Methadone as first-line opioid treatment for cancer pain in a developing country palliative care unit.

PURPOSE: The use of methadone for cancer pain is limited by the need of expertise and close titration due to variable half-life. Yet, it is a helpful palliative strategy in low-resources countries given its long-acting effect at low cost and worth additional study. Our aim was to describe the prescription and outcomes of methadone as a first-line treatment for cancer pain in a tertiary palliative care unit (PCU) in Argentina. METHODS: Retrospective review of medical records of patients with moderate to severe cancer pain seen at the PCU in 1-year period, who initiated strong opioids at the first consultation. Data collected during the first month of treatment included disease and pain characteristics, initial and final opioid type and dose and need for opioid rotation. RESULTS: Methadone was the most frequent opioid both at the initial and last assessment (71 and 66 % of the prescriptions). In all, treatment with strong opioids provided considerable decrease in pain intensity (p < 0.001) with low and stable opioid dose. Median and interquartile range (IR) of oral morphine equivalent daily dose (OMEDD) was 26 (16-32) and 39 (32-55) mg for initial and final assessments, respectively (p = 0.3). In patients initiated with methadone, the median (IR) daily methadone dose was 5 (4-6) mg at first and 7.5 (6-10) mg at final assessment, and the median (IR) index of opioid escalation was 0 (0-4) mg; (p < 0.05). Patients on methadone underwent less percentage of opioid rotation (15 versus 50 %; p < 0.001) and longer time to rotation (20.6 ± 4.4 versus 9.0 ± 2.7 days; p < 0.001) than patients on other opioids. CONCLUSIONS: Results indicate the preference of methadone as first-line strong opioid treatment in a PCU, providing good pain relief at low doses with low need for rotation. Several considerations about the costs of strong opioids in the region are given.

The Edmonton Symptom Assessment System as a screening tool for depression and anxiety.

PURPOSE: Mood disorders are among the most important psychiatric problems in patients with cancer. However, they are frequently underdiagnosed and therefore undertreated. This may lead to difficulties with symptom control, social withdrawal, and poor quality of life. This study was conducted to evaluate the screening performance of the Edmonton Symptom Assessment System (ESAS) for depression and anxiety, compared to Hospital Anxiety and Depression Scale (HADS). METHODS: We retrospectively reviewed and analyzed ESAS and HADS data collected from three previous clinical trials conducted by our group. The diagnosis of depression and/or anxiety, and moderate/severe depression and/or anxiety made when patients scored 8 or more, and 11 or more in HADS questionnaire, respectively. The sensitivity, specificity, positive, and negative predictive values for ESAS were calculated. RESULTS: Of 216 patients analyzed, the median (range) score for depression was 2 (0-10) and anxiety 3 (0-10) using ESAS, and 6 (0-16) and 7 (0-19) using HADS, respectively. A cut off of 2 out of 10 or more in the ESAS gave a sensitivity of 77% and 83% with a specificity of 55% and 47% for depression and moderate/severe depression, respectively. A cutoff of 2 out of 10 or more in the ESAS gave a sensitivity of 86% and 97%, and a specificity of 56% and 43% for anxiety and moderate/severe anxiety, respectively. CONCLUSION: Our data suggest that the ideal cutoff point of ESAS for the screening of depression and anxiety in palliative care is 2 out of 10 or more. More research is needed to define the ideal cutoff point for screening of severe depression and anxiety.

Medical students' palliative care education in a Latin American university: a three-year experience at Austral University in Buenos Aires, Argentina.

BACKGROUND: The School of Medicine of Austral University incorporated palliative care as an elective in undergraduate medicine curriculum during 2010. OBJECTIVE: We analyzed the experience and results after 3 years of teaching palliative care. We compared students who chose palliative care as an elective subject (PC Group) with students who did not (Non-PC Group). We focused on the experience of contact with palliative care patients and self-perceived attitudes. Additionally, the impact produced by palliative care education in knowledge, self-perceived attitudes, and comfort was evaluated. METHODS: All the students tested completed a questionnaire on their attitude when exposed to dying patients. Students in the PC Group completed an additional questionnaire to assess their level of knowledge and their self-perceived comfort when interacting with patients. RESULTS: We tested 146 students. All students in the PC Group and 95.2% in the Non-PC Group considered that specific death issues ought to be part of the curriculum. Some students indicated that they could be present in a mandatory course. Before taking their elective, students in the PC Group confirmed a lack of technical training to understand palliative care patients, as did those students in the Non-PC Group. After taking a palliative care elective students expressed an improvement in self-perceived attitudes toward suffering and there was a significant increase (p<0.0001-0.0045) in knowledge. They also expressed an improvement in comfort levels in evaluation and treatment of pain. More than 95% of the students in the PC Group rated the experience as valuable and perceived the content as not available elsewhere in their training. DISCUSSION/CONCLUSION: Our results show that palliative care education provides opportunities to improve attitudes not specific to this discipline: interprofessional collaboration, holistic care, patient-centered care, self-awareness, and humanism. We conclude that an exposure to palliative care improved student's perception about the complexities of dying patients and their care.

The challenge of international consensus: defining an opioid essential prescription package.

PURPOSE OF REVIEW: To describe a new strategy that aimed to facilitate opioid prescription for better pain management. RECENT FINDINGS: The International Association of Hospice and Palliative Care recently develop a single prescription package (drugs and dosing) with one opioid, one laxative, and one antiemetic for the initiation of opioid treatment in cancer pain and other life-threatening conditions, with the intention to facilitate opioid use, improve patient compliance, and reduce adverse effects. SUMMARY: The opioid essential prescription package was an international project designed to ensure that opioids are better tolerated by reducing the adverse effects of opioids, which could lead to more sustained improvements in pain management.

Strategic pain management: the identification and development of the IAHPC opioid essential prescription package.

The aim of this study was to determine by consensus the components of an opioid essential prescription package (OEPP) to be used when initiating a prescription for the control of moderate to severe chronic pain. Palliative care physicians (n=60) were sampled from the International Association for Hospice and Palliative Care (IAHPC) membership list to represent a range of countries of varying economic levels and diverse geographical regions. Using a Delphi study method, physicians were asked to rank preferences of drug and dosing schedule for first-line opioid, antiemetic, and laxative for the treatment of adults with chronic pain due to cancer and other life-threatening conditions. Overall response rates after two Delphi survey rounds were 95% (n=57) and 82% (n=49), respectively. A consensus (set at ≥75% agreement) was reached to include morphine as first-line opioid at a dose of 5 mg orally every 4 hours. Consensus was reached to include metoclopramide as a first-line antiemetic, but there was no consensus on "regular" or "as needed" administration. No consensus was reached regarding a first-line laxative, but a combination of senna and docusate secured 59% agreement. There was consensus (93% agreement) that laxatives should always be given regularly when opioid treatment is started. Further work is needed to establish a recommended dose of metoclopramide and a type and dose of laxative. The resulting OEPP is international in scope and is designed to ensure that opioids are better tolerated by reducing adverse effects of opioids, which could lead to more sustained improvements in pain management.