"It turned out right for both of us": A qualitative study about a preference for home death and actual place of death.

This qualitative study was conducted in Norway to explore couples' preference for home death when one of the partners was dying from cancer, and what made home death possible or not. We conducted dyad interviews with five couples. After the patients' death, the spouses participated in individual interviews. The data were interpreted using thematic narrative analysis. One patient died at home, and three died in a healthcare institution. The narratives show how interdependency and mutual care were important when dealing with home death. When care needs were manageable at home, home was perceived a safe place and the preferred place for death. When care needs were experienced to become unmanageable at home, the sense of safety changed and admission to a health care institution was considered the best option. Regardless of place of death, the spouses experienced the end to have turned out right for their partner and themselves.

How should respiratory depression and loss of airway patency be handled during initiation of palliative sedation?

BACKGROUND: Loss of airway patency has been reported during initiation of palliative sedation. In present guidelines the loss of airway patency during initiation of palliative sedation is not addressed. Airway patency can be restored by jaw thrust/chin lift or placing the patient in the recovery position. AIM: A structured ethical analysis of how respiratory depression and loss of airway patency during initiation of palliative sedation should be handled. The essence of the dilemma is whether it is appropriate to apply simple non-invasive methods to restore airway patency in order to avoid the patient's immediate death. DESIGN: A structured analysis based on the four principles of healthcare ethics and stakeholders' interests. RESULTS: Beneficence and autonomy support a decision not to regain airway patency whereas non-maleficence lends weight to a decision to restore airway patency. Whether the proportionality criterion of the principle of double effect is met depends on the features of the individual case. The ethical problem appears to be a genuine dilemma where important values and arguments point to different conclusions. CONCLUSION: Whether to restore airway patency when the airway is obstructed during initiation of palliative sedation will ultimately be based on clinical judgment taking into account both any known patient preferences and relevant clinical information. There are strong arguments favoring both options in this clinical and ethical dilemma. The fact that a clear and universal recommendation cannot be made does not imply indifference regarding what is the clinically and ethically best option for each individual patient.

Prevalence of Triggers and Patient Harm Identified by Global Trigger Tool in Specialized Palliative Care.

Background: Global trigger tool (GTT) was developed for identification of patient harm. In palliative patients deterioration can be expected, and there are no data on whether cases classified as "patient harm" actually represents a potential for improved patient safety. Objectives: The primary aim was to test the performance and suitability of GTT in palliative care patients. The secondary aim was to pilot triggers for substandard palliative care. Design and Measurements: GTT was applied in 113 consecutive patients at a palliative ward at a Norwegian university hospital. Cases of patient harm were further evaluated to decide if the case was (a) a natural part of the disease trajectory or (b) a foreseeable consequence of treatment decisions. Potential triggers for substandard palliative care were tested. Results: Two hundred twelve triggers (1.9 per hospitalization) and 26 cases of patient harm were identified. The positive predictive value (PPV) for identifying patient harm was 0.12. The most prevalent harm was pressure ulcers (8.8%). Of the 26 cases of patient harm, 6 cases were a natural part of the disease trajectory and 10 consequences of treatment decisions. In 21 (18%) patients triggers being piloted for substandard palliative care were present, identifying 9 cases of substandard palliative care. The highest PPV (0.67) was observed for "Cessation of antibiotics less than 5 days before death." Conclusions: With the exception of pressure ulcers, GTT triggers were infrequent or had a very poor PPV for patient harm. Triggers related to overtreatment might be suitable for identifying substandard palliative care.

Prevalence of use of non-prescription analgesics in the Norwegian HUNT3 population: Impact of gender, age, exercise and prescription of opioids.

