In Norway, approximately 50% of older people die in nursing homes (NH). Holistic care and pharmacological management are key factors in quality at the end of life. The purpose of this longitudinal study was to describe the use of opioids in an NH during a 5-year period. We focused on palliative care, symptoms, and suffering during the last 3 days before death. Data were collected from spring 2013 to spring 2018. We used the interRAI assessment instrument annually and when the resident died. We conducted a semi-structured interview with nurses on duty at the deathbed. At the time of death, the residents had an average age of 88.9 years and an average stay of 2.9 years (N = 100). At the first assessment, 19% of the residents used 1 or more type of opioids. On the day of death, 55% had an active prescription for opioids, mainly as subcutaneous injections. The results illustrate the different uses of opioids, including managing pain, dyspnoea, sedation, for comfort, as a prophylaxis, or a combination of reasons. Cancer- and cardiovascular diagnoses were the strongest predictor for using morphine (P < 0.05). Identification of the residents’ needs for opioids is a challenge for palliative care nurses, both ethically and legally.
Background: Responding to an epidemic of opioid-related deaths, guidelines and laws have been implemented to promote safe opioid prescribing practices.
Objective: This study evaluates differences in screening practices and knowledge of laws between oncologists and cardiologists who prescribe opiates.
Design: Surveys regarding screening practices and knowledge of opioid prescribing laws were distributed in March 2017 to oncology and congestive heart failure (CHF) clinicians at the University of Virginia. Chi-square and Wilcoxon rank sum tests were used.
Results: Forty-six of 129 (35.6%) oncology providers and 7 of 14 (50%) CHF providers reported prescribing opiates in their clinic with usable survey results. The majority of oncology (65.22%) and cardiology (85.71%) providers report screening for substance abuse “when indicated” (p = 0.053). Only 19.6% of oncologists reported always using the prescription monitoring program (PMP), while 71.43% of cardiologists reported using it always (p = 0.014). Of the oncology providers, 66.67% report never using the urine drug screen (UDS), while 86.7% of cardiologists reported using it “when indicated” (p = 0.0086). Up to 34.78% of the oncologists and 57.14% of the cardiologists reported of never screening the family members for misuse (p = 0.317). Knowledge of laws was similar between groups, with 14.29% of cardiology and 17.39% of oncology providers reporting no knowledge of opioid prescribing laws (p = 0.2869).
Conclusions: Routine screening for substance misuse risk was uncommon for both groups, but cardiology providers were more likely to use the PMP or UDS. Knowledge gaps regarding Virginia laws were noted in both groups. Improved education regarding best practices and laws, as well as programs to promote screening, is needed for all providers.
BACKGROUND: More than 15,000 children die annually in the United States due to an underlying life-limiting disease and the majority of those children experience distressing symptoms, which are not adequately relieved, such as pain and dyspnea. Multimodal analgesia, that is multiple agents, interventions, rehabilitation, psychological modalities, and integrative (nonpharmacologic) therapies, act synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. However, opioids, such as morphine, fentanyl, hydromorphone, oxycodone, and methadone (in the United Kingdom: diamorphine) remain the mainstay medication to effectively treat pain and dyspnea in children with serious illness.
METHODS: This article reviews commonly used opioids in Pediatric Palliative Care, which a special emphasis on 2 potentially particularly effective multimechanistic opioids: tramadol and methadone.
RESULTS: Methadone, due to its multimechanistic action profile, is possibly among the most effective and most underutilized opioid analgesics in children with severe unrelieved pain at end of life. However, methadone should not be prescribed by those unfamiliar with its use: Its effects should be closely monitored for several days, particularly when it is first started and after any dose changes.
CONCLUSIONS: Tramadol appears to play a key role in treating episodes of inconsolability in children with progressive neurologic, metabolic, or chromosomally based condition with impairment of the central nervous system. However, the recent 2017 United States Food and Drug Administration (FDA) warning against pediatric use of tramadol does not seem to be based on clinical evidence, and therefore puts children at risk for unrelieved pain or increased respiratory depression.
