Ces recommandations de la Haute Autorité de Santé ont pour objectifs de mieux définir les modalités d'utilisation des traitements médicamenteux, en particulier hors AMM, en situation palliative et phase terminale chez l'adulte :
- pour l'antalgie des douleurs rebelles ou la prévention des douleurs rebelles provoquées ;
- pour la sédation, qu'elle soit proportionnée ou profonde et continue maintenue jusqu'au décès ;
- y compris, le cas échéant, les modalités spécifiques au domicile.
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CONTEXT: It is uncertain whether terminally ill schizophrenic cancer patients are hypoalgesic or have disparities in pain management.
OBJECTIVES: To analyze the dosage of opioids used in terminally ill cancer patients with and without schizophrenia.
METHODS: This is a population-based retrospective cohort study based on data derived from the Taiwan National Health Insurance Research Database. Patients aged > 20 and newly diagnosed between 2000 and 2012 with at least one of the six most common cancers were included. After 1:4 matching, 1001 schizophrenic cancer patients comprised the schizophrenia cohort, while 4004 cancer patients without schizophrenia comprised the non-schizophrenia cohort. The percentage of opioid use, accumulated dose, and average daily dose near the end of life were analyzed for each cohort using multiple logistic and linear regression models.
RESULTS: The percentage of opioid use was lower in the schizophrenic cohort than the non-schizophrenic cohort during the last month prior to death [69.6 % versus 84.8%, odd ratio (OR) = 0.40, 95% confidence interval (CI) = 0.34-0.48]. The accumulated dose of opioid consumption was also lower in the schizophrenic cohort (2407 mg versus 3694 mg, p value <0.05).
CONCLUSION: Near the end of life, cancer patients with schizophrenia use less opioid than their non-schizophrenic counterparts. Cognitive impairment may be a cause in the disparity in end-of-life care for terminally ill schizophrenic cancer patients. Thus, we should formulate a more accurate pain scale system and pay attention to their need for pain treatment.
Background: To the best of our knowledge, the change in opioid prescription patterns upon referral to a palliative care team (PCT) was not previously investigated in the Middle East.
Objective: This study aimed to explore the change in the pattern of opioid prescription and the pain scores before and after referring inpatients to a PCT.
Methods: We conducted a retrospective review of patients’ records including all inpatients =15 years newly referred to the PCT over a period of 21 months at King Faisal Specialist Hospital and Research Center, Riyadh.
Results: Of 631 patients, 52.3% were females, the median age was 54 years, and 96.7% had cancer. The proportion of patients on opioids before referral (83.4%) increased to 93.3% in the postreferral period, P < .0001. Patients receiving opioids on a regular basis increased from 31.9% before referral to 49.9% after referral to the PCT, P < .0001. Morphine was the most commonly prescribed opioid on a regular basis pre- and postreferral. Upon referral, the administration of opioids through the subcutaneous route increased from 3.7% to 10.9%, P < .0001. On average, pain scores were reduced by 1 point on a 0 to 10 numeric scale within 48 hours of seeing a patient by the PCT, P < .0001.
Conclusion: Patients referred to a PCT are likely to get their opioid prescription optimized and pain scores improved shortly after the PCT involvement. Patients with cancer-related pain requiring opioids should be referred to a PCT as early as possible.
Background: This study aimed to assess the characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain in comparison with patients receiving at least 60 mg of oral morphine equivalents (OME).
Materials and Methods: Patients with advanced cancer receiving less than 60 mg/day of OME with episodes of BTcP were included in the analysis (group L). Data were compared with patients receiving doses of opioids =60 mg of OME (group H). Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded.
Results: A total of 1,418 and 2,474 patients were included in groups L and H, respectively. A lower number of BTcP episodes (p = .005), a lower BTcP intensity (p = .0001), a faster BTcP onset (p = .024), and a longer time to meaningful pain relief after taking a BTcP medication (p = .009) were found in group L as compared with group H. In group L, BTcP interference on daily activity was less than in group H (p = .009). Patients in group L were less likely to be prescribed an opioid as BTcP medication in comparison with patients in group H (p = .0001). Opioid doses used for BTcP were significantly higher in group H. Patients in group L were more likely to be less satisfied (p = .003) than patients in group H. No adverse effects of severe intensity were reported in both groups.
