12885-018-4478-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
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 .
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Affiliation(s)
- Ersilia Lucenteforte
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Laura Vagnoli
- Pain and Palliative Care Unit, Meyer children's hospital, Florence, Italy
| | - Alessandra Pugi
- Clinical Trial Office, Meyer Children's Hospital, Florence, Italy
| | - Giada Crescioli
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Niccolò Lombardi
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Maurizio Aricò
- Direzione Generale, Azienda Sanitaria Provinciale, Ragusa, Italy
| | - Sabrina Giglio
- Medical Genetics Unit, Meyer Children's University Hospital, Florence, Italy.,Medical Genetics Unit, Department of Clinical and Experimental Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Andrea Messeri
- Pain and Palliative Care Unit, Meyer children's hospital, Florence, Italy
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Valentina Maggini
- Department of Neuroscience, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy. .,Center for Integrative Medicine, Careggi University Hospital, Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3 - 50134, Florence, Italy.
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11
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Lawlor PG, Lawlor NA, Reis-Pina P. The Edmonton Classification System for Cancer Pain: a tool with potential for an evolving role in cancer pain assessment and management. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/23809000.2018.1467211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Niamh A Lawlor
- Ottawa Hospital Cancer Program, The Ottawa Hospital (NAL), Ottawa, Canada
| | - Paulo Reis-Pina
- Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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12
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Mercadante S, Aielli F, Masedu F, Valenti M, Verna L, Mercadante A, Porzio G. Pattern of symptoms and symptomatic treatment in adults and the aged population: a retrospective analysis of advanced cancer patients followed at home. Curr Med Res Opin 2016; 32:893-8. [PMID: 26824824 DOI: 10.1185/03007995.2016.1149055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Sebastiano Mercadante
- a Anesthesia and Intensive Care & Pain Relief and Supportive Care, La Maddalena Cancer Center and University of Palermo , Palermo , Italy
| | - Federica Aielli
- b 'L'Aquila per la Vita' Home Care Unit and Department of Applied Clinical Sciences and Biotechnology , University of L'Aquila , L'Aquila , Italy
| | - Francesco Masedu
- c Department of Applied Clinical Sciences and Biotechnology , Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila , L'Aquila , Italy
| | - Marco Valenti
- c Department of Applied Clinical Sciences and Biotechnology , Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila , L'Aquila , Italy
| | - Lucilla Verna
- b 'L'Aquila per la Vita' Home Care Unit and Department of Applied Clinical Sciences and Biotechnology , University of L'Aquila , L'Aquila , Italy
| | | | - Giampiero Porzio
- b 'L'Aquila per la Vita' Home Care Unit and Department of Applied Clinical Sciences and Biotechnology , University of L'Aquila , L'Aquila , Italy
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13
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Mercadante S, Mercadante A, Aielli F. Effect of aging on pain relief in the older cancer patients: pharmacokinetic and pharmacodynamic aspects. Expert Opin Drug Metab Toxicol 2016; 12:711-3. [PMID: 26895533 DOI: 10.1517/17425255.2016.1152263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sebastiano Mercadante
- a Anesthesia and Intensive Care & Pain Relief and Supportive Care , La Maddalena Cancer Center and University of Palermo , Palermo , Italy
| | | | - Federica Aielli
- c Applied Clinical Sciences and Biotechnology , University of L'Aquila , L'Aquila , Italy
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Age differences in the last week of life in advanced cancer patients followed at home. Support Care Cancer 2015; 24:1889-95. [PMID: 26471279 DOI: 10.1007/s00520-015-2988-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
A retrospective analysis of a consecutive sample of patients admitted to a home care program was performed. Data were recorded in the last week through a backward analysis from the day before death as follows: 1 week before dying (-1W), 3 days before death (-3D), and the day before dying (-1D). Data to be collected included the Edmonton Symptom Assessment System (ESAS), background pain intensity, the prevalence of breakthrough pain, the use of opioids in the last week, and the need for palliative sedation, with indications, duration, and drugs used. Patients were distributed according to the following age ranges: adults (<65 years, A) and aged (≥65 years, O). Of the latter group, three subgroups were assessed: old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Four hundred eleven patients were assessed. At -W1, no statistical differences in intensity of ESAS items ≥4 among the age subgroups were found. For ESAS values at -1W, -3D, and -1D, no statistical differences were found unless for anorexia at -1W (p = 0.000) (more likely), depression at -3D (p = 0.000) (less likely), depression (p = 0.000), and dyspnea (p = 0.01) (less likely) at -1D in the oldest group (O3). No differences in pain intensity among the groups were found (p = 0.54). Opioid doses increased in time and were significantly lower in older patients (p = 0.000). The subcutaneous route was more frequently used at -3D and -1D in older patients. No differences in opioid switching were found among the groups (p = 0.56). Adult patients required more often palliative sedation (p = 0.003). Older patients have problems relatively similar to adult patients in the last week of life, unless for some symptoms. Older patients had also a lower opioid consumption, a more frequent use of the subcutaneous route, and a lower need for palliative sedation.