Opiophobia is one of the principal causes of opioids' under-prescription in palliative care. From periods of abuse to times where their use was banned - which is still the case in some countries - the history of opioids is complex and it partially explains opiophobia. One of the main concern about the use of opioids is the risk of -dependence. Furthermore, scientific literature is not clear on this subject, in particular due to the fact that the scientific community has not yet come to an agreement on the terminology. This article shows, on the basis of specific studies, the predominance of opiophobia among the population and it outlines an historic overview of the use of opioids. In the last section, it focuses on the concept of dependence and the difficulty of measuring it in chronic opioid therapies.
BACKGROUND: Dyspnea is commonly found in most conditions among patients with progressive noncancer disease.
OBJECTIVE: To clarify the effectiveness and safety of opioid administration for the treatment of dyspnea immediately before death in patients with noncancer disease.
METHODS: A retrospective case-series study involving 13 consecutive terminally ill patients who were near death and diagnosed with noncancer disease, and had refractory dyspnea and received opioid therapy, was performed. The authors investigated the route of administration, period, dosage of opioids, intensity of dyspnea-scored according to the Japanese version of the Support Team Assessment Schedule-and clinical course from a review of medical records.
RESULTS: The mean age of the patients was 86.5 ± 7.6years (range: 72-98years). The primary causes of dyspnea that led to opioid administration were heart failure (n = 10) and respiratory failure (n = 3). Oxycodone was used in one patient who experienced a complication of chronic renal failure; morphine was used in the other 12 patients. The route of opioid administration was continuous infusions in 11 patients, suppository in one, and oral administration in one. The final dose of oral morphine equivalents was 20.1 ± 8.1 mg/d (range: 5-36 mg [median: 18 mg]). All patients improved in symptom score after opioid administration. The score was significantly decreased from 3.2 ± 0.7 at the beginning of opioid administration to 1.2 ± 0.6 at final estimation ( P < .001). No severe adverse events occurred.
CONCLUSIONS:: Low-dose opioid administration in patients with terminally ill noncancer improved dyspnea and occurred no severe adverse events.
Importance: The recent parenteral opioid shortage (POS) has potential implications for cancer-related pain management in hospitalized patients.
Objective: This study compared changes in opioid prescriptions and clinically improved pain (CIP) among patients treated by an inpatient palliative care (PC) team before and after our institution first reported the POS.
Design, Setting, and Participants: A cohort study of 386 eligible patients with cancer treated at a comprehensive cancer center 1 month before and after the announcement of the POS. We reviewed data from electronic health records, including patient demographics, opioid type, route of administration, and dose. Board-certified palliative care specialists assessed CIP at follow-up day 1.
Exposures: The announcement of the POS by the institution's pharmacy and therapeutics committee on February 8, 2018.
Main Outcomes and Measures: The primary outcome was to measure the change in opioid prescription patterns of physicians, and the secondary outcome was to measure the proportion of patients who achieved CIP before and after announcement of the POS.
Results: Of 386 eligible patients, 196 were men (51%), 270 were white (70%), and the median age was 58 years (interquartile range, 46-67 years). Parenteral opioids were prescribed less frequently by the referring oncology teams after the POS (56 of 314 [18%]) vs before the POS (109 of 311 [35%]) (P < .001). The PC team also prescribed fewer parenteral opioids after the POS (96 of 336 [29%]) vs before the POS (159 of 338 [47%]) (P < .001). After the POS (vs before the POS), significantly fewer patients achieved CIP on follow-up day 1 (119 [62%] vs 144 [75%] of 193; P = .01). Multivariate analysis showed that before the POS, patients had an 89% higher chance of achieving CIP on follow-up day 1 (odds ratio, 1.89; 95% CI, 1.22-2.94; P = .005).
Conclusions and Relevance: There was a significant change in opioid prescription patterns associated with the POS. Furthermore, after the POS, fewer patients achieved CIP. These factors have potential implications for patient satisfaction and hospital length of stay.
PURPOSE: High-strength opioid formulations were delisted (removed) from Ontario's public drug formulary in January 2017, except for palliative patients. We evaluated the impact of this policy on opioid utilization and dosing.
METHODS: We conducted a longitudinal study among patients receiving publicly funded, high-strength opioids from August 2016 to July 2017. The primary outcome measure was weekly median daily opioid dose (in milligrams of morphine or equivalent; MME) of (1) publicly funded and (2) all opioid prescriptions irrespective of funding source, evaluated using interrupted time series analyses and stratified by palliative care status.
