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.
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.
OBJECTIVES: To identify and synthesize available recommendations from scientific societies and experts on pain management at the end-of-life in the ICU.
DATA SOURCES: We conducted a systematic review of PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and Biblioteca Virtual en Salud from their inception until March 28, 2019.
STUDY SELECTION: We included all clinical practice guidelines, consensus statements, and benchmarks for quality.
DATA EXTRACTION: Study selection, methodological quality, and data extraction were performed independently by two investigators. A quality assessment was performed by four investigators using the Appraisal of Guidelines for Research and Evaluation II instrument. The recommendations were then synthesized and categorized.
DATA SYNTHESIS: Ten publications were included. The Appraisal of Guidelines for Research and Evaluation II statement showed low scores in various quality domains, especially in the applicability and rigor of development. Most documents were in agreement on five topics: 1) using a quantitative tool for pain assessment; 2) administering narcotics for pain relief and benzodiazepines for anxiety relief; 3) against prescribing neuromuscular blockers during withdrawal of life support to assess pain; 4) endorsing the use of high doses of opioids and sedatives for pain control, regardless of the risk that they will hasten death; and 5) using quality indicators to improve pain management during end-of-life in the ICU.
CONCLUSIONS: In spite of the lack of high-quality evidence, recommendations for pain management at the end-of-life in the ICU are homogeneous and are justified by ethical principles and agreement among experts. Considering the growing demand for the involvement of palliative care teams in the management of the dying patients in the ICU, there is a need to clearly define their early involvement and to further develop comprehensive evidence-based pain management strategies. Based on the study findings, we propose a management algorithm to improve the overall care of dying critically ill patients.
Je me suis toujours demandé pourquoi notre pays était si en retard dans le traitement de la douleur. Pendant que les infirmiers américains et anglais bénéficiaient sur les plages du débarquement de caisses de morphine avec seringues idoines pour passer de soldats blessés en soldats moribonds en leur injectant, à travers les pantalons ou autres blousons, de quoi soulager leurs douleurs indépendamment de tout diagnostic lésionnel, nos médecins en étaient encore à se demander si la personne qui se tordait de douleur dans un lit de malade n’était pas pour le moins quelqu’un qui « en rajoutait » ou au pire un hystérique qui s’ignorait. En 1954 un médecin, au demeurant jouissant d’une réputation flatteuse dans le microcosme médical de la ville de Brest, trouvait incongrue voire scandaleuse la demande de l’épouse d’un malade au bout de son cœur après une longue carrière de séquelles de RAA1 (il allait mourir trois semaines après d’un ultime OAP2) sous le prétexte que la morphine risquait d’en faire un toxicomane…
Background: Cancer is a major burden of disease and a public health problem, as it is one of the main causes of morbidity and mortality worldwide. It is estimated that 25% of cancer patients die without receiving proper pain management.
Objective: To acknowledge the epidemiological profile of first-time patients at the palliative care service of a referral center, along with the pharmaceutical treatment and social and familiar implications of the treatment costs in first-time patients.
Methods: A survey including 28 questions was conducted including 490 first-time patients at the National Cancer Institute in Mexico City.
Results: Median age was 53 years; 63.3% (n = 310) were females; 72% were married or single (50.5% and 21.2%, respectively). The most frequent diagnoses were gastrointestinal tumors, followed by urological, and skin/soft tissue carcinomas (19.8%, 12.5%, and 12%, respectively). Pain prevalence was 50.4% among the cohort. From the subgroup of participants with pain, 26.7% presented an intensity =7.
Conclusions: As most patients in our study presented pain, there is a need of strengthening public policy about opioid treatments.
BACKGROUND: Pain is one of the most common symptoms that has a severe impact on quality of life and is associated with numerous psychosocial issues in cancer patients. Palliative care, which is a recent development in China, mainly focuses on symptom control and provides psychosocial support in order to improve quality of life for terminally ill patients. This meta-analysis aimed to evaluate the effects of palliative care on cancer pain in China.
METHODS: The four most comprehensive Chinese academic databases-CNKI, Wanfang, Vip and CBM-were searched from their inception until July 2019. Medline/PubMed, Web of Science, EBSCO and internet search (Google and Google Scholar) were also searched. Randomized controlled studies assessing the effects of palliative care on cancer pain were analyzed. The pooled random-effect estimates of standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated. Subgroup analysis was conducted by moderating factors for heterogeneity.
RESULTS: The present meta-analysis included 18 studies with a total of 1370 patients. The random-effect model showed a significant effect size of palliative care on cancer pain (SMD = 1.475, p < 0.001; 95% CI = 1.071–1.878). Age, pharmacological/non-pharmacological strategies and publication date could account for the heterogeneity through subgroup analysis to some extent.
CONCLUSIONS: Palliative care was largely effective for relieving pain among Chinese adults with cancer, indicating that an adequate system should be urgently established to provide palliative care for cancer patients in Chinese medical settings. However, given the extent of heterogeneity, our findings should be interpreted cautiously.
