Neuroleptic strategies for terminal agitation in patients with cancer and delirium at an acute palliative care unit: a single-centre, double-blind, parallel-group, randomised trial.

BACKGROUND: The role of neuroleptics for terminal agitated delirium is controversial. We assessed the effect of three neuroleptic strategies on refractory agitation in patients with cancer with terminal delirium. METHODS: In this single-centre, double-blind, parallel-group, randomised trial, patients with advanced cancer, aged at least 18 years, admitted to the palliative and supportive care unit at the University of Texas MD Anderson Cancer Center (Houston, TX, USA), with refractory agitation, despite low-dose haloperidol, were randomly assigned to receive intravenous haloperidol dose escalation at 2 mg every 4 h, neuroleptic rotation with chlorpromazine at 25 mg every 4 h, or combined haloperidol at 1 mg and chlorpromazine at 12·5 mg every 4 h, until death or discharge. Rescue doses identical to the scheduled doses were administered at inception, and then hourly as needed. Permuted block randomisation (block size six; 1:1:1) was done, stratified by baseline Richmond Agitation Sedation Scale (RASS) scores. Research staff, clinicians, patients, and caregivers were masked to group assignment. The primary outcome was change in RASS score from time 0 to 24 h. Comparisons among group were done by modified intention-to-treat analysis. This completed study is registered with ClinicalTrials.gov, NCT03021486. FINDINGS: Between July 5, 2017, and July 1, 2019, 998 patients were screened for eligibility, with 68 being enrolled and randomly assigned to treatment; 45 received the masked study interventions (escalation n=15, rotation n=16, combination n=14). RASS score decreased significantly within 30 min and remained low at 24 h in the escalation group (n=10, mean RASS score change between 0 h and 24 h -3·6 [95% CI -5·0 to -2·2]), rotation group (n=11, -3·3 [-4·4 to -2·2]), and combination group (n=10, -3·0 [-4·6 to -1·4]), with no difference among groups (p=0·71). The most common serious toxicity was hypotension (escalation n=6 [40%], rotation n=5 [31%], combination n=3 [21%]); there were no treatment-related deaths. INTERPRETATION: Our data provide preliminary evidence that the three strategies of neuroleptics might reduce agitation in patients with terminal agitation. These findings are in the context of the single-centre design, small sample size, and lack of a placebo-only group. FUNDING: National Institute of Nursing Research.

Safe Opioid Use, Storage, and Disposal Strategies in Cancer Pain Management.

Opioids are required by a majority of patients with advanced cancer. Oncologists and palliative care clinicians are faced with the challenge of safely prescribing opioids in the current environment of an opioid crisis. Many patients with cancer use opioids unsafely, store them in unsecure locations, and do not dispose of unused opioids, leading to increased availability of these opioids for others to misuse. More than 50% of people who misuse opioids obtain the drugs from a friend or relative with or without their consent. Patient and provider education has been shown to improve safe opioid use, promote secure storage, and also increase disposal of unused opioids safely in drug take-back programs that are now widely available. This article highlights the importance of patient education and cautious opioid prescribing in patients with cancer. IMPLICATIONS FOR PRACTICE: The current opioid crisis makes it challenging to effectively manage cancer pain. Providers play a prominent role in minimizing opioid misuse. Cautious prescribing with limits enforced on the quantity of opioids prescribed, close follow-up, and consistent and frequent provision of opioid education are a must. Evidence points to the impact of patient education in promoting safety around opioid use. Most people who misuse prescription opioids obtain them from family or friends. Storing opioids in the open or not disposing of unused opioids increases the availability of these opioids for misuse by others. The importance of not sharing, always locking up, and disposing of unused and expired opioids must be highlighted as part of the opioid education that must be delivered every time that opioids are prescribed. Information about local drug take-back programs may also help increase disposal of unused opioids.

Symptom frequency and change of oldest old cancer patients.

