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Mercadante S. Opioid dose titration for cancer pain. Eur J Pain 2024; 28:359-368. [PMID: 37947151 DOI: 10.1002/ejp.2194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Opioid dose titration is a fundamental process of opioid therapy in cancer pain. AIMS To assess data opioid dose titration. METHODS The principal opioid dose titration methods, outcomes, and modalities of administration regarding the different opioid preparations were examined in different clinical contexts. RESULTS Most studies suggested that opioid-naive patients should be started at doses of 15-30 mg/day of oral morphine equivalents. Opioid-tolerant patients may receive low or higher doses of oral morphine equivalents, depending on the level of opioid tolerance. Generally, dose increments of 30%-50% seem to be indicated to start dose titration. Some patients with severe excruciating cancer pain may present as an emergency requiring a rapid application of powerful analgesic strategies. The intravenous use of opioids may circumvent this problem providing a faster pain relief, due to the large availability and rapid achievement of effective plasma concentrations. DISCUSSION Opioid dose titration is a delicate passage in patients with cancer pain. This approach may be different according to different clinical conditions. Opioid dose titration requires expertise to optimize cancer pain management while minimizing the development of adverse effects. CONCLUSION While most approaches are meaningful and partially supported by existing literature, more studies are necessary to establish advantages and disadvantages in different clinical conditions. Optimization of opioid dose titration is of paramount importance. SIGNIFICANCE This review provides the most recent insights on the different modalities of opioid dose titration in cancer pain management.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
- Regional Home Care Program, SAMOT, Palermo, Italy
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Kumar V, Sirohiya P, Garg R, Gupta N, Bharti SJ, Velpandian T, Mishra S, Bhatnagar S. Comparison of two techniques (intermittent intravenous bolus morphine vs. morphine infusion) for analgesic titration in patients who had advanced cancer with severe pain: a prospective randomised study. BMJ Support Palliat Care 2023; 13:338-344. [PMID: 32895226 DOI: 10.1136/bmjspcare-2020-002397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/16/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the analgesic efficacy of two techniques of morphine titration (intermittent intravenous bolus vs infusion) by calculating rescue dosage in a day at 1 week after analgesic titration. METHODS One hundred and forty cancer patients were randomised into two groups. In group 1, intravenous morphine 1.5 mg bolus given every 10 min until Numerical Rating Scale (NRS) pain score <4 is achieved. Total intravenous dose converted to oral dose (1:1) and administered every 4 hours. In group 2, intravenous bolus morphine 0.05 mg/kg body weight administered followed by 0.025 mg/kg/hour intravenous infusion. The NRS pain score was recorded every 10 min but infusion rate was titrated every 30 min if required. The infusion rate of morphine was doubled if the pain score was unchanged and increased to 50% when NRS was between 4 and baseline. If NRS<4, then infusion at same rate was continued. Once the NRS<4 for two consecutive hours, total intravenous dose for 24 hours was calculated and converted to oral morphine in a ratio of 1:3 and divided into six doses given over 24 hours. For rescue (pain score ≥4) analgesia, one-sixth of the total daily oral dose was prescribed. The primary outcome of this study was to note the number of rescue doses of oral morphine in a day at 1 week. RESULTS The rescue dosage in a day at 1-week post discharge from the palliative care unit was significantly higher in group 1 as compared with group 2. CONCLUSION Intravenous infusion morphine may be a better analgesic titration technique for analgesia in patients with advanced cancer. TRIAL REGISTRATION NUMBER CTRI/2018/04/013369.
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Affiliation(s)
- Vinod Kumar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prashant Sirohiya
- Anaesthesia, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sachidanand Jee Bharti
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Thirumurthy Velpandian
- Department of Ocular Pharmacology, Dr Rajendra Prasad Centre for Opthalmic Sciences, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
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Serra S, Spampinato MD, Riccardi A, Guarino M, Fabbri A, Orsi L, De Iaco F. Pain Management at the End of Life in the Emergency Department: A Narrative Review of the Literature and a Practical Clinical Approach. J Clin Med 2023; 12:4357. [PMID: 37445392 DOI: 10.3390/jcm12134357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Access to pain management is a fundamental human right for all people, including those who are at the end of life (EOL). In end-stage patients, severe and uncontrolled pain is a common cause of admission to the emergency department (ED), and its treatment is challenging due to its complex, often multifactorial genesis. The aim of this narrative review was to identify the available literature on the management of severe EOL pain in the ED. The MEDLINE, SCOPUS, EMBASE, and CENTRAL databases were searched from inception to 1 April 2023 including randomised controlled trials, observational studies, systemic or narrative reviews, case reports, and guidelines on the management of EOL pain in the ED. A total of 532 articles were identified, and 9 articles were included (5 narrative reviews, 2 retrospective studies, and 2 prospective studies). Included studies were heterogeneous on the scales used and recommended for pain assessment and the recommended treatments. No study provided evidence for a better approach for EOL patients with pain in the ED. We provide a narrative summary of the findings and a review of the management of EOL pain in clinical practice, including (i) the identification of the EOL patients and unmet palliative care needs, (ii) a multidimensional, patient-centred assessment of the type and severity of pain, (iii) a multidisciplinary approach to the management of end-of-life pain, including an overview of non-pharmacological and pharmacological techniques; and (iv) the management of special situations, including rapid acute deterioration of chronic pain, breakthrough pain, and sedative palliation.