Background: Low-dose methadone in addition to another ongoing opioid therapy is a promising approach for managing complex cancer-related pain and is, despite limited evidence, used in clinical practice.
Objective: To investigate the use of low-dose methadone in specialized palliative care in Sweden.
Design: Specialized palliative care services in Sweden answered a survey regarding methadone use in individual patients over 12 months.
Setting/Subjects: The survey was an add-on to the Swedish Register of Palliative Care's (SRPC) mandatory end-of-life questionnaire (ELQ).
Results: Sixty of 133 invited units (45%) participated in the study. A total of 4780 ELQs were registered. Four hundred ten of these patients received methadone (9%). In 96% of these patients, methadone was prescribed as an add-on to ongoing opioid therapy, mostly because of poor pain control due to mixed nociceptive and neuropathic pain (70%). Methadone was used for a median of 21 days, in 86% of cases until death. Mean daily methadone doses increased from 7 mg at start to 21 mg (p < 0.005) during the last 24 hours. Corresponding morphine equivalent daily doses of other opioids were 184 and 199 mg (p < 0.05), respectively. A pain-relieving effect was reported in 94% of the patients. Adverse effects were seen in 20% of the patients; none of these was severe.
Conclusion: The addition of low-dose methadone to an ongoing opioid therapy in patients with complex cancer-related pain is well established in Swedish specialized palliative care. It appears to have good pain-relieving effects and to be safe.
OBJECTIVES: The aim of this study was to investigate symptom prevalence, symptom relief, and palliative care indicators during the last week of life, comparing them for patients with motor neuron disease (MND), central nervous system tumors (CNS tumor), and other neurological diseases (OND).
MATERIAL & METHODS: Data were obtained from the Swedish Register for Palliative Care, which documents care during the last week of life. Logistic regression was used to compare patients with MND (n = 419), CNS tumor (n = 799), and OND (n = 1,407) as the cause of death.
RESULTS: The most prevalent symptoms for all neurological disease groups were pain (52.7% to 72.2%) and rattles (58.1% to 65.6%). Compared to MND and OND, patients with CNS tumors were more likely to have totally relieved pain, shortness of breath, rattles, and anxiety. They were also more likely to have their pain assessed with a validated tool; to receive symptom treatment for anxiety, nausea, rattles, and pain; to have had family members receive end-of-life discussions; to have someone present at death; and to have had their family members offered bereavement support. Both patients with CNS tumor and MND were more likely than patients with OND to receive consultation with a pain unit and to have had end-of-life discussions.
CONCLUSIONS: The study reveals high symptom burden and differences in palliative care between the groups during the last week of life. There is a need for person-centered care planning based on a palliative approach, focused on improving symptom assessments, relief, and end-of-life conversations.
CONTEXT: Fear of pain resonates with most people, in particular in relation to dying. Despite this, there are still people dying with unrelieved pain.
OBJECTIVES: We quantified the risk, and investigated risk factors, for dying with unrelieved pain in a nationwide observational cohort study.
METHODS: Using data from Swedish Register of Palliative Care we analysed 161 762 expected deaths during 2011-2015. The investigated risk factors included cause of death, place of death, absence of an end-of-life (EoL) conversation, and lack of contact with pain management expertise. Modified Poisson regression models were fitted to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for unrelieved pain.
RESULTS: Unrelieved pain during the final week of life was reported for 25% of the patients with pain, despite prescription of opioids PRN in 97% of cases. Unrelieved pain was common both among patients dying from cancer and from non-malignant chronic diseases. Significant risk factors for unrelieved pain included hospital death (RR = 1.84, 95% CI 1.79-1.88) compared with dying in specialist palliative care, absence of an EoL conversation (RR = 1.42, 95% CI 1.38-1.45), and dying from cancer in the bones (RR = 1.13, 95% CI 1.08-1.18) or lung (RR = 1.10, 95% CI 1.06-1.13) compared with non-malignant causes.
CONCLUSION: Despite almost complete prescription of opioids PRN for patients with pain, patients die with unrelieved pain. Health care providers, hospitals in particular, need to focus more on pain in dying patients. An EoL conversation is one achievable intervention.
Opioids have long been a mainstay of symptom management in palliative care (PC), allowing patients with terminal illnesses to have an improved quality of life. Unfortunately, these same medications have contributed to the explosion of the opioid epidemic. This article explores the case of a patient with opioid use disorder (OUD) and pancreatic cancer. We share our experience of managing his symptoms and treating OUD in the setting of an outpatient PC clinic. We explore the challenges and joys of this case while reflecting on the need for more research investigating best practices for individuals where opioids serve as both a pain reliever and contributor to further suffering from their OUD.