PURPOSE: The oldest old, described as those aged 85 and older, is a growing cancer population. There are limited studies evaluating the symptoms of the oldest old cancer patient population. Our study aimed to evaluate symptom frequency and clinical symptom change as assessed by the Edmonton Symptom Assessment System (ESAS) of the oldest old (≥ 85) compared to older adult (65-84) and general adult (18-64) outpatient cancer patients on initial consult and follow-up visit. METHODS: Retrospective review of a total of 441 patients, 200 randomly sampled patients in the general and older adult group and 41 consecutive patients in the oldest old group. Chart review was performed for demographic and clinical information including ESAS. RESULTS: The oldest old group had less advanced tumors and worse performance status and was receiving less cancer therapy. Eighty percent or more of these patients reported fatigue, sleep disturbance, appetite, and drowsiness. They experienced lower frequencies of pain (p < 0.0001), fatigue (p = 0.0338), nausea (p = 0.0151), feeling of well-being (p = 0.0245), sleep disturbance (p = 0.0484), financial distress (p = 0.0002), and spiritual distress (p = 0.0010) compared to the younger groups. Twenty-six to fifty-one percent of the oldest old patients' symptoms improved on the first follow-up visit. CONCLUSIONS: Oldest old cancer patients have high frequencies of multiple symptoms on initial referral. However, these symptom frequencies are lower when compared to younger age groups. Additionally, many of their symptoms improved on first follow-up visit in the palliative care clinic. More research is needed to address the needs of this growing cancer population and focus symptoms that can improve with palliative care intervention.

The Impact of an Educational Program on Patient Practices for Safe Use, Storage, and Disposal of Opioids at a Comprehensive Cancer Center.

BACKGROUND: Improper use, storage, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our previous study showed a large proportion of cancer patients have unsafe opioid practices. Our objective was to determine whether an improvement occurred in the patterns of use, storage, and disposal of opioids among cancer outpatients after the implementation of a patient educational program. PATIENTS AND METHODS: Our palliative care (PC) clinic provides every patient with educational material (EM) on safe opioid use, storage, and disposal every time they receive an opioid prescription. We prospectively assessed 300 adult cancer outpatients receiving opioids in our PC clinic, who had received the EM, and compared them with 300 patients who had not received the EM. The previously used surveys pertaining to opioid use, storage, and disposal were administered, and demographic information was collected. Sharing or losing their opioids was defined as unsafe use. RESULTS: Patients who received EM were more aware of the proper opioid disposal methods (76% vs. 28%; p ≤ .0001), less likely to share their opioids with someone else (3% vs. 8%; p = .0311), less likely to practice unsafe use of opioids (18% vs. 25%; p = .0344), and more likely to be aware the danger of their opioids when taken by others (p = .0099). Patients who received the EM were less likely to have unused medication at home (38% vs. 47%; p = .0497) and more likely to keep their medications in a safe place (hidden, 75% vs. 70%; locked, 14% vs. 10%; p = .0025). CONCLUSION: The use of EM on opioid safety for patients with advanced cancer was associated with improved patient-reported safe opioid use, storage, and disposal. The Oncologist 2017;22:115-121Implications for Practice: Prescription opioid abuse is a fast-growing epidemic that has become more prominent recently, even in the cancer pain population. A previous study reported that 26% of cancer outpatients seen in the supportive care center either lose their pain medications or share their pain medications with someone else. This study demonstrates that the implementation of an opioid educational program and distribution of educational material on opioid safety brings about an improvement in opioid storage, use, and disposal practices in patients being prescribed opioids for cancer-related pain. Our study highlights the importance of consistent and thorough opioid education at every instance in which opioids are prescribed.

Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial.