Conclusion: Patients receiving lower doses of opioids exhibit some differences in BTcP presentation: fewer episodes with lower intensity and a faster onset, a longer time to meaningful pain relief, and less satisfaction with BTcP medication. A relevant percentage of patients was receiving fentanyl preparations normally reserved for patients receiving higher doses of opioids.
Most pediatric clinicians aspire to promote the physical, emotional, and developmental well-being of children, hoping to bestow a long and healthy life. Yet, some infants, children, and adolescents confront life-threatening illnesses and life-shortening conditions. Over the past 70 years, the clinician's response to the suffering of these children has evolved from veritable neglect to the development of pediatric palliative care as a subspecialty devoted to their care. In this article, we review the history of how clinicians have understood and responded to the suffering of children with serious illnesses, highlighting how an initially narrow focus on anxiety eventually transformed into a holistic, multidimensional awareness of suffering. Through this transition, and influenced by the adult hospice movement, pediatric palliative care emerged as a new discipline. Becoming a discipline, however, has not been a panacea. We conclude by highlighting challenges remaining for the next generation of pediatric palliative care professionals to address.
Context: The effect of methadone on corrected QT interval (QTc) in patients with cancer pain is not well-known.
Objectives: To describe and characterize the effect of low-, moderate-, and high-dose enteral methadone on QTc interval in patients with cancer.
Methods: Retrospective cohort study including patients prescribed enteral methadone during the 27-month study period. Participants were divided into 3 methadone daily dose groups: <30 (low dose), 30 to 59 (moderate dose), =60 (high dose) mg. The primary outcome was the incidence of QTc prolongation (>450 ms for females and >430 ms for males). Secondary outcomes included the magnitude of change in QTc after starting methadone, the incidence of clinically significant QTc prolongation (>500 ms) and the prevalence of torsades de pointes and syncope.
Results: Two hundred three patients met study inclusion criteria: 91 (45%) low dose, 52 (26%) moderate dose, and 60 (29%) high dose. Incidence of QTc prolongation for low-, moderate-, and high-dose groups was 50 (55%), 37 (71%), and 43 (72%), respectively (P = .039, low vs high dose). Incidence of clinically significant QTc prolongation was 10 (11%), 4 (8%), and 7 (12%) for low-, moderate-, and high-dose groups. For patients without QTc prolongation prior to initiating methadone, 62% of moderate-dose patients and 67% of high-dose patients had QTc prolongation, while taking methadone.
Conclusion: This study found a notably high incidence of QTc prolongation in patients with cancer using enteral methadone. Future studies should aim to determine the risk of adverse cardiac effects in the cancer population and determine appropriate monitoring of methadone for pain management.
Introduction: Intravenous lidocaine is an option for intractable pain caused by advancing cancer and wound care. We report a case of intractable cancer pain and wound care pain managed with concurrent use of lidocaine administered as a twice daily intravenous bolus in addition to continuous intravenous infusion.
Case Description: A 31-year-old male with rapidly progressing locally advanced squamous cell cancer affecting the gluteal area developed extensive painful and purulent ulcerating wounds affecting the coccyx, superior gluteal cleft, and buttocks. Laboratory tests were within normal limits, except for low albumin results. The patient's Palliative Performance Score was 60%. A trial of intravenous lidocaine 150 mg administered twice daily before dressing changes improved analgesia according to the patient's report. For additional improvement, a continuous intravenous infusion of lidocaine 1 mg/minute was initiated, in addition to the twice daily bolus infusions of lidocaine. The patient's pain score with dressing changes improved from 8–10 of 10 to 4–5 of 10 within 24 hours after initiation of the continuous intravenous lidocaine infusion. Lidocaine infusion was administered for a period of 45 days with targeted lidocaine blood levels not exceeding 5 mcg/mL. Twice daily lidocaine bolus infusions before dressing changes were administered for a total duration of 63 days. The lidocaine continuous intravenous infusion was discontinued on day 45 of therapy as a potential contributing factor to central nervous system adverse effects and in anticipation of transition to a subacute rehabilitation facility.
