Introduction : Les personnes atteintes de cancer et vivant à domicile sont de plus en plus en nombreuses. Les proches aidants sont des acteurs importants auprès de la personne malade. Ils sont confrontés, à ce titre, aux douleurs cancéreuses sévères de leur proche. La douleur est l’un des symptômes les plus fréquents en cancérologie, souvent insuffisamment soulagée. L’objectif de cette étude était de mieux connaître la perception qu’ont les proches aidants de leur rôle à domicile, particulièrement vis-à-vis de la douleur liée au cancer et de ses traitements.
Méthode : Une étude qualitative a été menée au moyen d’entretiens semi-dirigés auprès de proches aidants de patients atteints d’un cancer en phase palliative spécifique ou symptomatique et présentant des douleurs nécessitant l’administration d’opioïdes. Les thèmes explorés ont été la communication, l’anticipation, la coordination, l’accompagnement et l’adaptation.
Résultats : Douze entretiens ont été réalisés. La plupart des proches aidants disent se rendre disponibles pour le confort du patient, la surveillance des symptômes et l’usage des opioïdes. Ces derniers sont sources de nombreux questionnements. En outre, les proches aidants se sentent responsables de tout faire et de s’organiser pour faire face à la douleur. Enfin, ils se considèrent comme les mieux placés pour soutenir au quotidien le patient, tant pour les aspects pratiques que socio-affectifs. Les professionnels de santé, en particulier les infirmiers libéraux, sont des éléments importants sur lesquels ils peuvent s’appuyer.
Discussion : L’enjeu pour les proches aidants est de conforter leur rôle dans le soulagement des douleurs du malade à domicile. Communiquer, coordonner les différents acteurs et participer aux prises de décision sont les moyens d’y parvenir mais ces fonctions sont variables dans le temps. Il convient de trouver l’équilibre dans la charge qui leur incombe. Cela invite les professionnels à être attentifs à leurs besoins en proposant une aide flexible et adaptée à chaque situation.
Background: The opioid epidemic has spurred investigations for nonopioid options, yet limited research persists on medical marijuana's (MMJ) efficacy in managing cancer-related symptoms.
Objective: We sought to characterize MMJ's role on symptomatic relief and opioid consumption in the oncologic population.
Design: Retrospective chart review of MMJ-certified oncology patients was performed. Divided patients into MMJ use [MMJ(+)] versus no use [MMJ(-)], and Edmonton Symptom Assessment System (ESAS)-reported pain cohorts: “mild-moderate” versus “severe.”
Measurements: Medical records were reviewed for ESAS, to measure physical and emotional symptoms, and opiate consumption, converted into morphine milligram equivalents (MME). Minimal clinically important differences were determined. Wilcoxon signed-rank tests determined statistical significance between MMJ-certification and most recent palliative care visit.
Results: Identified 232 patients [95/232 MMJ(-); 137/232 MMJ(+)]. Pain, physical and total ESAS significantly improved for total MMJ(-) and MMJ(+); however, only MMJ(+) significantly improved emotional ESAS. MMJ(-) opioid consumption increased by 23% (97.5–120 mg/day MME, p = 0.004), while it remained constant (45–45 mg/day MME, p = 0.522) in MMJ(+). Physical and total ESAS improved in mild-moderate-MMJ(-) and MMJ(+). Pain and emotional symptoms worsened in MMJ(-); while MMJ(+)'s pain remained unchanged and emotional symptoms improved. MMJ(-) opioid consumption increased by 29% (90–126 mg/day MME, p = 0.012); while MMJ(+)'s decreased by 33% (45–30 mg/day MME, p = 0.935). Pain, physical, emotional, and total ESAS scores improved in severe-MMJ(-) and MMJ(+); opioid consumption reduced by 22% in MMJ(-) (135–106 mg/day MME, p = 0.124) and 33% in MMJ(+) (90–60 mg/day MME, p = 0.421).
Conclusions: MMJ(+) improved oncology patients' ESAS scores despite opioid dose reductions and should be considered a viable adjuvant therapy for palliative management.
Nalbuphine (Nubain) is a unique opioid analgesic that was first manufactured in the 1970s. It is not a controlled substance in the United States as it was removed from the shedule II drug list in 1976 in response to assuring safety data. Considering ongooing opioid shortages in the acute settings, it is prudent to re-examine malbuphine as an analgesic for serious ill patients.