Importance: The use of benzodiazepines to control agitation in delirium in the last days of life is controversial. Objective: To compare the effect of lorazepam vs placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium in the setting of advanced cancer. Design, Setting, and Participants: Single-center, double-blind, parallel-group, randomized clinical trial conducted at an acute palliative care unit at MD Anderson Cancer Center, Texas, enrolling 93 patients with advanced cancer and agitated delirium despite scheduled haloperidol from February 11, 2014, to June 30, 2016, with data collection completed in October 2016. Interventions: Lorazepam (3 mg) intravenously (n = 47) or placebo (n = 43) in addition to haloperidol (2 mg) intravenously upon the onset of an agitation episode. Main Outcomes and Measures: The primary outcome was change in Richmond Agitation-Sedation Scale (RASS) score (range, -5 [unarousable] to 4 [very agitated or combative]) from baseline to 8 hours after treatment administration. Secondary end points were rescue neuroleptic use, delirium recall, comfort (perceived by caregivers and nurses), communication capacity, delirium severity, adverse effects, discharge outcomes, and overall survival. Results: Among 90 randomized patients (mean age, 62 years; women, 42 [47%]), 58 (64%) received the study medication and 52 (90%) completed the trial. Lorazepam + haloperidol resulted in a significantly greater reduction of RASS score at 8 hours (-4.1 points) than placebo + haloperidol (-2.3 points) (mean difference, -1.9 points [95% CI, -2.8 to -0.9]; P < .001). The lorazepam + haloperidol group required less median rescue neuroleptics (2.0 mg) than the placebo + haloperidol group (4.0 mg) (median difference, -1.0 mg [95% CI, -2.0 to 0]; P = .009) and was perceived to be more comfortable by both blinded caregivers and nurses (caregivers: 84% for the lorazepam + haloperidol group vs 37% for the placebo + haloperidol group; mean difference, 47% [95% CI, 14% to 73%], P = .007; nurses: 77% for the lorazepam + haloperidol group vs 30% for the placebo + haloperidol group; mean difference, 47% [95% CI, 17% to 71%], P = .005). No significant between-group differences were found in delirium-related distress and survival. The most common adverse effect was hypokinesia (3 patients in the lorazepam + haloperidol group [19%] and 4 patients in the placebo + haloperidol group [27%]). Conclusions and Relevance: In this preliminary trial of hospitalized patients with agitated delirium in the setting of advanced cancer, the addition of lorazepam to haloperidol compared with haloperidol alone resulted in a significantly greater reduction in agitation at 8 hours. Further research is needed to assess generalizability and adverse effects. Trial Registration: clinicaltrials.gov Identifier: NCT01949662.

Frequency of unsafe storage, use, and disposal practices of opioids among cancer patients presenting to the emergency department.

OBJECTIVE: Approximately 75% of prescription opioid abusers obtain the drug from an acquaintance, which may be a consequence of improper opioid storage, use, disposal, and lack of patient education. We aimed to determine the opioid storage, use, and disposal patterns in patients presenting to the emergency department (ED) of a comprehensive cancer center. METHOD: We surveyed 113 patients receiving opioids for at least 2 months upon presenting to the ED and collected information regarding opioid use, storage, and disposal. Unsafe storage was defined as storing opioids in plain sight, and unsafe use was defined as sharing or losing opioids. RESULTS: The median age was 53 years, 55% were female, 64% were white, and 86% had advanced cancer. Of those surveyed, 36% stored opioids in plain sight, 53% kept them hidden but unlocked, and only 15% locked their opioids. However, 73% agreed that they would use a lockbox if given one. Patients who reported that others had asked them for their pain medications (p = 0.004) and those who would use a lockbox if given one (p = 0.019) were more likely to keep them locked. Some 13 patients (12%) used opioids unsafely by either sharing (5%) or losing (8%) them. Patients who reported being prescribed more pain pills than required (p = 0.032) were more likely to practice unsafe use. Most (78%) were unaware of proper opioid disposal methods, 6% believed they were prescribed more medication than required, and 67% had unused opioids at home. Only 13% previously received education about safe disposal of opioids. Overall, 77% (87) of patients reported unsafe storage, unsafe use, or possessed unused opioids at home. SIGNIFICANCE OF RESULTS: Many cancer patients presenting to the ED improperly and unsafely store, use, or dispose of opioids, thus highlighting a need to investigate the impact of patient education on such practices.

The opioid rotation ratio of strong opioids to transdermal fentanyl in cancer patients.