Discussion: Intravenous lidocaine added to the efficacy of standard analgesic medications and nerve block procedures in our patient. This case demonstrates increasing blood lidocaine levels with continuous intravenous infusion despite stable clinical parameters and laboratory markers of major organ function. Monitoring lidocaine levels is a prudent course of action to identify drug accumulation with administration of lidocaine by continuous intravenous infusion.
Context: Research shows an increased symptom burden in young adult (YA) cancer patients compared with their older adult counterpart.
Objectives: The purpose of this study was to identify differences in clinical characteristics and related outcomes between YA and older adult cancer patients admitted for cancer-related pain.
Materials and Methods: We retrospectively identified 190 hospitalized patients in a single academic center with admissions for cancer-related pain. Patients were grouped into either "young adult" (18-39) or "older adult (>40) cohorts. We compared differences in patient characteristics and pain regimens.
Results: Median oral morphine equivalent per 24 hours was higher in the YA group (194 mg vs. 70 mg, p = 0.010). Younger patients received patient-controlled analgesia (PCA) more frequently (p = 0.023). The number of palliative care consults and adjuvants prescribed did not differ between groups (p > 0.05), althoughYAs more frequently had an inpatient pain anesthesia consult (p = 0.047).
Conclusion: Findings show increased opioid requirements and PCA use in YAs being treated for malignancy compared with their older adult counterpart.
CONTEXT: Unrelieved cancer pain at the end of life interferes with achieving patient-centered goals.
OBJECTIVE: To compare effects of usual hospice care and PAINRelieveIt® on pain outcomes in patients and their lay caregivers.
METHODS: In a 5-step, stepped wedge randomized, controlled study, 234 patients (49% male, 18% Hispanic, 51% racial minorities) and 231 lay caregivers (26% male, 20% Hispanic, 54% racial minorities) completed pre/post pain measures. They received usual hospice care with intervention components that included a summary of the patient's pain data, decision support for hospice nurses, and multimedia education tailored to the patient's and lay caregiver's misconceptions about pain.
RESULTS: The intervention effect on analgesic adherence (primary outcome) was not significant. Posttest worst pain intensity was significantly higher for the experimental group, but the difference (0.70; CI=[0.12, 1.27]) was not clinically meaningful. There was nearly universal availability of prescriptions for strong opioids and adjuvant analgesics for neuropathic pain in both groups. Lay caregivers' pain misconceptions (0-5 scale) were significantly lower in the experimental group compared to the usual care group (mean difference controlling for baseline is 0.38; CI=[0.08, 0.67]; p=.01).
CONCLUSION: This RCT was a negative trial for the primary study outcomes, but positive for a secondary outcome. The trial is important for clearly demonstrating the feasibility of implementing the innovative set of interventions.
Background: Increasing the total opioid dose is the standard approach for managing uncontrolled cancer pain. Other than simply increasing the opioid dose, palliative care interventions are multidimensional and may improve pain control in the absence of opioid dose increase.
Objective: The purpose of this study was to determine the proportion of patients referred to our inpatient palliative care (IPC) team who achieved clinically improved pain (CIP) without opioid dose increase.
Design: We reviewed consecutive patients referred to our IPC team.
Setting/Subjects: Eligibility criteria included (1) taking opioid medication; (2) having =2 consecutive visits with the IPC team; and (3) an Edmonton Symptom Assessment Scale (ESAS) pain score =4 at consultation.
Measurements: We assessed patient demographics and clinical variables, including cancer type, opioid prescription data (type, route, and oral morphine equivalent daily dose [MEDD]), presence of opioid rotation, psychological consultation, changes in adjuvant medications (e.g., corticosteroids; antiepileptics—gabapentin and pregabalin; benzodiazepines; and neuroleptics), and achievement of CIP.
Results: Of the 300 patients enrolled, CIP was achieved in 196 (65%) patients. Of CIP patients, 85 (43%) achieved CIP without an increase in MEDD. CIP without MEDD increase was associated with more adjuvant medication changes (p = 0.003), less opioid rotation (p = 0.005), and lower symptom distress scale of ESAS (p = 0.04).