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Affiliation(s)
- Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47521 Cesena, Italy
| | | | | | - Mario Guarino
- UOC MEU Ospedale CTO-AORN dei Colli Napoli, 80131 Napoli, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Luciano Orsi
- Palliative Care Physician and Scientific Director of "Rivista Italiane di Cure Palliative", 26013 Crema, Italy
| | - Fabio De Iaco
- Struttura Complessa di Medicina di Emergenza Urgenza Ospedale Maria Vittoria, ASL Città di Torino, 10144 Torino, Italy
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Long DA, Koyfman A, Long B. Oncologic Emergencies: Palliative Care in the Emergency Department Setting. J Emerg Med 2020; 60:175-191. [PMID: 33092975 DOI: 10.1016/j.jemermed.2020.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 06/25/2020] [Accepted: 09/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL). OBJECTIVE This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain. DISCUSSION As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL. CONCLUSIONS Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.
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Affiliation(s)
- Drew A Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Nakajima N. Effectiveness of rapid titration with intravenous administration of oxycodone injection in advanced cancer patients with severe pain. Jpn J Clin Oncol 2019; 49:1061-1064. [PMID: 31612910 DOI: 10.1093/jjco/hyz145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/02/2019] [Indexed: 11/14/2022] Open
Abstract
Some cancer patients suddenly develop severe, excruciating pain that requires rapid management using opioid medication. This study aimed to evaluate the effectiveness of rapid titration using oxycodone injection. Study subjects were advanced cancer patients who experienced severe pain (numeric rating scale ≥7) and needed prompt pain relief. Primary endpoint was (i) time required for the initial sign of significant analgesia to become evident. Secondary endpoints were (ii) pain relief stabilization success rate and (iii) adverse effects. Groups treated with oxycodone (oxycodone group) and morphine (morphine group) were retrospectively compared. The oxycodone group had 33 cases and the morphine group had 32 cases: (i) 15.6 ± 4.3 min in the oxycodone group and 19.3 ± 4.7 min in the morphine group (P = 0.001); (ii) 70 and 63% within 24 hours, and 88 and 84% within 48 hours in the oxycodone group and the morphine group, respectively (P = 0.36, 0.48). Although (iii) adverse effects appeared in both groups in the form of respiratory suppression, etc., the effects were mild. Rapid titration using oxycodone injections may be considered a beneficial choice.
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Affiliation(s)
- Nobuhisa Nakajima
- Division of Community-based Medicine and Primary Care, University of the Ryukyus Hospital, Japan
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6
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Ma JD, Tran V, Chan C, Mitchell WM, Atayee RS. Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice. J Oncol Pharm Pract 2015; 22:757-765. [PMID: 26428283 DOI: 10.1177/1078155215607089] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We have previously reported the development of an outpatient palliative care practice under pharmacist-physician collaboration. The Doris A. Howell Service at the University of California, San Diego Moores Cancer Center includes two pharmacists who participate in a transdisciplinary clinic and provide follow-up care to patients. OBJECTIVE This study evaluated pharmacist interventions and patient outcomes of a pharmacist-led outpatient palliative care practice. METHODS This was a retrospective data analysis conducted at a single, academic, comprehensive cancer center. New (first visit) patient consultations were referred by an oncologist or hematologist to an outpatient palliative care practice. A pharmacist evaluated the patient at the first visit and at follow-up (second, third, and fourth visits). Medication problems identified, medication changes made, and changes in pain scores were assessed. RESULTS Eighty-four new and 135 follow-up patient visits with the pharmacist occurred from March 2011 to March 2012. All new patients (n = 80) were mostly women (n = 44), had localized disease (n = 42), a gastrointestinal cancer type (n = 21), and were on a long-acting (n = 61) and short-acting (n = 70) opioid. A lack of medication efficacy was the most common problem for symptoms of pain, constipation, and nausea/vomiting that was identified by the pharmacist at all visits. A change in pain medication dose and initiation of a new medication for constipation and nausea/vomiting were the most common interventions by the pharmacist. A statistically significant change in pain score was observed for the third visit, but not for the second and fourth visits. CONCLUSIONS A pharmacist-led outpatient palliative care practice identified medication problems for management of pain, constipation, and nausea/vomiting. Medication changes involved a change in dose and/or initiating a new medication. Trends were observed in improvement and stabilization of pain over subsequent clinic visits.