Cancer-related incident bone pain is a form of breakthrough pain caused by movement and is most commonly associated with bone metastases. it is often distinguished from other common forms of bone pain such as arthritis or the pain associated from the administration of filgrastim-like products that are usually constant in nature and worse at night. Management of incident bone pain often requires a multimodal approach as the onset of oral immediate release (IR) opioids may be too slow to address a rapid-onset pain elicited by activity. Cancer-related incident bone pain is correlated with a decreased patient-reported quality of life, a reduced functional capacity, as well as increased psychological distress. Although there is not a clear association with the size, location, or number of bone metastasis, ~70% of patients with bone metastases will develop pain.
Background: Palliative care (PC) teams increasingly care for patients with cancer into survivorship. Cancer survivorship transcends distinctions between acute, chronic, malignant, and nonmalignant pain. Partnering with oncologists, PC teams manage pain that persists after disease-directed treatment, evaluate changing symptoms as possible signs of cancer recurrence, taper opioids and mitigate risk of opioid misuse, and manage comorbid opioid use disorder (OUD). While interdisciplinary guidelines exist for pain management in survivorship, there is a need to develop a conceptual model that fully translates the biopsychosocial framework of PC into survivorship pain management.
Objective: This review frames a model for pain management in cancer survivorship that balances analgesia with the imperative to minimize risk of OUD, recognizes signs of disease recurrence, and provides whole-person care.
Methods: Comprehensive narrative review of the literature.
Results: Little guidance exists for co-management of pain, psychological distress, and opioid misuse in survivorship. We identified themes for whole-person pain management in survivorship: use of opioids and co-analgesic medications to prevent recurrent pain from residual tissue damage following cancer treatment, opioid tapering to the lowest effective dose, utilization of nonpharmacologic psychological interventions shown to reduce pain, screening for and management of OUD in partnership with addiction medicine specialists, maintaining vigilance for disease recurrence, and engaging in shared medical decision making.
Conclusions: The management of pain in cancer survivorship is complex and requires interdisciplinary care that balances analgesia with the imperative to reduce long-term inappropriate opioid use and manage OUD, while maintaining therapeutic presence with patients in the spirit of PC.
CONTEXT: Patients with cancer face symptoms due to disease and treatment, and pain is common and complex. The opioid crisis may complicate patients' and clinicians' experiences of managing pain in cancer care.
OBJECTIVES: In our study of perceptions and experiences with palliative care at an outpatient cancer center, we examined communication around symptom management throughout cancer care, and pain and its management emerged as particularly salient. The objective of this paper is to describe, from the perspectives of patients, caregivers, and oncology healthcare professionals, the role of palliative care in navigating the complicated dynamics of pain management amidst the opioid crisis.
METHODS: A qualitative descriptive study with grounded theory components was designed to investigate experiences with and perceptions of specialist palliative care and symptom management, including pain. Interviews were audio-recorded and transcribed, and focused coding identified themes related to pain and pain management from all three perspectives.
RESULTS: 44 patients, caregivers, and non-palliative care healthcare professionals completed interviews. Patients with cancer and their caregivers had many concerns about pain management and were specifically concerned about opioid use and stigma. For patients, palliative care improved pain management and helped to de-stigmatize appropriate pain management. Oncology clinicians reported that partnering with palliative care facilitated complex pain management and also provided moral support around difficult opioid recommendations for patients.
CONCLUSION: Palliative care offers the potential to uniquely support both patients and other oncology professionals in optimally navigating the complexity around pain management for cancer care in the midst of the opioid crisis.
PURPOSE: Little information exists on factors that predict opioid misuse in oncology. We adopted the Screener and Opioid Assessment for Patients With Pain-Short Form (SOAPP-SF) and toxicology testing to assess for opioid misuse risk. The primary objective was to (1) identify characteristics associated with a high-risk SOAPP-SF score and noncompliant toxicology test, and (2) determine SOAPP-SF utility to predict noncompliant toxicology tests.
METHODS: From July 1, 2017, to December 31, 2017, new patients completed the Edmonton Symptom Assessment Scale (ESAS), SOAPP-SF, and narcotic use agreement. Toxicology test results were collected at subsequent visits.
RESULTS: Of 223 distinct patients, 96% completed SOAPP-SF. Mean age was 61 ± 12.7 years, 58% were female, 68% were White, and 28% were Black. Eighty-three eligible patients (38%) completed toxicology testing. Younger age, male sex, and increased ESAS depression scores were associated with high-risk SOAPP-SF scores. Smoking habit was associated with an aberrant test. An SOAPP-SF score >= 3 predicted a noncompliant toxicology test.