BACKGROUND: Transdermal fentanyl (TDF) is 1 of the most common opioids prescribed to patients with cancer. However, the accurate opioid rotation ratio (ORR) from other opioids to TDF is unknown, and various currently used methods result in wide variation of the ORR. The objective of this study was to determine the ORR of the oral morphine equivalent daily dose (MEDD) to the TDF dose when correcting for the MEDD of breakthrough opioids (the net MEDD) in cancer outpatients. METHODS: The records of 6790 consecutive patients were reviewed at the authors' supportive care center from 2010 to 2013 to identify those who underwent rotation from other opioids to TDF. Data regarding Edmonton Symptom Assessment Scale scores and MEDDs were collected for patients who returned for a follow-up visit within 5 weeks. Linear regression analysis was used to estimate the ORR between the TDF dose and the net MEDD (the MEDD before opioid rotation [OR] minus the MEDD of the breakthrough opioid used along with TDF after OR). RESULTS: In total, 129 patients underwent OR from other opioids to TDF. The mean patient age was 56 years, 59% were men, and 88% had advanced cancer. Uncontrolled pain (80%) was the most frequent reason for OR. In 101 patients who underwent OR and had no worsening of pain at follow-up, the median ORR from net MEDD to TDF (in mg per day) was 0.01 (range, -0.02 to 0.04), and the correlation coefficient of the TDF dose to the net MEDD was 0.77 (P < .0001). The ORR was not significantly impacted by body mass index or serum albumin. The ORR of 0.01 suggests that an MEDD of 100 mg is equivalent to 1 mg TDF daily or approximately 40 micrograms per hour of TDF (1000 micrograms/24 hours). CONCLUSIONS: The median ORR from MEDD to TDF in mg per day was 0.01. These results warrant further studies.

The Frequency, Characteristics, and Outcomes Among Cancer Patients With Delirium Admitted to an Acute Palliative Care Unit.

BACKGROUND: Delirium is a common neuropsychiatric condition seen in patients with severe illness, such as advanced cancer. Few published studies are available of the frequency, course, and outcomes of standardized management of delirium in advanced cancer patients admitted to acute palliative care unit (APCU). In this study, we examined the frequency, characteristics, and outcomes of delirium in patients with advanced cancer admitted to an APCU. METHODS: Medical records of 609 consecutive patients admitted to the APCU from January 2011 through December 2011 were reviewed. Data on patients' demographics; Memorial Delirium Assessment Scale (MDAS) score; palliative care specialist (PCS) diagnosis of delirium; delirium etiology, subtype, and reversibility; late development of delirium; and discharge outcome were collected. Delirium was diagnosed with MDAS score ≥7 and by a PCS using Diagnostic and Statistical Manual, 4th edition, Text Revision criteria. All patients admitted to the APCU received standardized assessments and management of delirium per best practice guidelines in delirium management. RESULTS: Of 556 patients in the APCU, 323 (58%) had a diagnosis of delirium. Of these, 229 (71%) had a delirium diagnosis on admission and 94 (29%) developed delirium after admission to the APCU. Delirium reversed in 85 of 323 episodes (26%). Half of patients with delirium (n = 162) died. Patients with the diagnosis of delirium had a lower median overall survival than those without delirium. Patients who developed delirium after admission to the APCU had poorer survival (p ≤ .0001) and a lower rate of delirium reversal (p = .03) compared with those admitted with delirium. CONCLUSION: More than half of the patients admitted to the APCU had delirium. Reversibility occurred in almost one-third of cases. Diagnosis of delirium was associated with poorer survival.

The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center.

BACKGROUND: Delirium is one of the most common neuropsychiatric complications in advanced cancer patients with a frequency of up to 85 % before death. It is associated with adverse clinical outcomes such as increased morbidity and mortality as well as significant family and patient distress. The aim of our study is to determine at the frequency of missed delirium (MD) and identify factors associated with MD. METHODS: Seven hundred seventy-one consecutive palliative care inpatient consults from August 1, 2009 to January 31, 2010 were reviewed. Demographics, Memorial Delirium Assessment Scale (MDAS), Edmonton Symptom Assessment Scale (ESAS), primary referral symptom, Eastern Cooperative Oncology Group (ECOG), and physician diagnosis of delirium were collected along with delirium etiology, subtype, and reversibility. Delirium was diagnosed with a MDAS score of ≥ 7 or by a palliative medicine specialist using Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV TR) Criteria. MD was reported in those patients found to have delirium by the palliative medicine specialists but were referred by the primary team for other reasons besides delirium. Chi-squared test and Wilcoxon-Mann-Whitney test were used to examine the difference on measurements among or between different groups. Univariate logistic regression model was applied to assess for associations for MD. RESULTS: Two hundred fifty-two (33 %) had a diagnosis of delirium by the palliative medicine specialist. One hundred fifty-three (61 %) were missed by the primary referring team. Females comprised 53 % (n = 81), white 62 % (n = 95), and pain was the most common referral symptom (n = 77, 50 %). Hypoactive delirium was the most common subtype of delirium in MD (n = 47, 63 %). Opioid-related delirium was the most common etiology of MD (n = 47, 31 %). Patients referred for pain were more likely to have MD (odds ratio (OR) = 2.57, p = 0.0109). Of the 82 patients with delirium that was reversed, 67 % (n = 55) had a diagnosis of MD. CONCLUSION: Sixty-one percent of patients with a diagnosis of delirium by a palliative care specialist were missed by the primary referring team. Patients with MD were frequently referred for pain. Universal screening of cancer patients for delirium is recommended.

Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: A prospective observational study.

BACKGROUND: Limited information is available on the symptomatic complications that occur in the last days of life. AIM: We documented the frequency, clinical course, and survival for 25 symptomatic complications among patients admitted to acute palliative care units. DESIGN: Prospective longitudinal observational study. MEASUREMENTS: Their attending physician completed a daily structured assessment of symptomatic complications from admission to discharge or death. SETTING/PARTICIPANTS: We enrolled consecutive advanced cancer patients admitted to acute palliative care units at MD Anderson Cancer Center, USA, and Barretos Cancer Hospital, Brazil. RESULTS: A total of 352 patients were enrolled (MD Anderson Cancer Center = 151, Barretos Cancer Hospital = 201). Delirium, pneumonia, and bowel obstruction were the most common complications, occurring in 43%, 20%, and 16% of patients on admission, and 70%, 46%, and 35% during the entire acute palliative care unit stay, respectively. Symptomatic improvement for delirium (36/246, 15%), pneumonia (52/161, 32%), and bowel obstruction (41/124, 33%) was low. Survival analysis revealed that delirium (p < 0.001), pneumonia (p = 0.003), peritonitis (p = 0.03), metabolic acidosis (p < 0.001), and upper gastrointestinal bleed (p = 0.03) were associated with worse survival. Greater number of symptomatic complications on admission was also associated with poorer survival (p < 0.001). CONCLUSION: Symptomatic complications were common in cancer patients admitted to acute palliative care units, often do not resolve completely, and were associated with a poor prognosis despite active medical management.

The need for a multidisciplinary approach to pain management in advanced cancer: A clinical case.

Advanced cancer patients are often affected by multiple complex symptoms brought about by persistent nociceptive stimuli and intense psychosocial distress. One such complex symptom, cancer pain, has continued to pose a challenge in medical management even though the concept of total pain was described several years ago by Cicely Saunders. Oftentimes, the application of a multidisciplinary approach is delayed after numerous opioid dose escalations and invasive procedures have been performed. The case presented here highlights the importance of timely multidisciplinary intervention and the use of an acute palliative care unit, which resulted in adequate pain control after multiple medical and invasive procedures that caused toxicities.

A palliative care intervention for pain refractory to a percutaneous cordotomy.

BACKGROUND: Intrathecal analgesia and radiofrequency techniques for tumor ablation are employed for palliation of symptoms. These interventions are efficacious in a select number of patients for controlling pain and improving quality of life. Careful selection of an appropriate candidate must be performed to prevent needless, invasive, and costly interventions, as interventional pain management alone will not treat total pain in cancer patients. We describe here a patient who experienced intractable pain and unsuccessfully underwent cordotomy but responded to the interdisciplinary (IDT) palliative care approach in an acute palliative care unit (APCU). CASE: A middle-aged female with ovarian cancer metastatic to the left psoas muscle and the supraclavicular and retroperitoneal lymph nodes was admitted with severe left thigh and flank pain. She had been unsuccessfully treated with different opioid regimens, hypogastric nerve block, epidural steroid injection, and cordotomy. The palliative care team was consulted while awaiting placement of an intrathecal pump. The patient was subsequently transferred to the APCU for symptom management and transition to hospice. On admission, her morphine equivalent daily dose (MEDD) was 660 mg. Our IDT--composed of a physician, fellow, nurse practitioner, counselor, chaplain, social worker, and physical and occupational therapists--was able to identify several sources of distress that likely contributed to her expression of pain. Our IDT focused on frequent counseling, improving her function, provided medication education, discussed goals of care, and educated about hospice. She was discharged to hospice care with good pain control and an 85% reduction in her MEDD. CONCLUSION: An APCU approach involving an IDT alleviated the need for invasive interventions by diagnosing and treating the psychosocial, emotional, and spiritual distress contributing to the patient's total pain expression. Successful management must be reflective of rigorous assessment of the physical, psychological, spiritual, social, and practical aspects before consideration of more invasive treatments.