Conclusions: Nearly half of the patients achieved CIP without MEDD increase, suggesting that the multidimensional palliative care intervention is effective in improving pain control in many opioid-tolerant patients without the need to increase the opioid dose.
The increased demand for palliative care services has led to concerns surrounding workforce knowledge and resiliency, specifically with regard to palliative pain management for patients with life-limiting illnesses. Educational preparedness of nurses along with best processes and practices is necessary to promote optimal care for patients requiring palliative pain management. Through analyzing Veterans Administration Strategic Analytics for Improvement and Learning data, a deficiency in short-stay self-reported palliative patient pain management at the Southwestern Veterans Administration Medical Center, a level 1B, tertiary care referral center was defined. Best practices in the palliative care industry were then identified, and a quality improvement plan in the form of a nurse-driven palliative care pain education hands-on simulation was generated to promote excellence in care. Quality improvement for short-stay palliative pain management at the Southwestern Veterans Administration Medical Center was the end goal.
Background: Malignant rectal pain (MRP) and tenesmus cause significant morbidity for cancer patients at all stages of disease. There is little evidence to guide management of these symptoms.
Objective: the objective of this review was to summarize the existing evidence base for palliative management of MRP and tenesmus outside of standard oncologic or surgical management.
Design: A systematic review of PubMed and Embase was conducted according to PRISMA guidelines using preselected search terms for publications between 1980 and January 2017.
Setting/Subjects: Studies that described management for patients with tenesmoid pain from malignant tumors of the rectum, anus, or perineum were identified.
Measurements: The primary outcome was response of pain to treatment.
Results: The search produced 1412 titles. Twenty articles met criteria for inclusion in the review, including 11 case series and 9 case reports. A variety of treatments were found with most patients receiving interventional procedures, but overall evidence to support any particular intervention is limited and of poor quality.
Conclusions: This review highlights the limited current evidence base for medical and interventional treatments for MRP and tenesmus. Further study is needed to clarify the best approach to managing these challenging symptoms.
Aim: Chronic pain is common in terminally ill patients with cancer and affects their quality of life. In this study, we wanted to evaluate pain severity and the adequacy of prescribed analgesics in terminally ill patients with cancer in North Palestine.
Methods: We conducted a cross-sectional descriptive study in North Palestine on 77 terminally ill patients with cancer. Pain experience was evaluated with Brief Pain Inventory-Short Form (BPI-SF). Pain management index (PMI) was calculated to determine the adequacy of interventions. The relationships between adequacy of pain management and socioeconomic and clinical factors were analyzed by the covariance method. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS version 15.0 [SPSS Inc., Chicago, USA]).
Results: Fifty-nine patients (76.6%) reported moderate-to-severe pain. According to the PMI, only 64.9% of the patients received adequate pain management. Thirty-five patients (45%) wanted additional treatment or an increase in the dose of pain medications. Although men and women reported similar pain severities, women were more likely to be inadequately treated (P = 0.027). Pain severity was significantly less in patients who received health-care services at least once in the last month before the interview, compared to those without recent access to health care (P = 0.024).
Conclusion: There is substantial inadequacy in pain management in patients with cancer. The BPI-SF should be routinely used to evaluate pain severity, and analgesics should be prescribed equitably without discrimination with regard to gender and socioeconomic status of patients.
Background: The high incidence of pain associated with end-stage cancers indicates the need for a new approach to understanding how and why patients, caregivers, and clinicians make pain management choices.
Aims: To provide pilot data and preliminary categories for developing a middle-range nursing theory and framework through which to scrutinize and identify problematic processes involved in management of poorly controlled pain for home hospice patients, caregivers, and nurses, the “caring triad.”
Design: A qualitative pilot study using constructivist grounded theory methodology to answer the question, “In the context of hospice, what are the social processes occurring for and between each member of the hospice caring triad and how can these processes be categorized?”
Settings: Home hospice care.
Participants/Subjects: hospice patients experiencing cancer pain, family caregivers, hospice nurses.