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Pain Characteristics and Analgesic Treatment in an Aged Adult Population: A 4-Week Retrospective Analysis of Advanced Cancer Patients Followed at Home. Drugs Aging 2015; 32:315-20. [DOI: 10.1007/s40266-015-0253-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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Morita T, Kuriya M, Miyashita M, Sato K, Eguchi K, Akechi T. Symptom Burden and Achievement of Good Death of Elderly Cancer Patients. J Palliat Med 2014; 17:887-93. [DOI: 10.1089/jpm.2013.0625] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tatsuya Morita
- Department of Palliative Care and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Meiko Kuriya
- Department of Palliative Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuki Sato
- Department of Palliative Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenji Eguchi
- Department of Internal Medicine and Medical Oncology, Teikyo University School of Medicine, Tokyo, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Abstract
OBJECTIVE The present review was performed to identify possible differences observed between adults and elderly patients and between males and females in randomized clinical trials of breakthrough pain (BTP). METHODS A systematic search of the existing literature from 1998 to September 2013 was performed. Randomized clinical trials reporting data on older patients were selected. RESULTS Sixteen comparative studies were selected. The age range of inclusion criteria patients was mainly between 18-80 or ≥18 years. In some cases this data was unreported. The mean age of patients was 48-64 years, but information regarding the number of elderly patients was present in three studies only. Gender distribution was more or less 50%:50%. No subgroup analysis of efficacy or adverse effects of BTP medications for age and gender was reported. CONCLUSION There is a need for more information regarding the use of opioids for BTP according to age and gender.
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18
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Opioid needs of terminally ill patients with gynecologic malignancies. Int J Clin Oncol 2014; 20:405-10. [DOI: 10.1007/s10147-014-0708-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
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19
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Effectiveness of polymer-coated extended-release morphine sulfate capsules in older patients with persistent moderate-to-severe pain: A subgroup analysis of a large, open-label, community-based trial. Curr Ther Res Clin Exp 2014; 68:137-50. [PMID: 24683205 DOI: 10.1016/j.curtheres.2007.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2007] [Indexed: 11/21/2022] Open
Abstract
UNLABELLED Abstract. BACKGROUND Opioid analgesics may offer benefits over nonopioids in some older patients, especially those with moderate-to-severe pain. Polymer-coated extended-release morphine sulfate (P-ERMS) has been found to be efficacious and well tolerated in patients with chronic, moderate-to-severe, nonmalignant pain when used QD or BID. OBJECTIVE The purpose of this analysis was to determine the effectiveness of P-ERMS in older patients (aged >65 years) with persistent, moderate-to-severe, inadequately controlled, nonmalignant pain. METHODS This was a subgroup analysis of the older population from an openlabel trial in community-based pain clinics in which patients underwent treatment with P-ERMS for persistent, moderate-to-severe, inadequately controlled, nonmalignant pain (≥4 on a scale of 0-10). Patients received P-ERMS at a dose determined by the investigator based on their previous analgesic regimen, QD (morning or evening) for a 4-week treatment period. Dose increases were permitted after weeks 1 and 2; switching to BID was allowed after week 2, if needed. Measurements included changes in pain and sleep scores (0-10 scale), quality of life (QOL) scores (physical and mental component summaries [PCS and MCS, respectively] of the 36-Item Short-Form Health Survey instrument), and patient and clinician assessments of current treatment based on a 9-point scale ranging from -4 to +4. RESULTS One hundred forty-eight older patients (mean [SD]age, 73.4 [5.5] years) began treatment with P-ERMS; 86 (58.1%) of those patients completed the study. Pain and sleep scores significantly improved (decreased) from baseline to week 4 (7.4 vs 5.0 and 5.0 vs 3.2, respectively; both, P < 0.001). PCS and MCS scores significantly improved (increased) from baseline (27.7 vs 31.6 and 37.6 vs 40.8, respectively; both, P < 0.05), as did patient and clinician global assessments (-1.2 vs 1.1 and -1.5 vs 1.4; both, P < 0.001). Results found in these older patients were similar to those observed in the younger patients (aged ≤65 years). A majority (71.4%) of the older patients remained on QD administration and took significantly lower mean daily doses than younger patients (77.0 vs 105.2 mg/d, respectively; P = 0.001). The dropout rate for the subgroup was 41.1%, which was similar to that reported in previous studies in mixed-age populations taking other extended-release morphine formulations. Of the patients who discontinued (n = 60), adverse events (AEs) were the most prevalent reason (n = 29). The most common treatment-related AEs were constipation (19.6%) and nausea (9.5%). CONCLUSIONS This subgroup analysis of a previously published study revealed that the older patients in that study who were receiving P-ERMS for persistent, moderate-to-severe, inadequately controlled, nonmalignant pain who completed the study attained significant improvements in pain, sleep, and QOL scores compared with baseline. Patient and clinician satisfaction with treatment increased significantly from baseline to study end. Older patients utilized significantly lower mean daily doses than younger patients (P < 0.001), and >70% remained on a QD administration regimen for the duration of the study.