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Affiliation(s)
- Joseph D Ma
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California (UC), San Diego, La Jolla, CA, USA UC San Diego, Moores Cancer Center, La Jolla, CA, USA
| | - Victor Tran
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California (UC), San Diego, La Jolla, CA, USA
| | - Carissa Chan
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California (UC), San Diego, La Jolla, CA, USA
| | | | - Rabia S Atayee
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California (UC), San Diego, La Jolla, CA, USA UC San Diego, Moores Cancer Center, La Jolla, CA, USA
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Drew D, Gordon D, Renner L, Morgan B, Swensen H, Manworren R. The Use of “As-Needed” Range Orders for Opioid Analgesics in the Management of Pain:. Pain Manag Nurs 2014; 15:551-4. [DOI: 10.1016/j.pmn.2014.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Chung KC, Barlev A, Braun AH, Qian Y, Zagari M. Assessing Analgesic Use in Patients with Advanced Cancer: Development of a New Scale-The Analgesic Quantification Algorithm. PAIN MEDICINE 2014; 15:225-32. [DOI: 10.1111/pme.12299] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Karen C. Chung
- Global Health Economics; Amgen Inc.; Thousand Oaks California USA
| | - Arie Barlev
- Global Health Economics; Amgen Inc.; Thousand Oaks California USA
| | - Ada H. Braun
- Global Development Hematology/Oncology; Amgen Inc.; Thousand Oaks California USA
| | - Yi Qian
- Global Biostatistics and Epidemiology; Amgen Inc.; Thousand Oaks California USA
| | - Martin Zagari
- Global Health Economics; Amgen Inc.; Thousand Oaks California USA
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Fisher J, Urquhart R, Johnston G. Use of opioid analgesics among older persons with colorectal cancer in two health districts with palliative care programs. J Pain Symptom Manage 2013; 46:20-9. [PMID: 23017627 PMCID: PMC3747099 DOI: 10.1016/j.jpainsymman.2012.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 07/05/2012] [Accepted: 07/11/2012] [Indexed: 11/30/2022]
Abstract
CONTEXT Prescription of opioid analgesics is a key component of pain management among persons with cancer at the end of life. OBJECTIVES To use a population-based method to assess the use of opioid analgesics within the community among older persons with colorectal cancer (CRC) before death and determine factors associated with the use of opioid analgesics. METHODS Data were derived from a retrospective, linked administrative database study of all persons who were diagnosed with CRC between January 1, 2001 and December 31, 2005 in Nova Scotia, Canada. This study included all persons who 1) were 66 years or older at the date of diagnosis; 2) died between January 1, 2001 and April 1, 2008; and 3) resided in health districts with formal palliative care programs (PCPs) (n=657). Factors associated with having filled at least one prescription for a so-called "strong" opioid analgesic in the six months before death were examined using multivariate logistic regression. RESULTS In all, 36.7% filled at least one prescription for any opioid in the six months before death. Adjusting for all covariates, filling a prescription for a strong opioid was associated with enrollment in a PCP (odds ratio [OR]=3.18, 95% CI=2.05-4.94), residence in a long-term care facility (OR=2.19, 95% CI=1.23-3.89), and a CRC cause of death (OR=1.75, 95% CI=1.14-2.68). Persons were less likely to fill a prescription for a strong opioid if they were older (OR=0.97, 95% CI=0.95-0.99), male (OR=0.59, 95% 0.40-0.86), and diagnosed less than six months before death (OR=0.62, 95% CI=0.41-0.93). CONCLUSION PCPs may play an important role in enabling access to end-of-life care within the community.
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Affiliation(s)
- Judith Fisher
- Pharmaceutical Services, Department of Health and Wellness, Halifax, Nova Scotia, Canada.