RESULTS: Following policy implementation, the weekly median daily dose of publicly funded opioids decreased immediately among non-palliative patients by 10 MME (95% confidence limit [CL], -16.8 to -3.1) from a pre-intervention dose of 424.5 MME (95% CL, 417.8-431.2) and fell gradually among palliative patients by 3.9 MME per week (95% CL, -5.5 to -2.3) from a pre-intervention dose of 450.1 MME (95% CL, 432.5-467.7). In contrast, among all opioid prescriptions, gradual reductions in weekly median daily doses were observed only for non-palliative patients, which decreased by 0.7 MME per week (95% CL, -1.3 to -0.2) from a pre-intervention dose of 426.2 MME (95% CL, 420.9-431.5).
CONCLUSION: The delisting of publicly-funded, high-strength opioids was accompanied by changes in funding source and small reductions in the weekly median daily doses dispensed. Although observed dose reductions of less than 1 MME weekly are likely not clinically relevant, safety implications of these changes require further monitoring.
BACKGROUND: Opioid errors are a leading cause of patient harm and adversely impact palliative care inpatients' pain and symptom management. Yet, the factors contributing to opioid errors in palliative care are poorly understood. Identifying and better understanding the individual and system factors contributing to these errors is required to inform targeted strategies.
OBJECTIVES: To explore palliative care clinicians' perceptions of the factors contributing to opioid errors in Australian inpatient palliative care services.
DESIGN: A qualitative study using focus groups or semi-structured interviews.
SETTINGS: Three specialist palliative care inpatient services in New South Wales, Australia.
PARTICIPANTS: Inpatient palliative care clinicians who are involved with, and/or have oversight of, the services' opioid delivery or quality and safety processes.
METHODS: Deductive thematic content analysis of the qualitative data. The Yorkshire Contributory Factors Framework was applied to identify error-contributing factors.
FINDINGS: A total of 58 clinicians participated in eight focus groups and 20 semi-structured interviews. Nine key error contributory factor domains were identified, including: active failures; task characteristics of opioid preparation; clinician inexperience; sub-optimal skill mix; gaps in support from central functions; the drug preparation environment; and sub-optimal clinical communication.
CONCLUSION:: This study identified multiple system-level factors contributing to opioid errors in inpatient palliative care services. Any quality and safety initiatives targeting safe opioid delivery in specialist palliative care services needs to consider the full range of contributing factors, from individual to systems/latent factors, which promote error-causing conditions.
BACKGROUND: Methadone may play a role in the control of refractory cancer pain in opioid switching, although some cases fail to switch to methadone.
OBJECTIVE: To evaluate the differences in the clinical aspects in switching to methadone between successful cases (SCs) and unsuccessful cases (UCs).
DESIGN: This was a retrospective study of the clinical aspects of cancer patients who experienced opioid switching from other opioids to methadone.
SETTING/SUBJECTS: Eighty-seven patients who were prescribed oral methadone in our hospital were analyzed. Methadone was initiated from other opioids due to refractory pain in the stop-and-go switching. Among the 87 cases, 7 cases were excluded from further analysis because methadone administration was stopped due to vomiting or self-cessation within six days from switching.
RESULTS: Among the 80 cases who had methadone for seven days or more, 70 cases (SCs) were successful in switching to methadone, according to the Japanese definition, although 10 cases (UCs) who experienced the rapid progression of illness failed due to oral difficulty in the course of titration. In comparison of the clinical characteristics between SCs and UCs, the number of days alive from the start of the administration of methadone was significantly greater in the SCs than in the UCs (SCs: 87.1, UCs: 19, p < 0.0001), but no significant differences were observed for any other factors.
CONCLUSION: From this comparative retrospective study of opioid switching to methadone for cancer pain control between SCs and UCs, early switching to methadone may be useful for patients with advanced cancer pain.