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Morley-Forster PK, Pergolizzi JV, Taylor R, Axford-Gatley RA, Sellers EM. Mitigating the risk of opioid abuse through a balanced undergraduate pain medicine curriculum. J Pain Res 2013; 6:791-801. [PMID: 24353438 PMCID: PMC3862507 DOI: 10.2147/jpr.s47192] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Chronic pain is highly prevalent in the United States and Canada, occurring in an estimated 30% of the adult population. Despite its high prevalence, US and Canadian medical schools provide very little training in pain management, including training in the safe and effective use of potent analgesics, most notably opioids. In 2005, the International Association for the Study of Pain published recommendations for a core undergraduate pain management curriculum, and several universities have implemented pilot programs based on this curriculum. However, when outcomes have been formally assessed, these initiatives have resulted in only modest improvements in physician knowledge about chronic pain and its treatment. This article discusses strategies to improve undergraduate pain management curricula and proposes areas in which those efforts can be augmented. Emphasis is placed on opioids, which have great potency as analgesics but also substantial risks in terms of adverse events and the risk of abuse and addiction. The authors conclude that the most important element of an undergraduate pain curriculum is clinical experience under mentors who are capable of reinforcing didactic learning by modeling best practices.
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Affiliation(s)
- Patricia K Morley-Forster
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada ; Outpatient Pain Clinic, St Joseph's Hospital, London, ON, Canada
| | - Joseph V Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA ; Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA ; NEMA Research Inc, Naples, FL, USA
| | | | - Robert A Axford-Gatley
- Clinical Content and Editorial Services, Complete Healthcare Communications, Inc, Chadds Ford, PA, USA
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21
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Singh JA, Lewallen DG. Predictors of use of pain medications for persistent knee pain after primary Total Knee Arthroplasty: a cohort study using an institutional joint registry. Arthritis Res Ther 2012; 14:R248. [PMID: 23157942 PMCID: PMC3674590 DOI: 10.1186/ar4091] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 10/25/2012] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION To study the use of pain medications for persistent index knee pain and their predictors after primary Total Knee Arthroplasty (TKA). METHODS The Mayo Total Joint Registry collects patient-reported data including pain medication use on all patients who undergo TKA. We used data from patients who underwent primary TKA from 1993-2005. We examined whether gender, age (reference, ≤ 60 yrs), body mass index (BMI; reference, <25 kg/m2), comorbidities measured by Deyo-Charlson index (5-point increase), anxiety and depression predicted use of pain medications (non-steroidal anti-inflammatory drugs (NSAIDs) and opioids) 2- and 5-years after primary TKA. Multivariable logistic regression additionally adjusted for operative diagnosis, American Society of Anesthesiologists (ASA) score, implant fixation and distance from the medical center. RESULTS 7,139 of the 10,957 eligible (65%) at 2-years and 4,234 of 7,404 eligible (57%) completed questionnaires. Significant predictors of NSAIDs use were (Odds ratio (95% confidence interval)): male gender at 2- and 5-years, 0.5 (0.4, 0.6) and 0.6 (0.5, 0.8); age >70-80 years, 0.7 (0.5, 0.9), 0.6 (0.4, 0.8); and depression, 1.4 (1.0, 1.8) and 1.7 (1.1, 2.5). BMI ≥ 40 was associated with NSAIDs use only at 2-years, 1.6 (1.1, 2.5). Significant predictors of opioid pain medication use at 2- and 5-years were: male gender, 0.5 (0.3, 0.9) and 0.4 (0.2, 0.8); age >70-80 years, 0.3 (0.1, 0.6), 0.3 (0.1, 0.8); and anxiety, 3.0 (1.6, 5.7) and 4.0 (1.7, 9.4). CONCLUSIONS Female gender and younger age were associated with higher risk of use of NSAIDs and opioids after primary TKA. Depression was associated with higher NSAID use and anxiety with higher opioid pain medication use after primary TKA.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service and Center for Surgical Medical Acute care Research and Transitions (C-SMART), Birmingham VA Medical Center, Birmingham, AL 35294, USA
- Department of Medicine, School of Medicine and Division of Epidemiology, School of Public Health, University of Alabama, Birmingham, AL 35294, USA
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905 USA
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905 USA
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Neurolytic celiac plexus block reduces occurrence and duration of terminal delirium in patients with pancreatic cancer. J Anesth 2012; 27:88-92. [PMID: 22990527 DOI: 10.1007/s00540-012-1486-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 08/27/2012] [Indexed: 02/08/2023]
Abstract
PURPOSE WHO's three step ladder sometimes cannot provide adequate pain relief for pancreatic cancer. Some patients develop terminal delirium (TD). The aim of this study was to test if the addition of a celiac plexus block (CPB) to pharmacotherapy could reduce the incidence of TD. METHODS Pancreatic cancer patients under the care of our palliative-care team were investigated with regard to the duration and occurrence of TD, pain scores [numerical rating score (NRS)] and daily opioid dose. Between August 2007 to September 2008, 17 patients received only pharmacotherapy (control group). Then, we modified our guideline for analgesia, performing CPB 7 days after the first intervention of our team. Between October 2008 to September 2009, 19 patients received CPB. RESULTS The opioid doses in CPB group were significantly lower both at 10 days after the first intervention (3 days after CPB) (27 ± 11 vs. 66 ± 82 mg; p = 0.029) and 2 days before death (37 ± 25 vs. 124 ± 117 mg; p = 0.009). NRS in the CPB group were significantly lower both at 10 days after the first intervention (0 [0-2] vs. 3 [2-5], p < 0.0001) and 2 days before death (1 [0-2] vs. 3 [1-4.5], p = 0.018). The occurrence and duration of TD in CPB group were both reduced (42 vs. 94 %, p = 0.019; and 1.8 ± 2.9 vs. 10.4 ± 7.5 days, p = 0.0003). CONCLUSION The duration and occurrence of TD and the pain severity were significantly less in pancreatic cancer patients who underwent neurolytic CPB.
