Factors associated with opioid dispensation for patients with COPD and lung cancer in the last year of life: A retrospective analysis

Expectations of respiratory physicians from psychologists in palliative care for patients with non-cancer respiratory diseases

BACKGROUND

Psychological symptoms are common in patients with non-malignant respiratory disease (NMRD). Psychologists can likely play a role in NMRD palliative care. We aimed to explore the expectations of respiratory physicians from psychologists in NMRD palliative care.

METHODS

An ad hoc questionnaire was developed based on a free-descriptive questionnaire survey among respiratory physicians from four hospitals in Japan. Using this questionnaire, we surveyed respiratory physicians from eight hospitals in Japan and assessed their expectations of psychologists' support and outcomes. Expectations were compared between physicians with and without experience of working with psychologists.

RESULTS

The quantitative questionnaire was completed by 129 physicians. Data analysis from 108 participants revealed that the highly expected support included "getting early information on patients' psychological distress" (97.2%) and "counseling family members regarding anxiety caused by changes in patient's condition" (96.3%). Physicians also expected "relief in patient's psychological distress" (96.3%) and "providing the psychological support that families need" (95.4%) from psychologists. Compared to physicians with experience of working with psychologists, those without expected more in terms of "giving specific advice on the way of communication and psychological support" (p = 0.035) and "providing psychological support for difficult-to-handle patients and families on behalf of other medical staff" (p = 0.036).

CONCLUSIONS

Respiratory physicians may expect relief of psychological distress experienced by patients and their families from psychologists by getting information about their distress and providing psychological support. These results may be useful for psychologists to provide palliative care for patients with NMRD in collaboration with respiratory physicians.

Comparison of end-of-life care in people with chronic obstructive pulmonary disease or lung cancer: A systematic review

BACKGROUND

Palliative care has been widely implemented in clinical practice for patients with cancer but is not routinely provided to people with chronic obstructive pulmonary disease.

AIM

The study aims were to compare palliative care services, medications, life-sustaining interventions, place of death, symptom burden and health-related quality of life among chronic obstructive pulmonary disease and lung cancer populations.

DESIGN

Systematic review with meta-analysis (PROSPERO: CRD42019139425).

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL and PsycINFO were searched for studies comparing palliative care, symptom burden or health-related quality of life among chronic obstructive pulmonary disease, lung cancer or populations with both conditions. Quality scores were assigned using the QualSyst tool.

RESULTS

Nineteen studies were included. There was significant heterogeneity in study design and sample size. A random effects meta-analysis (n = 3-7) determined that people with lung cancer had higher odds of receiving hospital (odds ratio: 9.95, 95% confidence interval: 6.37-15.55, p < 0.001) or home-based palliative care (8.79, 6.76-11.43, p < 0.001), opioids (4.76, 1.87-12.11, p = 0.001), sedatives (2.03, 1.78-2.32, p < 0.001) and dying at home (1.47, 1.14-1.89, p = 0.003) compared to people with chronic obstructive pulmonary disease. People with lung cancer had lower odds of receiving invasive ventilation (0.26, 0.22-0.32, p < 0.001), non-invasive ventilation (0.63, 0.44-0.89, p = 0.009), cardiopulmonary resuscitation (0.29, 0.18-0.47, p < 0.001) or dying at a nursing home/long-term care facility (0.32, 0.16-0.64, p < 0.001) than people with chronic obstructive pulmonary disease. Symptom burden and health-related quality of life were relatively similar between the two populations.

CONCLUSION

People with chronic obstructive pulmonary disease receive less palliative measures at the end of life compared to people with lung cancer, despite a relatively similar symptom profile.

Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive, incurable illness, which leads to significant morbidity over long periods of time and mortality. Treatment aims to reduce symptoms, improve exercise capacity and quality of life, reduce exacerbations, slow disease progression and reduce mortality. However, breathlessness is common in patients with advanced COPD and remains undertreated. As all reversible causes of breathlessness are being optimally managed, consideration should be given to specific non-pharmacological and pharmacological treatment strategies for breathlessness. Low dose morphine has been shown to reduce safely and effectively breathlessness in patients with severe COPD and refractory dyspnoea. However, despite numerous guidelines recommending opioids in this clinical setting, many barriers limit their uptake by clinicians. Integration of palliative care earlier in the disease course can help to improve symptom control for people with severe COPD and refractory breathlessness. A multidisciplinary approach involving both respiratory and palliative care teams offers a new model of care for these patients.

Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study

OBJECTIVE

To evaluate the safety of benzodiazepines and opioids in patients with very severe chronic obstructive pulmonary disease (COPD).

DESIGN

Population based longitudinal consecutive cohort study.

SETTING

Centres prescribing long term oxygen therapy in Sweden.

PATIENTS

2249 patients starting long term oxygen therapy for COPD in Sweden between 2005 and 2009 in the national Swedevox Register.