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Hallenbeck J. Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death? J Palliat Med 2012; 15:848-53. [DOI: 10.1089/jpm.2011.0167] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- James Hallenbeck
- School of Medicine, Department of Medicine, Division of General Medical Disciplines, Stanford University, Stanford, California
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11
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Klepstad P, Kaasa S, Borchgrevink PC. Starting step III opioids for moderate to severe pain in cancer patients: dose titration: a systematic review. Palliat Med 2011; 25:424-30. [PMID: 21708850 DOI: 10.1177/0269216310386280] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The European Association for Palliative Care recommendation for starting morphine for cancer pain is dose titration with immediate release (IR) oral morphine given every 4 h with additionally doses for breakthrough pain. As part of a EU 6th framework programme to revise the guidelines we review the evidence regarding starting treatment and dose titration of opioids in adult patients with moderate to severe cancer pain. Relevant papers were identified though a systematic search in Medline for papers published until the end of 2009. We identified 15 relevant papers. Thirteen papers were descriptive papers reporting the results from starting treatment with oral morphine (six studies), starting treatment with intravenous morphine (two studies) and starting treatment with transdermal fentanyl (four studies). All treatment strategies resulted in acceptable pain control and were well tolerated. Two randomized controlled trials were identified. One study compared starting opioid treatment with intravenous morphine versus IR oral morphine and one study compared IR oral morphine versus sustained release oral morphine.
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Affiliation(s)
- Pål Klepstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
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12
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Lamba S, Quest TE. Hospice care and the emergency department: rules, regulations, and referrals. Ann Emerg Med 2010; 57:282-90. [PMID: 21035900 DOI: 10.1016/j.annemergmed.2010.06.569] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 05/19/2010] [Accepted: 06/16/2010] [Indexed: 11/19/2022]
Abstract
Emergency clinicians often care for patients with terminal illness who are receiving hospice care and many more patients who may be in need of such care. Hospice care has been shown to successfully address the multidimensional aspects of the end-of-life concerns of terminally ill patients: dying with dignity, dying without pain, reducing the burden on family and caregivers, and achieving a home death, when desired. Traditional emergency medicine training may fail to address hospice as a system of care. When they are unfamiliar with the hospice model, emergency clinicians, patients, and caregivers may find it difficult to properly use and interact with these care services. Potential poor outcomes include the propagation of misleading or inaccurate information about the hospice system and the failure to guide appropriate patient referrals. This article reviews the hospice care service model and benefits offered, who may qualify for hospice care, common emergency presentations in patients under hospice care, and a stepwise approach to initiating a hospice care referral in the emergency department.
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Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ, USA.
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Nurses' Knowledge, Attitudes, and Practice Patterns Regarding Titration of Opioid Infusions at the End of Life. J Hosp Palliat Nurs 2010. [DOI: 10.1097/njh.0b013e3181cf791c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dy SM, Asch SM, Naeim A, Sanati H, Walling A, Lorenz KA. Evidence-Based Standards for Cancer Pain Management. J Clin Oncol 2008; 26:3879-85. [DOI: 10.1200/jco.2007.15.9517] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
High-quality management of cancer pain depends on evidence-based standards for screening, assessment, treatment, and follow-up for general cancer pain and specific pain syndromes. We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Providers should routinely screen for the presence or absence and intensity of pain and should perform descriptive pain assessment for patients with a positive screen, including assessment for likely etiology and functional impairment. For treatment, providers should provide pain education, offer breakthrough opioids in patients receiving long-acting formulations, offer bowel regimens in patients receiving opioids chronically, and ensure continuity of opioid doses across health care settings. Providers should also follow up on patients after treatment for pain. For metastatic bone pain, providers should offer single-fraction radiotherapy as an option when offering radiation, unless there is a contraindication. When spinal cord compression is suspected, providers should treat with corticosteroids and evaluate with whole-spine magnetic resonance imaging scan or myelography as soon as possible but within 24 hours. Providers should initiate definitive treatment (radiotherapy or surgical decompression) within 24 hours for diagnosed cord compression and should follow up on patients after treatment. These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes.