Hospice health-care professionals (HCP) evaluate and manage cancer pain in patient homes. This study explores HCP’s perceptions of barriers that affect pain management for home hospice cancer patients. A convenience sample of 20 experienced hospice HCP were recruited from a regional hospice agency. Data were collected through two focus groups using semistructured interviews and analyzed using a constant comparative approach to generate themes. An unexpected finding revealed patient’s religious and cultural beliefs about suffering and family caregiver’s beliefs that patients deserve to suffer due to past actions are barriers to pain management in home hospice. Hospice HCP can identify patients at risk for suffering at the end of life. Interventions targeting spiritual suffering and needs are needed. Home hospice HCP have an ethical obligation to address undue suffering through family’s withholding of necessary pain medications and should consider alternative placement when home is not suitable for a peaceful death.
Cancer is the most common cause of mortality worldwide. Although recent advances of multiple modality cancer management have significantly improved the cure and control rates, a significant proportion of patients are still refractory to the standard and available treatments. Early initiation of palliative care can reduce cancer suffering, improve health-related quality of life and possibly prolong survival. It also allows patients and their caretakers to perceive the trajectory of their cancer, so that better and advanced care planning can be contemplated and implemented. The traditional beliefs and perceptions of cancer also differ significantly between the East and the West, which may also affect the preferential approach to palliative care. This review provides an overview of palliative care services in Hong Kong, as compared with other parts of the world. In addition, we shall also explore how cancer perceptions affect the decision-making on palliative care.
BACKGROUND:: Paclitaxel-treated patients can suffer from years of peripheral neuropathy with pain, numbness, and tingling. Promising preclinical data with poly (ADP-ribose) polymerase (PARP) inhibitors led us to explore this class of agents to palliate this neuropathy.
METHODS:: We relied on a completed trial that tested the antineoplastic effects of veliparib (NCT01012817). Data from patients who had been enrolled on NCT01012817, who previously received paclitaxel, and who had completed a validated pain assessment instrument were evaluated for improvement in their pain scores.
RESULTS:: All 34 eligible patients were women, and all had a metastatic gynecological malignancy. On a 10-point scale (higher numbers indicative of worse pain), the average baseline score was 3.6 (range: 0-7). Seven patients (21%; 95% confidence interval: 9%-38%) manifested a drop in pain score (1 score lower than baseline followed by at least one consecutive value also below baseline). Of note, no patients initiated other therapy for neuropathy while on NCT01012817.
CONCLUSION:: The PARP inhibitors merit further study for chemotherapy-induced peripheral neuropathy. For patients suffering from peripheral neuropathy, these putative palliative effects might prompt earlier consideration of a PARP inhibitor as part of cancer treatment.
Background: Opioid refractory pain is a common problem in pain management. Dexmedetomidine is suggested to have opioid-sparing effects, with well-described use in surgical and intensive care unit settings. Some authors advocate its benefit in reducing delirium. Its effects are thought to be exhibited through agonism of pre- and postsynpatic a2-receptors in the central nervous system. It is more selective on a2-receptors than clonidine, accounting for its relatively lower incidence of hypotension. Its use in sedation is favored because it does not depress the respiratory system. The main side effects reported include bradycardia.
Case Description: Twenty-eight-year-old woman with triple negative left breast cancer and a locally destructive tumor was admitted to hospice after exhausting her disease-directed therapy options. Her chief complaint was a throbbing, burning pain to the left chest wall, lower back, and bilateral lower extremities, rated 8/10 on a 10-point verbal scale. Multiple pharmacologic agents for pain, including patient-controlled analgesia infusions with adjuvant methadone and steroids, had failed to provide consistent pain management. Symptoms were difficult to control in the home setting, and she required multiple admissions to our inpatient hospice unit for pain management. She also developed episodes of delirium shortly after hospice admission. We attributed her symptoms to rapid disease progression. After failed pain control with opioids, ketamine, and lidocaine, we trialed a dexmedetomidine infusion. While on the infusion, her pain rating decreased to 0/10 and she had no delirium. Pain recurred soon after cessation of the infusion, initially rated 6/10.
Conclusion: Dexmedetomidine is safe for opioid refractory pain in the hospice inpatient setting. However, its effects may not be sustained. There is potential for use in end-of-life care, with added benefit for possible control of delirium.
Background: A reality of the current political and legal environment is that while marijuana and cannabis-based products remain not approved for human consumption at the federal level in the United States, several states have authorized use for constituents. While state lines represent meaningful cultural and geographical identity markers, the reality is that patients and families readily cross state lines to access medical interventions and care.
Methods: We present the case of a six-year-old child with intractable seizures and severe neuropathic pain managed on medical marijuana (MM) in her home state of Colorado; where medicinal use of marijuana is authorized at the state level; traveling across state lines to access surgical care in Nebraska where MM is prohibited.
Conclusion: The case report shares the communication and creativity invested in adequate symptom management for this child weaned off of MM perioperatively. The case recognizes the unique complexities of shared symptom management goals within state-specific care models.