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Retrospective evaluation of inpatient celecoxib use after total hip and knee arthroplasty at a Veterans Affairs Medical Center. J Arthroplasty 2012; 27:1033-40. [PMID: 22386610 DOI: 10.1016/j.arth.2012.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 01/20/2012] [Indexed: 02/01/2023] Open
Abstract
A retrospective cohort study (1.5 years) was performed to investigate the efficacy of celecoxib vs non-celecoxib use in patient who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study time frame encompassed a pre and post period of a local policy decision opening access to short-term celecoxib use after TKA/THA. Primary end point was the amount of opioid use during their inpatient stay postprocedure. The TKA (n = 81) and THA (n = 60) groups were analyzed independently. Both celecoxib groups used significantly less opioids during their inpatient stay vs noncelecoxib groups, given in oral morphine milligram equivalents (TKA: 203 vs 337 mg, P = .002; THA: 214 vs 336 mg, P = .005). Other secondary outcome measures showed that the celecoxib groups also reported reduction in pain scores, total as needed (PRN) opioid doses, PRN opioid doses per day, average dose of PRN opioids, total PRN opioids, use of intravenous opioids, and rehabilitation facility admissions (in the TKA group only). Linear regression analysis showed a statistically significant inverse relationship between opioid consumption and age. Short-term celecoxib use after TKA/THA may lead to a reduction in overall opioid use and improved pain scores; however, further studies will be required to validate the results of this study.
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Zhao J, Xin X, Xie GX, Palmer PP, Huang YG. Molecular and cellular mechanisms of the age-dependency of opioid analgesia and tolerance. Mol Pain 2012; 8:38. [PMID: 22612909 PMCID: PMC3517334 DOI: 10.1186/1744-8069-8-38] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 05/09/2012] [Indexed: 01/17/2023] Open
Abstract
The age-dependency of opioid analgesia and tolerance has been noticed in both clinical observation and laboratory studies. Evidence shows that many molecular and cellular events that play essential roles in opioid analgesia and tolerance are actually age-dependent. For example, the expression and functions of endogenous opioid peptides, multiple types of opioid receptors, G protein subunits that couple to opioid receptors, and regulators of G protein signaling (RGS proteins) change with development and age. Other signaling systems that are critical to opioid tolerance development, such as N-methyl-D-aspartic acid (NMDA) receptors, also undergo age-related changes. It is plausible that the age-dependent expression and functions of molecules within and related to the opioid signaling pathways, as well as age-dependent cellular activity such as agonist-induced opioid receptor internalization and desensitization, eventually lead to significant age-dependent changes in opioid analgesia and tolerance development.
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Affiliation(s)
- Jing Zhao
- Department of Anesthesia, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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Mercadante S, Bruera E. The effect of age on opioid switching to methadone: a systematic review. J Palliat Med 2012; 15:347-51. [PMID: 22352334 DOI: 10.1089/jpm.2011.0198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this review was to assess from the existing literature the effect of age on the outcome of opioid switching to methadone, and the possible influence on conversions ratios. DISCUSSION Older patients represent a challenge for physicians, as a further factor may play a role in dosing methadone and possibly on successful switching. Although existing data are not conclusive because this aspect did not receive particular attention in most studies, at the present time age has not been found to be independently associated with the dose ratio. Further prospective studies in a large sample of patients, subgrouped for classes of age, opioid doses, and reasons to switch, should be designed to provide more information.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Palliative Care Unit, La Maddalena Cancer Center & Palliative Medicine, University of Palermo, Palermo, Italy.
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Rashidi NM, Zordan RD, Flynn E, Philip JA. The Care of the Very Old in the Last Three Days of Life. J Palliat Med 2011; 14:1339-44. [DOI: 10.1089/jpm.2011.0308] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nadia Mohamad Rashidi
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
| | - Rachel Dolores Zordan
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
| | - Eleanor Flynn
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
- Medical Education Department, The University of Melbourne, Carlton, Victoria, Australia
| | - Jennifer A.M. Philip
- Centre for Palliative Care, St. Vincent's Hospital & University of Melbourne, Fitzroy, Victoria, Australia
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McLachlan AJ, Bath S, Naganathan V, Hilmer SN, Le Couteur DG, Gibson SJ, Blyth FM. Clinical pharmacology of analgesic medicines in older people: impact of frailty and cognitive impairment. Br J Clin Pharmacol 2011; 71:351-64. [PMID: 21284694 DOI: 10.1111/j.1365-2125.2010.03847.x] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Pain is highly prevalent in frail older people who often have multiple co-morbidities and multiple medicines. Rational prescribing of analgesics in frail older people is complex due to heterogeneity in drug disposition, comorbid medical conditions, polypharmacy and variability in analgesic response in this population. A critical issue in managing older people with pain is the need for judicious choice of analgesics based on a comprehensive medical and medication history. Care is needed in the selection of analgesic medicine to avoid drug-drug or drug-disease interactions. People living with dementia and cognitive impairment have suboptimal pain relief which in part may be related to altered pharmacodynamics of analgesics and challenges in the systematic assessment of pain intensity in this patient group. In the absence of rigorously controlled trials in frail older people and those with cognitive impairment a pharmacologically-guided approach can be used to optimize pain management which requires a systematic understanding of the pharmacokinetics and pharmacodynamics of analgesics in frail older people with or without changes in cognition.