With the increasing prevalence of the left ventricular assist device (LVAD) in patients with end-stage cardiomyopathies, an increasing number of these patients are dying of noncardiac conditions. It is likely that the palliative care clinician will have an ever-increasing role in managing end of life for patients with LVADs, including discontinuation of LVAD support. There exists a paucity of literature describing strategies for effective delivery of palliative care in patients requesting discontinuation of LVAD therapy. Here, we present a case of a patient with metastatic cancer who requested LVAD discontinuation. Because of practical concerns and patient preference, the patient did not have intravenous (IV) access and medications requiring IV administration could not be used. Therefore, a strategy using intranasal midazolam and sufentanil was applied, the LVAD was deactivated, and the patient died comfortably. This case is, to our knowledge, the first to describe a strategy for delivery of palliative care in patients requesting discontinuation of LVAD support, particularly in the absence of IV access. Such a strategy may be applicable to patients wishing to die at home, and therefore allow greater latitude for patients and clinicians in their approach to the end of life.
Cancer-related neuropathic pain (CNP) requires therapy involving multiple pharmaceuticals, including anticonvulsants and antidepressants; however, strong evidence to support this practice is limited. This study is a cross-sectional questionnaire-based survey. As the standard dose of adjuvant analgesics for CNP refractory to opioid therapy is not clear, the purpose of this study is to clarify the opinions of specialists about the usage of duloxetine and pregabalin for patients with CNP refractory to opioid therapy. Two hundred and eight certified palliative care specialists were surveyed and a total of 87 (42%) responses were analyzed. Twenty-five percent of specialists had considered increasing duloxetine doses up to 60 mg/day and 58% had considered increasing pregabalin doses up to 300 mg/day for CNP refractory to opioid therapy. However, 23% of the specialists succeeded in increasing duloxetine doses up to 60 mg/day and 17% in increasing pregabalin doses up to 300 mg/day, respectively.
BACKGROUND: Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety.
AIM: To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness.
DESIGN: Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909.
DATA SOURCES: Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools.
RESULTS: From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance.
CONCLUSION: This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.
The current opioid crisis in the United States is a major problem facing health-care providers, even at the end of life. Opioids continue to be the mainstay treatment for pain at the end of life, with the prevalence of pain reported in up to 80% of patients and tends to increase as one gets closer toward the end of life. In the past year, 20.2 million Americans had a substance use disorder (SUD) and SUDs are disabling disorders that largely go untreated. In addition, the coexistence of both a mental health and SUD is very common with the use of opioids often as a means of chemical coping. Most hospice programs do not have standardized SUD policies/guidelines in place despite the increasing concerns about substance abuse within the United States. The goal of this article is to review the literature on this topic and offer strategies on how to manage pain in patients who have active SUD or who are at risk for developing SUD in those dying on hospice.
Opioid and sedative use are common 'active' practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas' Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt-and therefore weaken-the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.
BACKGROUND: Cancer pain remains a difficult problem, for which opioids are often necessary. At present it is difficult to predict the effectiveness of opioid therapy.
OBJECTIVES: We aim to assess the association between patient characteristics and opioid treatment response in cancer patients, and develop a model to predict probability of response.
SUBJECTS: We used data from two previously published randomized clinical trials, in which patients with head and neck cancer were treated with fentanyl or methadone (total N = 134).
MEASUREMENTS: Treatment success was defined as =50% pain reduction at one and five weeks. We analyzed patient characteristics (age, sex, depression, and anxiety), treatment characteristics (having had chemotherapy, radiotherapy, surgery, methadone, or fentanyl) and pain characteristics (neuropathic and nociceptive).
DESIGN: Based on univariable and multivariable regression analyses determinants of therapy success were assessed. Based on these analyses a prediction model was developed.
RESULTS: Our analyses show that one-week therapy success was associated with methadone (odds ratio [OR] = 5.21), duration of pain in months (OR = 1.12), neuropathic pain (OR = 3.36), and age of the patient in years (OR = 0.95). Inclusion of these four characteristics into our prediction model resulted in an area under the curve of 81.6%.
CONCLUSIONS: Careful analyses of patient attributes, treatment, and pain type of patients with head and neck cancer resulted in a prediction model that allowed to predict short-term pain relief and the opioid treatment response in neuropathic and nociceptive pain owing to cancer.
CONTEXT: Chronic pain, or pain lasting > 3 months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT).
OBJECTIVE: Our objective was to explore palliative care providers' experiences with managing chronic pain in cancer survivors prescribed LTOT, specifically in ambulatory palliative care settings, and their strategies for overcoming challenges.