CONCLUSION: Male sex, young age, and higher ESAS depression score were associated with a high SOAPP-SF score. Smoking habit was associated with an aberrant test. An SOAPP-SF of >= 3 (sensitivity, 0.74; specificity, 0.64), not >= 4, was predictive of an aberrant test; however, performance characteristics were decreased from those published by Inflexxion, for >= 4 (sensitivity, 0.86; specificity, 0.67). The specificity warrants caution in falsely labeling patients. The SOAPP-SF may aid in meeting National Comprehensive Cancer Network recommendations to screen oncology patients for opioid misuse.
Background: Patients with cancer-related pain use opioids for nociceptive pain, while gabapentinoids are common to treat neuropathic pain. The simultaneous use of opioids with gabapentinoids has been associated with an increased risk of opioid-related death.
Objectives: Determine the frequency of combined use of gabapentinoids among patients receiving opioids for cancer-related pain. We also examined if concomitant use of opioids and gabapentinoids together was associated with increased scores of fatigue and drowsiness on the Edmonton Symptom Assessment Scale (ESAS) compared to patients on opioids.
Design: Retrospective study of patients on opioids and opioids plus gabapentinoids at their third visit to the outpatient Supportive Care Center.
Results: We found that 48% (508/1059) of patients were on opioids. Of these patients, 51% (257/508) were on opioids only, and 49% (251/508) were on opioids plus gabapentinoids. The median (interquartile range [IQR]) morphine equivalent daily dose for patients on opioids was 75 (45, 138) mg, and opioids plus gabapentinoids was 68 (38, 150) mg (p = 0.94). The median (IQR) gabapentinoid equivalent daily dose was 900 (300, 1200) mg. The median (IQR) for ESAS-fatigue in patients on opioids was 5 (3, 7), and opioids plus gabapentinoids was 5 (3, 7) (p = 0.27). The median (IQR) for ESAS-drowsiness in patients on opioids was 3 (0, 5), and opioids plus gabapentinoids was 3 (0, 6) (p = 0.11).
Conclusion: Almost 50% of advanced cancer patients receiving opioids for pain were exposed to gabapentinoids. Maximal efforts should be made to minimize potential complications from the concomitant use of opioids with gabapentinoids.
Introduction : En France, la méthadone est autorisée uniquement comme traitement de substitution. Elle peut être utilisée pour les douleurs liées au cancer. Le but de cette étude est d’évaluer l’efficacité et les effets secondaires de la méthadone dans cette indication.
Méthode : Il s’agit d’une étude rétrospective de janvier 2010 à février 2011, incluant tous les patients recevant de la méthadone pour la première fois. Le soulagement était considéré comme obtenu si l’intensité de la douleur était inférieure ou égale à 3/10 sur l’échelle d’évaluation numérique (EN) ou inférieure ou égale à 30/100 sur une échelle visuelle analogique (Eva), à j7 et j28. Les effets secondaires et leur persistance ont été explorés pendant l’instauration, à j7 et j28.
Résultats : Vingt-deux patients ont été inclus. Vingt patients ont été évalués au 7e jour, dix-huit patients à 28e. À j7, seize patients (80 %) étaient soulagés et onze (61 %) au 28e jour. Peu de patients ont présenté des effets indésirables : 8 patients (40 %) à j7 et 3 (16,7 %) à j28.
Conclusion : La méthadone est un traitement utile contre la douleur cancéreuse, en particulier pour la douleur cancéreuse rebelle et complexe.
This study aimed to analyze the trends of opioid use disorders, cannabis use disorders, and palliative care among hospitalized patients with gastrointestinal cancer and to identify their associated factors.
We analyzed the National Inpatient Sample data from 2005 to 2014 and included hospitalized patients with gastrointestinal cancers. The trends of hospital palliative care and opioid or cannabis use disorders were analyzed using the compound annual growth rates (CAGR) with Rao-Scott correction for 2 tests. Multivariate logistic regression analyses were performed to identify the associated factors.
From 2005 to 2014, among 4,364,416 hospitalizations of patients with gastrointestinal cancer, the average annual rates of opioid and cannabis use disorders were 0.4% (n = 19,520), and 0.3% (n = 13,009), respectively. The utilization rate of hospital palliative care was 6.2% (n = 268,742). They all sharply increased for 10 years (CAGR = 9.61%, 22.2%, and 21.51%, respectively). The patients with a cannabis use disorder were over 4 times more likely to have an opioid use disorder (Odds ratios, OR = 4.029; P < .001). Hospital palliative care was associated with higher opioid use disorder rates, higher in-hospital mortality, shorter length of hospital stay, and lower hospital charges. (OR = 1.527, 9.980, B = -0.054 and -0.386; each of P < .001).