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Affiliation(s)
- Andrew J McLachlan
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia.
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Christo PJ, Li S, Gibson SJ, Fine P, Hameed H. Effective treatments for pain in the older patient. Curr Pain Headache Rep 2011; 15:22-34. [PMID: 21128021 DOI: 10.1007/s11916-010-0164-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
By 2050, the number of older persons across the globe will exceed the number of younger people for the first time in history. Chronic conditions, especially pain, will rise in prevalence as the population ages. Controlling pain in this unique subset of the population demands careful attention to pharmacokinetic and pharmacodynamic factors and their specific impact on pharmacotherapies, relevant complementary and alternative medicine therapies, and interventional strategies.
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Affiliation(s)
- Paul J Christo
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University School of Medicine, 550 North Broadway, Baltimore, MD 21205, USA.
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Radha Krishna LK, Poulose JV, Tan BSA, Goh C. Opioid Use amongst Cancer Patients at the End of Life. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2010. [DOI: 10.47102/annals-acadmedsg.v39n10p790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: Concerns about the life shortening effect of opioids is a well known fact in the medical world when considering administration of these drugs for symptom alleviation at end of life. This study described the patterns of opioid use among cancer patients referred to a hospital-based specialist palliative care service for symptom management. This study also examined whether opioid use among terminally ill cancer patients during the last 2 days of life had any influence on survival. Materials and Methods: A retrospective review of case notes of patients who were diagnosed with terminal cancer and had passed away in a 95-bedded oncology ward between September 2006 and September 2007 was conducted. Data were collected on patients’ characteristics and patterns of opioid use including opioid doses and dose changes at 48 hours and 24 hours before death. Results: There were 238 patients who received specialist palliative care, of whom 132 (55.5%) were females. At 48 hours and 24 hours before death, 184 (77.3%) patients and 187 (78.6%) patients had received opioids, respectively. The median daily doses at 48 hours and 24 hours were 48 mg and 57 mg oral morphine equivalent doses (OME), respectively. Indications for opioid use were pain (41.1%), dyspnoea, (29.1%) and both dyspnoea and pain (30.8%). In the final 24 hours, 22.3% patients had a reduction in their mean opioid dose while 22.7% required an increase in their mean opioid dose. Increased age was associated with decreasing opioid doses (P = 0.003). Patients with spinal metastases required higher doses of opioids (P = 0.03) while those with lung metastases required lower doses (P = 0.011). Survival analysis using Kaplan-Meier survival curve revealed no significant survival difference between those who were on opioids and those who were not. Log rank test (Mantel-Cox) (P = 0.69). Conclusion: Our results showed that opioids are safe medications for symptom alleviation in terminally ill cancer patients during the last days of life and have no deleterious influence on survival.
Key words: Palliative care, Survival analysis, Terminal cancer
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Peniston JH, Xiang Q, Gould EM. Factors affecting acceptability of titrated oxymorphone extended release in chronic low back pain - an individual patient analysis. Curr Med Res Opin 2010; 26:1861-71. [PMID: 20521870 DOI: 10.1185/03007995.2010.490457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the influence of age, sex, and previous opioid experience on the likelihood of successfully titrating opioid-naive and experienced patients with chronic low back pain (CLBP) to an effective and well-tolerated dose of oxymorphone extended release (ER). METHODS Post hoc analysis of open-label titration phases of two enriched-enrollment randomized-withdrawal phase III trials in 575 adults with moderate-to-severe CLBP. Opioid-naive patients (n = 325) initiated oxymorphone ER at 10 mg/day (5 mg q12 h). Opioid-experienced patients (n = 250) initiated at a dose equianalgesic to their previous opioid and were allowed doses of 5 mg oxymorphone immediate-release rescue medication every 4-6 h, as needed. Oxymorphone ER was gradually titrated to a dose that reduced pain to <or=40 mm on a 100 mm visual analog scale. CLINICAL TRIAL REGISTRATION NCT00225797, NCT00226421. MAIN OUTCOME MEASURES Number of patients reaching stabilized oxymorphone ER dose, reasons for treatment discontinuation in patients not reaching stabilized dose. RESULTS Open-label titration was successful in 61% (348/575) of patients, and similar proportions of men (63%) and women (59%) and opioid-naive (63%) and experienced (57%) patients. Patients aged >or=65 years were less likely than patients aged <65 years to complete titration (45 vs. 63%; p = 0.002; 95% CI, -0.30 to -0.06) and more likely to discontinue owing to adverse events (40 vs. 15%; p < 0.001; 95% CI, 0.14-0.36). Oxycodone-experienced patients were less likely than hydrocodone-experienced patients to complete titration (46 vs. 62%, p = 0.03; 95% CI,-0.30 to -0.02). Among successfully titrated patients, pain decreased regardless of prior opioid therapy, sex, or age. CONCLUSIONS Most patients with CLBP were titrated to an effective, generally well-tolerated oxymorphone ER dose. Older patients and those converted from oxycodone may require more gradual titration. A study limitation is that patients initiated oxymorphone ER to comply with protocol, whereas treatment failure typically motivates opioid initiation or switching in clinical practice.