METHODS: We recruited providers through leading national palliative care organizations who manage chronic pain in cancer survivors. Asked to consider only cancer survivors with chronic pain when responding, participants completed an online survey that included questions about use of opioid risk mitigation tools, confidence in addressing opioid misuse behaviors and discussing/recommending management approaches, and access to addiction treatment.
RESULTS: Of 157 participants, most were physicians (83%) or nurse practitioners (15%). Most reported using opioid risk mitigation tools such as urine drug testing (71%), opioid treatment agreements (85%), and practitioner database monitoring programs (94%). Participants were confident (7-8/10) managing the most commonly encountered opioid misuse behaviors (missing appointments, marijuana use, and using more opioids than prescribed) and in their ability to recommend non-pharmacologic and non-opioid pharmacologic treatments for chronic pain (10/10). They were least confident prescribing naloxone or managing addiction (5/10); only 27% reported having training or systems in place to address addiction. Only 13% had a waiver to prescribe buprenorphine.
CONCLUSION: Palliative care providers are comfortable with many aspects of managing chronic pain in cancer survivors on LTOT, although challenges persist, including the lack of systems-based approaches and training in addiction treatment.
Background: Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF).
Methods: In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents' care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics.
Results: Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0-25.8) of residents in Poland to 77.9% (95% CI: 69.5-84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4-9.1) in Finland to 22.4% (95% CI: 14.7-32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6-12.8) in Finland to 47.9% (95% CI: 38.5-57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010).
Conclusions: Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases.
OBJECTIVES: This study investigated the use of opioid treatment plans that included the implementation of opioid dependence risk with a validated screening tool and opioid dependence risk tool (UDT) in a noncancer palliative pain clinic.
METHODS: We retrospectively reviewed the medical records for diagnostic information, information on analgesic medications, daily morphine equivalent dose, presence of pain management agreements and opioid dependence risk tools (ORT), and UDT. We recorded hospital days and emergency department visits.
RESULTS: Seventy-four patients were followed for a mean of 15.9 months. Ninety-three percent of patients had pain management agreements and 74% had ORT. The median score was 8: consistent with a high risk. More than half had UDT and 17.6% of patients had unexpected findings. Fifty-nine percent of patients had a psychiatric diagnosis. Hospital days and emergency department visits decreased by more than 30% ( P = .015 and P = .019). Significance of Findings: Both mental health problems and aberrant drug use were common in patients seen in a noncancer palliative care clinic. There were significant reductions in acute care utilization in the 12 months post intake in the clinic.
OBJECTIVE: The goal of this study was to examine the association between available patient and clinical characteristics and healthcare utilization in a cohort of breast, lung, and colorectal cancer patients within a safety-net hospital system.
METHODS: Data for 979 breast, lung, and colorectal cancer patients admitted to a large, urban hospital for the year 2010 were extracted from the electronic medical record (EMR). Univariate and multivariate logistic regression analyses were performed to examine the association between relevant independent variables that were able to be captured from the EMR in discrete fields, emergency room (ER) utilization, and hospitalizations among members of the cohort. Spearman correlation coefficients to test the correlations between nonsteroidal anti-inflammatory drug and opioid prescriptions and healthcare utilization were also calculated.
RESULTS: Of the 979 patients, 22% were 65 years and older, 43% were non-Hispanic black, 42% had Medicare, and 56% had colorectal cancer. Patient and clinical characteristics that were associated with increased ER utilization, included Hispanic ethnicity (adjusted odds ratio; AOR: 2.21, 95% confidence interval; CI: 1.52–3.21), non-Hispanic black race (AOR: 2.01, 95% CI: 1.43–2.82), and referral to palliative care (AOR: 2.15, 95% CI: 1.36–3.41). Referral to palliative care (AOR: 3.84, 95% CI: 1.47–10.0), low albumin (AOR: 2.42, 95% CI: 1.20–4.89), and presence of metastases (AOR: 1.98, 95% CI: 1.29–3.06) were associated with greater odds of hospitalization. Number of opioids prescribed strongly correlated with number of hospitalizations ( correlation = 0.74). Only 10.6% of patients had been referred to outpatient palliative care during the study period.
CONCLUSIONS: Some patient and clinical characteristics associated with increased ER visits and hospitalizations in this cohort include race/ethnicity, palliative care referral, markers of advanced disease, and number opioids prescribed. Increasing knowledge of palliative care and access to palliative care among the underserved should be a focus of future research.