Frequency and factors associated with falls in patients with advanced cancer presenting to an outpatient supportive care clinic.

OBJECTIVE: The aim of this study was to determine the frequency and factors associated with fall episodes in advanced cancer patients. METHOD: We analyzed data that included demographic characteristics, utilization of assistive devices, cancer diagnosis, metastatic site, performance status, medications including hypnotics and opioids, Edmonton Symptom Assessment Scale (ESAS) score, and Memorial Delirium Assessment Scale (MDAS) score in 384 consecutive patients who were newly referred to the Supportive Care Clinic at the MD Anderson Cancer Center from January 1 to December 31, 2009. All patients completed standardized forms to report falls within the last month. Multivariate backward regression analyses were employed to identify factors predictive of falls in advanced cancer. RESULTS: The mean age of patients was 58 years, and 192 (50%) were male. Mean (SD)/median score for pain was 5 (2.8), 5; fatigue 5.6 (2.6), 6; sleep disturbance 5(2.7), 5; drowsiness 3.7(3), 3; and anorexia 5(3), 5. Some 31 patients (8%) reported fall episodes within the past month, 17 (55%) of whom reported the use of assistive devices. Using assist devices (OR = 5.5, 95% CI: 2.6-11.9, p < 0.0001) and taking zolpidem (OR = 3.39, 95% CI: 1.39-7.7, p = 0.008) were associated with an enhanced chance of falling. Higher MDAS score (4.00 vs. 1.42, p = 0.001) and MDAS positive screening for delirium (21 vs. 3.6%, p < 0.001) were also associated with falls. However, severity on the ESAS at the initial consult was not associated with falls. SIGNIFICANCE OF RESULTS: We conclude that 31 of 384 patients (8%) with advanced cancer receiving outpatient supportive care reported falls in the previous month. Patients with assistive devices, taking zolpidem, and with a higher MDAS score, and a positive delirium screening reported more frequent falls. Further studies are warranted.

Delirium, agitation, and symptom distress within the final seven days of life among cancer patients receiving hospice care.

OBJECTIVE: Knowledge of symptom prevalence and adequate assessment of such symptoms at the end of life is important in clinical practice. We determined the frequency and severity of symptom distress and delirium using the Edmonton Assessment Scale (ESAS) and the Memorial Delirium Assessment Scale (MDAS) and evaluated the clinical utility of the Nursing Delirium Screening Scale (Nu-DESC) as scored by a caregiver as a screening tool for delirium. METHOD: We conducted a secondary analysis of the data from a previous randomized controlled trial on parenteral hydration at the end of life of patients admitted to home hospice. Only patients that had assessments within the last week of life were included. We collected the ESAS, MDAS, Nu-DESC, and Richmond Agitation Sedation Scale (RASS) results. The sensitivity and specificity of the Nu-DESC were then calculated. RESULTS: Some 78 of 261 patients were included in our study, 62 (80%) of which had moderate-to-severe symptoms corresponding to an ESAS score >4. These symptoms include: 73 (94%) anorexia, 63 (81%) fatigue, 56 (73%) drowsiness, 58 (75%) decreased well-being, and 39 (51%) pain. Delirium was diagnosed in 34 (44%) of patients using the MDAS. The Nu-DESC was found to have a sensitivity of 35%, a specificity of 80%, a positive predictive value (PPV) of 58%, and an negative predictive value (NPV) of 61% when used by caregivers. SIGNIFICANCE OF RESULTS: Hospice patients at the end of life have a high rate of symptom distress and delirium. The Nu-DESC is not a reliable tool for screening delirium when scoring is conducted by a caregiver. Our study illustrates the need for routine use of assessment tools to improve care.