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Affiliation(s)
- Sydney M. Dy
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Steven M. Asch
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Arash Naeim
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Homayoon Sanati
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Anne Walling
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Karl A. Lorenz
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
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Reuzel RPB, Hasselaar GJ, Vissers KCP, van der Wilt GJ, Groenewoud JMM, Crul BJP. Inappropriateness of using opioids for end-stage palliative sedation: a Dutch study. Palliat Med 2008; 22:641-6. [PMID: 18612030 DOI: 10.1177/0269216308091867] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To be able to distinguish end-stage palliative sedation from euthanasia without having to refer to intentions that are difficult to verify, physicians must be able to manage palliative sedation appropriately (i.e., see that death is not hastened as a result of disproportionate medication). In the present study, we assessed whether or not this requirement is met in the Netherlands. We sent a retrospective questionnaire to 1,464 medical specialists, general practitioners, and nursing home physicians in the Netherlands. Furthermore, we held two sets of 20 and 22 semi-structured in-depth interviews with general practitioners, internists, lung specialists, and nursing home physicians. Although most guidelines discourage the administration of opioids alone for purposes of palliative sedation, opioids alone were administered for 22% of all the patients reported upon. Those physicians who were more experienced, general practitioners, and physicians who had consulted a palliative care expert administered only opioids significantly less often than the other physicians. The interviewees reported difficulties in assessing the appropriateness of medication, feeling uncertain about the pharmacokinetics of drugs used in moribund patients. Given that no more than 2% of the respondents perceived palliative sedation to be used as a form of euthanasia and that the use of opioids alone was not associated with shorter survival rates, the inappropriate use of opioids can only be attributed to a lack of knowledge or skill and/or a tradition of alleviating refractory dyspnoea with the use of opioids and not as an intentional means of hastening death.
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Affiliation(s)
- R P B Reuzel
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
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Hoskin PJ. Opioids in context: relieving the pain of cancer. The role of comprehensive cancer management. Palliat Med 2008; 22:303-9. [PMID: 18541634 DOI: 10.1177/0269216308089307] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Optimal pain control requires detailed appraisal of each symptom; in many cases definitive treatment of the underlying cause will be the most effective means of pain control. As an example back pain may be due not only to bone metastases but also enlarging lymph nodes, renal pain or retroperitoneal tumour. Benign causes including degenerative joint disease should also be considered and each cause treated specifically alongside the use of analgesics.
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Affiliation(s)
- P J Hoskin
- Mount Vernon Cancer Centre, Northwood, Middlesex, UK.
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Affiliation(s)
- James F. Cleary
- Department of Medicine, University of Wisconsin, Madison Wisconsin
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20
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Fineberg IC, Wenger NS, Brown-Saltzman K. Unrestricted opiate administration for pain and suffering at the end of life: knowledge and attitudes as barriers to care. J Palliat Med 2006; 9:873-83. [PMID: 16910802 DOI: 10.1089/jpm.2006.9.873] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pain and symptom management is critical for quality end-of-life care in the hospital. Although guidelines support the use of unrestricted opiate administration to treat refractory pain and suffering in the dying patient, many patients die suffering with symptoms that could have been addressed. METHODS A multidisciplinary convenience sample of 381 hospital-based health care providers completed a survey evaluating their understanding of the principles of treating refractory pain and suffering at the end of life in the hospital, knowledge of the institution's policy about how to implement such care, and attitudes about and comfort with such treatment. RESULTS Respondents recognized pain and symptom management as a goal of unrestricted opiate use at the end of life, but 12% identified comfort for families or treatment of nonphysical suffering as the principal goal of this modality. Two thirds of respondents felt that unrestricted opiates were used too rarely and 45% felt they were used too late. However, 16% felt uncomfortable administering unrestricted opiates and 21% of physicians and nurses who had used restricted opiates reported having felt pressured to increase dosing of opiates. Knowledge deficits concerning appropriate candidates for unrestricted opiates and the protocol for appropriate implementation were common. CONCLUSIONS Knowledge deficits and attitudinal concerns may hamper the administration of unrestricted opiates for refractory pain and suffering at the end of life in the hospital. Clinician education and clarification of the appropriate use of this modality when there are differences in clinician and family perception of discomfort are needed.
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Affiliation(s)
- Iris Cohen Fineberg
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California 90024-1736, USA
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Abstract
Pain in older adults is a highly prevalent problem. While the basis of pain management in older individuals is similar to that for younger patients, it may differ in terms of presentation, assessment, and management. This article explores the basic concepts of pain control with a focus on older patients with cancer and highlights issues clinicians should consider when treating these individuals.
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Affiliation(s)
- Nathan E Goldstein
- Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Adult Development, The Mount Sinai Medical Center, Box 1070, One Gustave L. Levy Place, New York, NY 10029, USA.
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