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Affiliation(s)
- John H Peniston
- Feasterville Family Health Care Center, Feasterville, PA 19053, USA.
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Diffusion Effects of an Inpatient Hospice Unit on Improving the Parent Hospital's Pain Management of Terminally Ill Cancer Patients Not Receiving Hospice Care in Taiwan. Cancer Nurs 2010; 33:221-7. [DOI: 10.1097/ncc.0b013e3181cc51fc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Raphael J, Hester J, Ahmedzai S, Barrie J, Farqhuar-Smith P, Williams J, Urch C, Bennett MI, Robb K, Simpson B, Pittler M, Wider B, Ewer-Smith C, DeCourcy J, Young A, Liossi C, McCullough R, Rajapakse D, Johnson M, Duarte R, Sparkes E. Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. PAIN MEDICINE 2010; 11:872-96. [PMID: 20456069 DOI: 10.1111/j.1526-4637.2010.00841.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain. METHODS This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered. CONCLUSIONS It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.
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Affiliation(s)
- Jon Raphael
- Faculty of Health, Birmingham City University, Birmingham, UK.
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Low-dose gabapentin as useful adjuvant to opioids for neuropathic cancer pain when combined with low-dose imipramine. J Anesth 2010; 24:407-10. [DOI: 10.1007/s00540-010-0913-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 02/01/2010] [Indexed: 12/24/2022]
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Abstract
AbstractObjective:To deliver quality care at the end of life, understanding the impact of various changes and life transitions that occur in older age is essential. This review seeks to uncover potential sources of distress in an elder's physical, psychological, social, and spiritual well-being to shed light on the unique challenges and needs facing this age group.Methods:Papers relating to older adults (aged 65 years and older or a mean age of 65 years and older) with advanced/terminal cancer receiving palliative, hospice, or end-of-life care published after 1998 were reviewed.Results:Older adults with advanced cancer have unique needs related to changes in their physical, psychological, social, and spirituals well-being. Changes in each of these domains offer not only the risk of causing distress but also the potential for growth and development during the final stages of advanced cancer.Significance of results:Being aware of the various changes that occur with aging will help health care professionals tailor interventions to promote dignity-conserving care and greatly reduce the potential for suffering at the end of life.
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Reisfield GM, Chronister CW, Goldberger BA, Bertholf RL. Unexpected urine drug testing results in a hospice patient on high-dose morphine therapy. Clin Chem 2009; 55:1765-8. [PMID: 19786586 DOI: 10.1373/clinchem.2008.122754] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gary M Reisfield
- Department of Community Health, University of Florida Health Science Center, Jacksonville, FL 32209, USA
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Knotkova H, Fine PG, Portenoy RK. Opioid rotation: the science and the limitations of the equianalgesic dose table. J Pain Symptom Manage 2009; 38:426-39. [PMID: 19735903 DOI: 10.1016/j.jpainsymman.2009.06.001] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 06/19/2009] [Accepted: 06/22/2009] [Indexed: 11/23/2022]
Abstract
Opioid rotation refers to a switch from one opioid to another in an effort to improve the response to analgesic therapy or reduce adverse effects. It is a common method to address the problem of poor opioid responsiveness despite optimal dose titration. Guidelines for opioid rotation are empirical and begin with the selection of a safe and reasonably effective starting dose for the new opioid, followed by dose adjustment to optimize the balance between analgesia and side effects. The selection of a starting dose must be based on an estimate of the relative potency between the existing opioid and the new one. Potency, which is defined as the dose required to produce a given effect, differs widely among opioids, and among individuals under varying conditions. To effectively rotate from one opioid to another, the new opioid must be started at a dose that will cause neither toxicity nor abstinence, and will be sufficiently efficacious in that pain is no worse than before the change. The estimate of relative potency used in calculating this starting dose has been codified on "equianalgesic dose tables," which historically have been based on the best science available and have been used with little modification for more than 40 years. These tables, and the clinical protocols used to apply them to opioid rotation, may need revision, however, as the science underlying relative potency evolves. Review of these issues informs the use of opioid rotation in the clinical setting and defines key areas for future research.