The temporal trends of opioid use disorders and hospital palliative care use among patients with gastrointestinal cancer increased from 2005 to 2014, which is mostly attributed to patients with a higher risk of in-hospital mortality. Cannabis use disorders were associated with opioid use disorders. Palliative care was associated with both reduced lengths of stay and hospital charge.
Context: Limited access to opioids for cancer patients has been reported as a potential unintended consequence of recent regulations restricting opioid use and prescribing practices. To our knowledge, there are a limited number of peer-reviewed studies that evaluate cancer patients’ perceived difficulties when filling their opioid prescription. To understand these difficulties, we surveyed patients receiving opioids in our outpatient Supportive Care Center (SCC).
Objectives: The primary objective of this study was to evaluate cancer patients’ perceptions of overall difficulties when filling their opioid prescription. Secondary objectives included determining associations between patient characteristics and difficulty, and comparing difficulty between filling opioid and non-opioid prescriptions.
Methods: Cancer patients receiving opioids that had been seen two times or more at our SCC were asked to complete a survey. The information collected included patient demographics, clinical characteristics, and patients’ experiences filling their opioid prescription.
Results: The patients’ median age was 60 years; 54% were female and 69% were white. Forty-four patients (32%) reported that they have experienced difficulty filling their opioid prescription. More than 25% of those 44 patients perceived difficulty from interactions with the pharmacy/pharmacist. Forty-six patients (33%) reported more difficulty filling their opioid prescriptions than filling their non-opioid prescriptions.
Conclusions: This study provides evidence that patients with cancer visiting our SCC perceived difficulties obtaining their opioid prescriptions. The results suggest that negative interactions with the pharmacy/pharmacist contributes to their perceived difficulty. Additional research is needed to further characterize the contributors of the difficulties cancer patients face in filling their opioid prescriptions.
Coronavirus disease 2019 (COVID-19) has brought a tsunami of suffering that is devastating even well resourced countries. The disease has wreaked havoc on health systems and generated immense losses for families, communities, and economies, in addition to the growing death toll. Patients, caregivers, health-care providers, and health systems can benefit from the extensive knowledge of the palliative care community and by taking heed of long-standing admonitions to improve access to essential medicines, particularly opioids for the relief of breathlessness and pain.
Opioid addiction, if not well diagnosed and treated, can be a significant challenge for optimal pain management even in cancer patients. To date there is no definitive pharmacological standard of care for treating addiction, especially in this setting of patients. We present a clinical case series of three opioid-addicted advanced cancer patients, effectively treated with haloperidol, a well-known first-generation typical antipsychotic.
This article will focus on the following objectives specific to end-of-life care for professional case management:
Discuss recent industry topics that influence care processes.
Explore the opioid epidemic's impact on pain management.
Identify terms associated with end-of-life and life-limiting care.
Understand types of advance directives and care defining tools.
Define the purpose of psychiatric advance directives.
Discuss the shifting diagnostic face.
Discuss how inclusion manifests for the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) population.
Explore challenges working through adolescent decision making and treatment.
Review regulation and reimbursement shifts across the industry.
Identify the use of artificial intelligence.
Discuss the value of ethics committees in health care organizations.
Define the Four Cs of Care Considerations.
Identify ethical principles for consideration by the workforce.
Background/objectives: Opioids relieve symptoms in terminal care. We studied opioid underuse in long-term care facilities, defined as residents without opioid prescription despite pain and/or dyspnoea, 3 days prior to death.
Design and setting: In a proportionally stratified randomly selected sample of long-term care facilities in six European Union countries, nurses and long-term care facility management completed structured after-death questionnaires within 3 months of residents’ death.
Measurements: Nurses assessed pain/dyspnoea with Comfort Assessment in Dying with Dementia scale and checked opioid prescription by chart review. We estimated opioid underuse per country and per symptom and calculated associations of opioid underuse by multilevel, multivariable analysis.
Results: nurses’ response rate was 81.6%, 95.7% for managers. Of 901 deceased residents with pain/dyspnoea reported in the last week, 10.6% had dyspnoea, 34.4% had pain and 55.0% had both symptoms. Opioid underuse per country was 19.2% (95% confidence interval: 12.9–27.2) in the Netherlands, 25.2% (18.3–33.6) in Belgium, 29.3% (16.9–45.8) in England, 33.7% (26.2–42.2) in Finland, 64.6% (52.0–75.4) in Italy and 79.1% (71.2–85.3) in Poland (p < 0.001). Opioid underuse was 57.2% (33.0–78.4) for dyspnoea, 41.2% (95% confidence interval: 21.9–63.8) for pain and 37.4% (19.4–59.6) for both symptoms (p = 0.013). Odds of opioid underuse were lower (odds ratio: 0.33; 95% confidence interval: 0.20–0.54) when pain was assessed.