Methods: From a sample of triads including hospice patients, caregivers and nurses, data were collected at observational visits, individual interviews, and a focus group over the course of each triad's study involvement. We used recursive coding processes to interpret data.
Results: Three preliminary categories of social processes were identified: Pain Meaning, Working Toward Comfort, and Bridging Pain; and six subcategories: perceiving pain and discomfort, knowing what to do, planning activities, negotiating a pain plan, talking about pain, and being together in pain.
Conclusions: As illustrated in the caring triad cases presented, this study moved the management approach of pain from a dichotomous realm of nurse-patient, to the more naturalistic realm for home hospice of nurse-patient-caregiver. In analyzing social processes within and across triad members, we identified categories of impact to target assessment, intervention, and education to improve pain outcomes.
Background: Black cancer patients experience pain. Barriers to opioid medications for pain may include geographic factors. This study examines neighborhood factors associated with difficulties receiving prescription opioids from pharmacies for black cancer patients.
Design: A secondary data analysis of a study on opioid adherence was used to examine neighborhood-level and individual factors related to difficulties filling prescriptions for opioids.
Setting/Subjects: Patients being treated for cancer pain with opioids (n = 104) were recruited. All self-identified as black, were 21 years or older, had cancer diagnoses, and had been prescribed extended release opioids.
Measurements: A seven-item survey to identify problems filling opioids was completed by 98 participants along with a nine-item scale to assess perceived neighborhood characteristics. Scales of neighborhood amenities and neglect were created from the perceived neighborhood characteristics scale using principal components analysis. The 2009–2013 American Community Survey data were used to estimate the census tract percentage of non-Hispanic black residents, residents =25 years of age without a high school degree or equivalent, and households earning below the federal poverty level within the past 12 months.
Results: Nearly 51% reported problems getting their opioids filled: 28% had to wait days and 24% had to return to the pharmacy multiple times. The main theme identified in analysis of an open-ended question was pharmacies not stocking medication. Neighborhood locations that rated higher on the amenities scale were protective for pharmacies sufficiently stocking opioids.
Conclusions: Additional research on pharmacies sufficiently stocking opioid pain and neighborhood perceptions is warranted.
Transdermal fentanyl is widely used to control pain in cancer patients. The high pharmacokinetic variability of fentanyl is assumed to be due to cytochrome P450 3A-mediated (CYP3A) N-dealkylation to norfentanyl in humans. However, recently published clinical studies question the importance of the described metabolic pathway. In this small study in palliative cancer patients under real-life clinical conditions, the influence of CYP3A on fentanyl variability was investigated. In addition to the determination of midazolam plasma concentration to reveal CYP3A activity, plasma concentrations of fentanyl and its metabolite, norfentanyl, were measured in identical blood samples of 20 patients who participated in an ongoing trial and had been on transdermal fentanyl. Fentanyl, norfentanyl, midazolam, and 1'-OH-midazolam were quantified by liquid chromatography/tandem mass spectrometry. Plasma concentrations of fentanyl and norfentanyl exhibited a large variability. Mean estimated total clearance of fentanyl and mean metabolic clearance of midazolam (as a marker of CYP3A activity) were 75.5 and 36.3 L/h. Both clearances showed a weak correlation and hence a minimal influence of CYP3A on fentanyl elimination.
Background: Ketamine has been used as an adjuvant to opioid therapy for the management of refractory cancer pain but the current evidence is insufficient to draw any conclusions regarding its efficacy. We aimed to assess the response to ketamine in patients with refractory cancer pain treated in an oncology palliative care unit.
Methods: Patients with refractory cancer pain despite opioid dose escalation were selected for a trial of parenteral ketamine infusion according to a local protocol. The medical records of those patients treated between January 2004 and December 2018 were retrospectively reviewed. The primary endpoint of the study was a favorable response to ketamine, defined as a reduction in regular opioid dose with no increase in pain intensity or a reduction in pain intensity by =2 points on the numerical rating scale (NRS) with a stable regular opioid dose. The secondary endpoint was adverse events associated with ketamine.