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Affiliation(s)
- Helena Knotkova
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, USA
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Kodama Y, Takita M, Kawagoe S, Hirahara S, Kimura Y, Onozawa S, Wada T, Nakano K, Kami M, Matsumura T, Yuji K. Retrospective study on home care for patients with hematologic malignancies. Jpn J Clin Oncol 2009; 39:606-611. [PMID: 19535385 DOI: 10.1093/jjco/hyp064] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE There is a lack of sufficient information on the employment of home care for the treatment of hematologic malignancies. METHODS We provided home care to 580 patients from 1 January through 31 October 2007. Patients with hematologic malignancies were selected from these 580 patients; subsequently, by reviewing their medical records. RESULTS The main clinical condition in 15 (2.6%) of 580 patients was hematologic malignancies. The median age of the patients was 78 years (range, 64-92). Of the 15 patients, 12 showed a performance status (PS) of 3-4, and the condition of 6 patients was complicated with dementia. Food intake via the oral route was possible in 14 patients. These patients were administered palliative care. Among the seven patients who required pain control, four had been opioid users; however, none had used anticancer drugs for pain relief. Furthermore, three patients received blood transfusion. Although three patients developed severe complications (acute appendicitis, pneumonia and hyperglycemia), we were able to treat all cases adequately. Eight patients died at home due to aggravation of the primary diseases. The remaining seven patients were transferred to other hospitals for the treatment of complications or for the convenience of their respective families. CONCLUSIONS Even patients with hematologic malignancies could be candidates for home care if their underlying diseases are slowly progressive, and they can sustain themselves by oral intakes. Dementia and poor PS are not contraindicated to it.
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Affiliation(s)
- Yuko Kodama
- Division of Social Communication System for Advanced Clinical Research, the Institute of Medical Science, the University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo 108-8639, Japan.
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Weschules DJ. Development of Guidelines for Palliative Care Pharmacotherapy. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v19n04_06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bercovitch M, Adunsky A. High Dose Controlled-Release Oxycodone in Hospice Care. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v20n04_06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Benítez-Rosario MA, Salinas-Martín A, Aguirre-Jaime A, Pérez-Méndez L, Feria M. Morphine-methadone opioid rotation in cancer patients: analysis of dose ratio predicting factors. J Pain Symptom Manage 2009; 37:1061-8. [PMID: 19171458 DOI: 10.1016/j.jpainsymman.2008.05.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 05/13/2008] [Accepted: 06/16/2008] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Miguel Angel Benítez-Rosario
- Palliative Care Unit, NS Candelaria University Hospital, Canary Health Service, Department of Pharmacology, University of La Laguna, 38271 La Laguna, Tenerife, Spain.
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Peniston JH, Gould E. Oxymorphone extended release for the treatment of chronic low back pain: a retrospective pooled analysis of enriched-enrollment clinical trial data stratified according to age, sex, and prior opioid use. Clin Ther 2009; 31:347-59. [PMID: 19302907 DOI: 10.1016/j.clinthera.2009.02.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study assessed the potential effects of age, sex, and prior opioid use on the response to oxymorphone extended release (ER) in patients with moderate to severe chronic low back pain. METHODS Combined data from 2 placebo-controlled clinical trials with an enriched-enrollment, randomized-withdrawal design were analyzed. In patients aged > or =18 years with chronic low back pain, the dose of oxymorphone ER was titrated to a stable, tolerable, effective dose. Patients who completed titration were randomly assigned to a 12-week double-blind study period with oxymorphone ER or placebo. Oxymorphone immediate release 5 mg was permitted q4-6h, as needed for rescue medication or withdrawal symptoms, for 4 days after randomization and restricted to 10 mg/d thereafter. Pain intensity (100-mm visual analog scale [VAS]; 0 = no pain to 100 = worst pain imaginable) and time to study discontinuation due to lack of efficacy were compared with stratification by age (<65 vs > or =65 years), sex, and prior opioid use. Adverse events were categorized by severity and relation to study medication. RESULTS Of 575 patients, 348 completed titration and 347 entered the double-blind study phase. There were no significant between-group differences in demographic variables, except that the mean age in the oxymorphone ER group was significantly higher (P = 0.04), and the proportion of men was significantly lower (P = 0.01). There was no significant age difference between the oxymorphone ER and placebo groups stratified by age (<65 vs > or =65 years). Fewer patients aged > or =65 years versus <65 years completed titration (45.0% [36/80] vs 63.0% [312/495]; P = 0.002). The least-squares mean (SEM) differences in VAS pain scores between the oxymorphone ER (n = 174) and placebo (n = 169) groups were significant at each postbaseline assessment (P < 0.001) and at study completion (12.3 [2.8] mm; P < 0.001) and was not significantly affected by age, sex, or prior opioid use. Age and sex had no significant influence on adverse events or discontinuations due to lack of efficacy. More discontinuations due to lack of efficacy occurred among patients in the placebo group (hazard ratio, 5.01; P < 0.001) and among opioid-experienced patients. The latter effect was limited to opioid-experienced patients who received placebo. The rates of discontinuation due to lack of efficacy were similar between oxymorphone ER-treated opioid-naive and opioid-experienced patients (11.4% vs 11.6%). The proportion of patients who experienced opioid-related adverse events was significantly greater in the oxymorphone ER group compared with the placebo group (25.7% vs 16.3%; P = 0.03). The most frequent treatment-emergent adverse events in the oxymorphone ER group were nausea (8.0%), constipation (6.3%), vomiting (4.6%), and diarrhea (4.0%); in the placebo group were nausea (5.8%), diarrhea (4.7%), and increased sweating (2.3%). CONCLUSION In the enriched population of patients who successfully titrated to oxymorphone ER, oxymorphone ER was effective and generally well tolerated, independent of patients' age, sex, or previous opioid use.