Patterns of storage, use, and disposal of opioids among cancer outpatients.

PURPOSE: Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our objective was to determine the patterns of storage, utilization, and disposal of opioids among cancer outpatients. PATIENTS AND METHODS: We surveyed 300 adult cancer outpatients receiving opioids in our supportive care center and collected information regarding opioid use, storage, and disposal, along with scores on the CAGE (cut down, annoyed, guilty, eye-opener) alcoholism screening questionnaire. Unsafe use was defined as sharing or losing opioids; unsafe storage was defined as storing opioids in plain sight. RESULTS: The median age was 57 years. CAGE was positive in 58 of 300 patients (19%), and 26 (9%) had a history of illicit drug use. Fifty-six (19%) stored opioids in plain sight, 208 (69%) kept opioids hidden but unlocked, and only 28 (9%) locked their opioids. CAGE-positive patients (p = .007) and those with a history of illicit drug use (p = .0002) or smoking (p = .03) were more likely to lock their opioids. Seventy-eight (26%) reported unsafe use by sharing (9%) or losing (17%) their opioids. Patients who were never married or single (odds ratio: 2.92; 95% confidence interval: 1.48-5.77; p = .006), were CAGE positive (40% vs. 21%; p = .003), or had a history of illicit drug use (42% vs. 23%; p = .031) were more likely to use opioids unsafely. Overall, 223 of 300 patients (74%) were unaware of proper opioid disposal methods, and 138 (46%) had unused opioids at home. CONCLUSION: A large proportion of cancer patients improperly and unsafely use, store, and dispose of opioids, highlighting the need for establishment of easily accessed patient education and drug take-back programs.

The opioid rotation ratio of hydrocodone to strong opioids in cancer patients.

PURPOSE: Cancer pain management guidelines recommend initial treatment with intermediate-strength analgesics such as hydrocodone and subsequent escalation to stronger opioids such as morphine. There are no published studies on the process of opioid rotation (OR) from hydrocodone to strong opioids in cancer patients. Our aim was to determine the opioid rotation ratio (ORR) of hydrocodone to morphine equivalent daily dose (MEDD) in cancer outpatients. PATIENTS AND METHODS: We reviewed the records of consecutive patient visits at our supportive care center in 2011-2012 for OR from hydrocodone to stronger opioids. Data regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and MEDD were collected from patients who returned for follow-up within 6 weeks. Linear regression analysis was used to estimate the ORR between hydrocodone and MEDD. Successful OR was defined as 2-point or 30% reduction in the pain score and continuation of the new opioid at follow-up. RESULTS: Overall, 170 patients underwent OR from hydrocodone to stronger opioid. The median age was 59 years, and 81% had advanced cancer. The median time between OR and follow-up was 21 days. We found 53% had a successful OR with significant improvement in the ESAS pain and symptom distress scores. In 100 patients with complete OR and no worsening of pain at follow-up, the median ORR from hydrocodone to MEDD was 1.5 (quintiles 1-3: 0.9-2). The ORR was associated with hydrocodone dose (r = -.52; p < .0001) and was lower in patients receiving ≥40 mg of hydrocodone per day (p < .0001). The median ORR of hydrocodone to morphine was 1.5 (n = 44) and hydrocodone to oxycodone was 0.9 (n = 24). CONCLUSION: The median ORR from hydrocodone to MEDD was 1.5 and varied according to hydrocodone dose.

Characteristics and outcomes of advanced cancer patients who miss outpatient supportive care consult appointments.