MAIN OUTCOME MEASURES

Effects of benzodiazepines and opioids on rates of admission to hospital and mortality, adjusted for age, sex, arterial blood gases, body mass index (BMI), performance status, previous admissions, comorbidities, and concurrent drugs.

RESULTS

1681 (76%) patients were admitted to hospital, and 1129 (50%) died under observation. No patient was lost to follow-up. Benzodiazepines and opioids were not associated with increased admission: hazard ratio 0.98 (95% confidence interval, 0.87 to 1.10) and 0.98 (0.86 to 1.10), respectively. Benzodiazepines were associated with increased mortality (1.21, 1.05 to 1.39) with a dose response trend. Opioids also had a dose response relation with mortality: lower dose opioids (≤ 30 mg oral morphine equivalents a day) were not associated with increased mortality (1.03, 0.84 to 1.26) in contrast with higher dose opioids (1.21, 1.02 to 1.44). Concurrent benzodiazepines and opioids in lower doses were not associated with increased admissions (0.86, 0.53 to 1.42) or mortality (1.25, 0.78 to 1.99). Associations were not modified by being naive to the drugs or by hypercapnia.

CONCLUSIONS

Lower dose opioids are not associated with increased admissions or deaths in patients with COPD and might be safe for symptom reduction in severe respiratory disease.

A checklist for ascertaining study cohorts in oncology health services research using secondary data: report of the ISPOR oncology good outcomes research practices working group

OBJECTIVES

The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source.

METHODS

A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist.

RESULTS

The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others.

CONCLUSIONS

This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.

Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline

Dyspnea is a cardinal symptom of chronic obstructive pulmonary disease (COPD), and its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on quality of life. Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. There are many questions concerning optimal management and, specifically, whether various therapies are effective in this setting. The present document was compiled to address these important clinical issues using an evidence-based systematic review process led by a representative interprofessional panel of experts. The evidence supports the benefits of oral opioids, neuromuscular electrical stimulation, chest wall vibration, walking aids and pursed-lip breathing in the management of dyspnea in the individual patient with advanced COPD. Oxygen is recommended for COPD patients with resting hypoxemia, but its use for the targeted management of dyspnea in this setting should be reserved for patients who receive symptomatic benefit. There is insufficient evidence to support the routine use of anxiolytic medications, nebulized opioids, acupuncture, acupressure, distractive auditory stimuli (music), relaxation, handheld fans, counselling programs or psychotherapy. There is also no evidence to support the use of supplemental oxygen to reduce dyspnea in nonhypoxemic patients with advanced COPD. Recognizing the current unfamiliarity with prescribing and dosing of opioid therapy in this setting, a potential approach for their use is illustrated. The role of opioid and other effective therapies in the comprehensive management of refractory dyspnea in patients with advanced COPD is discussed.

[Alveolar epithelial cell injury as an etiopathogenic factor in pulmonary fibrosis]

Idiopathic pulmonary fibrosis (IPF) is characterized by a progressive accumulation of extracellular matrix and an imbalance between profibrotic and antifibrotic mediators. In the last few years, understanding of the mechanisms of the biology of IPF has increased. One of the most significant discoveries is the finding that alveolar epithelial cell injury plays an important role in the pathogenesis of this disease. In this review, we describe some of the mechanisms involved in alveolar cell injury and their contribution to the development of IPF.

Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease

BACKGROUND

A recent national practice guideline recommends the use of opioids for the treatment of refractory dyspnea in patients with advanced chronic obstructive pulmonary disease (COPD). We conducted two qualitative studies to explore the experiences of patients and family caregivers with opioids for refractory COPD-related dyspnea and the perspectives and attitudes of physicians toward opioids in this context.

METHODS

Patients (n = 8; 5 men, 3 women), their caregivers (n = 12; 5 men, 7 women) and physicians (n = 28, 17 men, 11 women) in Nova Scotia participated in the studies. Semistructured interviews were recorded, transcribed verbatim, coded conceptually and analyzed for emergent themes using interpretive description methodology.

RESULTS

Patients reported that opioids provided a sense of calm and relief from severe dyspnea. Family caregivers felt that opioids helped patients to breathe more "normally," observed improvements in patients' symptoms of anxiety and depression, and experienced reductions in their own stress. Patients reported substantial improvements in their quality of life. All patients and family caregivers wanted opioid therapy to continue. Most physicians were reluctant to prescribe opioids for refractory dyspnea, describing a lack of related knowledge and experience, and fears related to the potential adverse effects and legal censure.

INTERPRETATION

Discrepancies between the positive experiences of patients and family caregivers with opioids and the reluctance of physicians to prescribe opioids for refractory dyspnea constitute an important gap in care. Bridging this gap will require initiatives to improve the uptake of practice guidelines and to increase confidence in prescribing opioids for dyspnea refractory to conventional treatment.