Results: Among the 70 patients, mean pain score on NRS improved from 7.0 to 4.0 after ketamine (P<0.001). Forty-nine patients had a reduction of pain score by =2 points on NRS, 33 had =50% reduction in pain intensity. The median decrease in regular opioid dose was 25.5%, and the mean difference was -133.2 mg (P=0.002). A favorable response to ketamine was observed in 52 patients (74.3%). The use of more than one coanalgesic (odds ratio 3.451; 95% CI: 1.087–10.960; P=0.036) was associated with a favorable response to ketamine on multivariate analysis. Adverse events were mostly mild, with the commonest being drowsiness (45.7%), hypertension (34.3%) and nightmares (25.7%). Only five and three patients required temporary suspension and early termination of ketamine infusion respectively.
Conclusions: These data demonstrated the efficacy and safety of ketamine in a population of patients with refractory cancer pain. The use of more than one coanalgesic was associated with a favorable response to ketamine. Further large and multicentered studies are warranted to confirm these data.
Pain can have a devastating effect on the quality of life of patients in palliative medicine. Thus far, majority of research has been centered on opioid-based pain management, with a limited empirical evidence for the use of nonopioid medications in palliative care. However, opioid and nonopioid medications such as nonsteroidal anti-inflammatory drugs have their limitations in the clinical use due to risk of adverse effects, therefore, there is a need for more research to be directed to finding an alternative approach to pain management in comfort care setting. The purpose of this article is to discuss a potential new drug that would adequately alleviate pain and enhance quality of life without significant risks of adverse effects that would limit its use. Naltrexone is a reversible competitive antagonist at µ-opioid and -opioid receptors, which when used at standard doses of 50 to 150 mg was initially intended for use in opioid and alcohol use disorders. However, it was discovered that its use in low doses follows alternate pharmacodynamic pathways with various effects. When used in doses of 1 to 5 mg it acts as a glial modulator with a neuroprotective effect via inhibition of microglial activation. It binds to Toll-like receptor 4 and acts as an antagonist, therefore inhibiting the downstream cellular signaling pathways that ultimately lead to pro-inflammatory cytokines, therefore reducing inflammatory response. Its other mode of action involves transient opioid receptor blockade ensuing from low-dose use which upregulates opioid signaling resulting in increased levels of endogenous opioid production, known as opioid rebound effect. Low dose naltrexone has gained popularity as an off-label treatment of several autoimmune diseases including multiple sclerosis and inflammatory bowel disease, as well as chronic pain disorders including fibromyalgia, complex regional pain syndrome, and diabetic neuropathy. Low-dose naltrexone (LDN) may also have utility in improving mood disorders and the potential to enhance the quality of life. This article will therefore propose the potential off-label use of LDN in management of nonmalignant pain in the palliative medicine setting.
Ce travail de recherche a pour but de démontrer l'incidence de la vulnérabilité, non reconnue par le professionnel, sur son comportement dans la recherche de soulagement de la douleur du patient en fin de vie. Ce mémoire s'articule autour de la question : en quoi la vulnérabilité peut-elle modifier le comportement des soignants dans le soulagement de la douleur du patient en fin de vie ?
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This discussion article examines narrative positioning related to pain management for people who use substances at the end of life. We explore how dominant narrative genres associated with biomedicine, such as 'restitution' and narratives common within the context of drug services such as 'recovery' can hinder effective pain management within this population. We argue that these discourses can marginalise the ethical self-identity of patients who use substances at the end of life. It can also trouble health and social care professionals in supporting patients and generating counter-narratives that challenge those often associated with substance use. Stigma is a common experience for this population with stereotyping as 'junkies' and associated with criminality. They are positioned as drug-seeking, and this requires more surveillance at the end of life when opioid therapy is potentially more available and authorised. This can make it challenging to generate 'companion' stories that are positive and maintain moral adequacy. Dominant biomedical narrative genres often prevent the recognition of the fractured stories that people using substances can often present with. This can lead to narrative silencing and to the under treatment of pain. The person's self-identity is invested in narratives of recovery, and opioid use symbolises their addicted past because for practitioners, this population is at clinical risk with the potential for drug seeking behaviours. Whilst not requiring formal ethical review this discussion paper was constructed in accordance with good scientific practice with the work of other researchers respected and cited appropriately.