BACKGROUND: Missed appointments (MA) are frequent, but there are no studies on the effects of the first MA at supportive care outpatient clinics on clinical outcomes. METHODS: We determined the frequency of MA among all patients referred to our clinic from January-December 2011 and recorded the clinical and demographic data and outcomes of 218 MA patients and 217 consecutive patients who kept their first appointments (KA). RESULTS: Of 1,352 advanced-cancer patients referred to our clinic, 218 (16 %) had an MA. The MA patients' median age was 57 years (interquartile range, 49-67). The mean time between referral and appointment was 7.4 days (range, 0-71) for KA patients vs. 9.1 days (range, 0-89) for MA patients (P = 0.006). Reasons for missing included admission to the hospital (17/218 [8 %]), death (4/218 [2 %]), appointments with primary oncologists (37/218 [18 %]), other appointments (19/218 [9 %]), visits to the emergency room (ER) (9/218 [9 %]), and unknown (111/218 [54 %]). MA patients visited the ER more at 2 weeks (16/214 [7 %] vs. 5/217 [2 %], P = 0.010) and 4 weeks (17/205 [8 %] vs. 8/217 [4 %], P = 0.060). Median-survival duration for MA patients was 177 days (range, 127-215) vs. 253 days (range, 192-347) for KA patients (P = 0.013). Multivariate analysis showed that MAs were associated with longer time between referral and scheduled appointment (odds ratio [OR], 1.026/day, P = 0.030), referral from targeted therapy services (OR, 2.177, P = 0.004), living in Texas/Louisiana regions (OR, 2.345, P = 0.002), having an advanced directive (OR, 0.154, P < 0.0001), and being referred for symptom control (OR, 0.024, P = 0.0003). CONCLUSION: MA patients with advanced cancer have worse survival and increased ER utilization than KA patients. Patients at higher risk for MA should undergo more aggressive follow-up. More research is needed.

Snapshot of an acute palliative care unit in a tertiary cancer hospital.

Most palliative care (PC) programs in the United States provide consultation services that assist the primary medical team with issues ranging from controlling patients' symptoms to initiating end-of-life discussions. This approach may be sufficient to address many patients' needs. However, for certain patients with complex medical and psychosocial issues, a better alternative is a more streamlined approach that can be provided in an acute palliative care unit (APCU), where the PC staff assumes the role of the primary team. An APCU is a specialized unit that delivers highly sophisticated care with professionals from various disciplines working together to improve the quality of life of patients and their families. However, descriptions of the process of delivering PC in the APCU are limited. In this special report, we portray a single day with a series of patients whose care was managed at our APCU to illustrate the unique components of an APCU that allow holistic care for patients with multiple complex medical and psychosocial issues.

Approach to the older patient with cancer.

The incidence of cancer increases with advanced age. And as the world population ages, clinicians will be faced with a growing number of older patients with cancer. The challenge that clinicians face involves carefully choosing the type of therapeutic care plan that is most appropriate given a person's level of physical reserve, medical comorbidities, and psychosocial resources. Inclusion of assessment tools in clinical practice such as a comprehensive geriatric assessment can assist clinicians in identifying patients who will benefit from aggressive cancer care or palliative measures. The role of palliative care, especially in the frail older patient, is critical in improving quality of life. Improvement in best care practices in older patients with cancer requires their inclusion in clinical trials.

Concepts and definitions for "supportive care," "best supportive care," "palliative care," and "hospice care" in the published literature, dictionaries, and textbooks.

PURPOSE: Commonly used terms such as "supportive care," "best supportive care," "palliative care," and "hospice care" were rarely and inconsistently defined in the palliative oncology literature. We conducted a systematic review of the literature to further identify concepts and definitions for these terms. METHODS: We searched MEDLINE, PsycInfo, EMBASE, and CINAHL for published peer-reviewed articles from 1948 to 2011 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. Dictionaries/textbooks were also searched. RESULTS: Nine of 32 "SC/BSC," 25 of 182 "PC," and 12 of 42 "HC" articles focused on providing a conceptual framework/definition. Common concepts for all three terms were symptom control and quality-of-life for patients with life-limiting illness. "SC" focused more on patients on active treatment compared to other categories (9/9 vs. 8/37) and less often involved interdisciplinary care (4/9 vs. 31/37). In contrast, "HC" focused more on volunteers (6/12 vs. 6/34), bereavement care (9/12 vs. 7/34), and community care (9/12 vs. 6/34). Both "PC" and "SC/BSC" were applicable earlier in the disease trajectory (16/34 vs. 0/9). We found 13, 24, and 17 different definitions for "SC/BSC," "PC," and "HC," respectively. "SC/BSC" was the most variably defined, ranging from symptom management during cancer therapy to survivorship care. Dictionaries/textbooks showed similar findings. CONCLUSION: We identified defining concepts for "SC/BSC," "PC," and "HC" and developed a preliminary conceptual framework unifying these terms along the continuum of care to help build consensus toward standardized definitions.