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Affiliation(s)
- John H Peniston
- Feasterville Family Health Care Center, Feasterville, Pennsylvania 19053, USA.
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Costantini M, Ripamonti C, Beccaro M, Montella M, Borgia P, Casella C, Miccinesi G. Prevalence, distress, management, and relief of pain during the last 3 months of cancer patients’ life. Results of an Italian mortality follow-back survey. Ann Oncol 2009; 20:729-35. [DOI: 10.1093/annonc/mdn700] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Rurup ML, Borgsteede SD, van der Heide A, van der Maas PJ, Onwuteaka-Philipsen BD. Trends in the use of opioids at the end of life and the expected effects on hastening death. J Pain Symptom Manage 2009; 37:144-55. [PMID: 18692359 DOI: 10.1016/j.jpainsymman.2008.02.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 02/18/2008] [Accepted: 02/18/2008] [Indexed: 10/21/2022]
Abstract
The aim of our study was to describe trends in opioid use and perceptions of having hastened the end of life of a patient. In 2005, a questionnaire was sent to 6860 physicians in The Netherlands who had attended a death. The response rate was 78%. In 1995 and 2001 similar studies were done. Physicians less often administered opioids with the intention to hasten death in 2005 (3.1% of the non-sudden deaths) than in 2001 and in 1995 (7% and 10%, respectively). Physicians gave similar dosages of opioids in 2005, 2001, and 1995, but physicians in 2005 less often thought that life was actually shortened than in 2001 and 1995 (37% in 2005, 50% in 2001, and 53% in 1995). Of the physicians in 2005 who did think that the life of the patient was shortened by opioids, 94% did not give higher dosages than were, in their own opinion, required for pain and symptom management. Physicians in 2005 more often took hastening death into account when they gave higher dosages of opioids when the patient experienced more severe symptoms and with female patients. In older patients (>or=80 years), physicians took the hastening of death into account more often, but the actual dosages of opioids were lower. These data indicate that physicians in The Netherlands less often thought that death was hastened by opioids and less often gave opioids, with the intention to hasten death in 2005 than in 2001 and 1995.
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Affiliation(s)
- Mette L Rurup
- EMGO Institute, Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands.
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Cancer pain management at home (I): do older patients experience less effective management than younger patients? Support Care Cancer 2008; 17:787-92. [DOI: 10.1007/s00520-008-0549-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2008] [Accepted: 11/17/2008] [Indexed: 10/21/2022]
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Gnjidic D, Murnion BP, Hilmer SN. Age and opioid analgesia in an acute hospital population. Age Ageing 2008; 37:699-702. [PMID: 18687872 DOI: 10.1093/ageing/afn152] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Danijela Gnjidic
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, Australia.
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Bailey FA, Ferguson L, Williams BR, Woodby LL, Redden DT, Durham RM, Goode PS, Burgio KL. Palliative Care Intervention for Choice and Use of Opioids in the Last Hours of Life. J Gerontol A Biol Sci Med Sci 2008; 63:974-8. [DOI: 10.1093/gerona/63.9.974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Weschules DJ, Bain KT. A Systematic Review of Opioid Conversion Ratios Used with Methadone for the Treatment of Pain. PAIN MEDICINE 2008; 9:595-612. [DOI: 10.1111/j.1526-4637.2008.00461.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Pain is one of the symptoms that many tumor patients are especially afraid of in the final phase of their illness. Symptoms can change rapidly, making quick adaptation of the therapy necessary. This poses particular challenges to organizational structures in outpatient treatment if the patients' desire to spend their last days of life in their accustomed surroundings is to be realized. METHODS Pain intensity and the associated symptoms in a WHO step III opiate therapy during the last 3 days of life were investigated retrospectively among 601 tumor patients who had received medical care from Home Care Berlin. Differences in gender, age, living conditions/care situation and place of death were evaluated with due consideration for the different pain medications administered and for the different forms and routes of administration. RESULTS More than 80% of the patients reported freedom from pain or only moderate pain during the opiate therapy. Care provided by the hospice-at-home medical service Home Care Berlin allowed excellent control of tumor patients' symptoms with only moderate side-effects in their final days of life. Among patients receiving opioids by the transdermal route there were significantly more frequent complaints of pain (p=0.004) and nausea (p=0.001). During the last days of life continuous subcutaneous infusions containing opiates facilitated good analgesia within an acceptable spectrum of side-effects. Most problems with controlling symptoms in outpatients were encountered in younger patients. CONCLUSION Morphine emerged as the drug of first choice in this investigation, because it can be given parenterally and also because of its price. The use of subcutaneous and intravenous administration systems such as PCA pumps requires trained nursing services and regular house visits by physicians experienced in palliative medicine.
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Affiliation(s)
- James F. Cleary
- Department of Medicine, University of Wisconsin, Madison Wisconsin
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Yamashita K, Nabeshima A, Hara Y, Okochi J. [Influence of body weight, age, and primary tumor site on opioid dose in advanced cancer pain patients]. Nihon Ronen Igakkai Zasshi 2007; 44:345-50. [PMID: 17575439 DOI: 10.3143/geriatrics.44.345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
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.
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