Conclusion: Opioid underuse differs between countries. Pain and dyspnoea should be formally assessed at the end-of-life and taken into account in physicians orders.
Les soins palliatifs sont une approche multidisciplinaire pour améliorer la qualité de vie des patients et leurs familles à tous les stades d’une maladie grave. Cette approche est accomplie en gérant les symptômes pénibles tels que la douleur et la dyspnée. La dyspnée réfractaire se caractérise par une difficulté respiratoire persistante au repos ou avec un effort minimal malgré un traitement optimal de la maladie sous-jacente. L’utilisation d’opioïdes a été bien documentée dans ce contexte ; cependant, l’hésitation persiste lors de la prescription d’opioïdes jusqu’aux étapes terminales de la maladie. Ce travail décrit les preuves actuelles de l’utilisation des opioïdes pour le traitement de la dyspnée en soins palliatifs, les protocoles et les voies de leur administration.
PURPOSE OF REVIEW: Opioids are the only class of drug with the proven ability to control severe pain. The introduction of stringent opioid prescribing restrictions has inevitably impacted upon the ability of those prescribing opioids for advanced life-limited disease to practice as previously and could limit the supply of adequate pain relief to patients with cancer. This review considers the evidence that symptom management of patients with advanced cancer contributes to the "opioid problem" and whether there is adequate recognition of the risks involved.
RECENT FINDINGS: The literature suggests that the risk of opioid abuse is low in the palliative care population as is the risk of legal consequences for doctors prescribing opioids at the end of life. However, as many patients with cancer are living longer or surviving with chronic pain, palliative care physicians must be cognisant not only of the risks of long term opioid use but also of the risk of opioid misuse. Adherence to evidence or consensus-based guidelines is necessary to avoid inappropriate prescribing. In palliative care, it is appropriate not only to exercise a reasonable degree of opioid control and surveillance, primarily for the good of society, but also to ensure that the ability to treat pain in patients with advanced malignant disease is not compromised.
Opioids are an effective treatment for patients with intractable pain. Long-term administration of opioids for pain relief is being delivered by an increasing number of medical providers in the United States including primary care physicians and nonspecialists. One common complication of chronic opioid use is sleep-disordered breathing which can result in various morbidities as well as an increase in all-cause mortality. It is important for providers to understand the relationship between opioids and sleep-disordered breathing as well as methods to improve diagnosis and strategies for treatment. This review aims to update clinicians on the mechanism, diagnosis, and treatment of opioid-related sleep-disordered breathing in order to improve the quality of care for patients with chronic pain.
OBJECTIVES: The purpose of this quality improvement (QI) project was to improve the overall process of implementing continuous subcutaneous infusion of opioids (CSCIOs) at the West Palm Beach Veterans Affairs Medical Center and characterize their use in the hospice unit.
METHODS: A retrospective chart review from July 2014 to August 2017 was conducted to identify patients who had received CSCIO. Results were analyzed with descriptive statistics.The business philosphy, LEAN methodology "The 5 Whys" was utilized to identify the root causes for delayed infusion timeliness and corrections were implemented by August 2018. Follow-up retrospective time study completed from September 2018 to February 2019.
RESULTS: Of the 107 patients identified, 7 were excluded and 100 were reviewed. The mean age was 73 years, 94% male, and 86% Caucasian. A total of 55 veterans received morphine with an average final infusion rate of 2.5 mg/h. A total of 45 Veterans received hydromorphone with a final infusion rate of 1.3 mg/h. The average infusion duration until death was 5 days. Pharmacy verified 94 (94%) orders and nursing verified 55 (55%) orders within 1 hour (gold standard). Sixteen (16%) patients received CSCIO within 1 hour. The 5 Whys identified nursing order verification and pharmacy lack of visual STAT order notification for priority as the potential sources for infusion timeliness improvement. The follow-up time study confirmed improvement in pharmacy delivery time from 29% to 75% on time.
CONCLUSION: Pharmacist-led intervention directed to improve CSCIO processes in an inpatient hospice unit utilizing LEAN QI methodology increased timeliness of pharmacy CSCIO delivery.
Given the challenges of symptom management during hospice care, patients require responsive opioid prescribing. Within the context of the national opioid crisis, medication diversion in hospice is an increasing concern.
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