BACKGROUND: There are concerns about potential increasing use of over-the-counter (OTC) analgesics. The aims of this study were to examine 1) the prevalence of self-reported use of OTC analgesics; 2) the prevalence of combining prescription analgesics drugs with OTC analgesics and 3) whether lifestyle factors such as physical activity were associated with prevalence of daily OTC analgesic use. METHODS: Questionnaire data from the Nord-Trøndelag health study (HUNT3, 2006-08), which includes data from 40,000 adult respondents. The questionnaire included questions on use of OTC analgesics, socioeconomic conditions, health related behaviour, symptoms and diseases. Data were linked to individual data from the Norwegian Prescription Database. A logistic regression was used to investigate the association between different factors and daily use of paracetamol and/or non-steroid anti-inflammatory drugs (NSAIDs) in patients with and without chronic pain. RESULTS: The prevalence of using OTC analgesics at least once per week in the last month was 47%. Prevalence of paracetamol use was almost 40%, compared to 19% and 8% for NSAIDs and acetylsalicylic acid (ASA), respectively. While the use of NSAIDs decreased and the use of ASA increased with age, paracetamol consumption was unaffected by age. Overall more women used OTC analgesics. About 3-5% of subjects using OTC analgesics appeared to combine these with the same analgesic on prescription. Among subjects reporting chronic pain the prevalence of OTC analgesic use was almost twice as high as among subjects without chronic pain. Subjects with little physical activity had 1.5-4 times greater risk of daily use of OTC compared to physically active subjects. CONCLUSIONS: Use of OTC analgesics is prevalent, related to chronic pain, female gender and physical inactivity.

Use of nasal fentanyl for cancer pain: A pharmacoepidemiological study.

BACKGROUND: Breakthrough pain affects 40%-90% of patients with cancer pain. Nasal fentanyl is one of the recommended treatments, particularly if the breakthrough pain is of rapid onset. AIM: To investigate the prevalence of use of nasal fentanyl, to study which strong opioids have been used prior to nasal fentanyl and to examine which opioids are used concomitantly with nasal fentanyl. DESIGN: Longitudinal cohort study based on death cohorts defined according to year of death. SETTING/PARTICIPANTS: The study is based on data from the complete national Norwegian Prescription Database. The study population included all persons in Norway who died in the years 2010, 2011 and 2012 and who had received nasal fentanyl with reimbursement for palliative treatment. RESULTS: Of those who died from cancer in 2010, 2011 and 2012, 611 persons (2%) received dispensed prescriptions of nasal fentanyl. Two-thirds had received other short-acting strong opioids before nasal fentanyl. One quarter did not receive a long-acting opioid concomitantly with nasal fentanyl, but 68% of these received only one dispensed prescription of nasal fentanyl. Of those who received a long-acting opioid together with nasal fentanyl, transdermal fentanyl was the most common drug (65%). One-third received another short-acting opioid concomitantly with nasal fentanyl. CONCLUSION: The use of nasal fentanyl was surprisingly low. There is a need for clinical research addressing the use of nasal fentanyl without a long-acting opioid for background pain and the use of nasal fentanyl together with another short-acting opioid.

Chronic pain and use of opioids: a population-based pharmacoepidemiological study from the Norwegian prescription database and the Nord-Trøndelag health study.

In previous studies on prescription patterns of opioids, accurate data on pain are missing, and previous epidemiological studies of pain lack accurate data on opioid use. The present linkage study, which investigates the relationship between pain and opioid use, is based on accurate individual data from the complete national Norwegian prescription database and the Nord-Trøndelag health study 3, which includes about 46,000 people. Baseline data were collected in 2006 to 2008, and the cohort was followed up for 3 years. Of 14,477 people who reported chronic nonmalignant pain, 85% did not use opioids at all, 3% used opioids persistently, and 12% used opioids occasionally. Even in the group reporting severe or very severe chronic pain, the number not using opioids (2680) was far higher than the number who used opioids persistently (304). However, three quarters of people using opioids persistently reported strong or very strong pain in spite of the medication. Risk factors for the people with chronic pain who were not persistent opioid users at baseline to use opioids persistently 3 years later were occasional use of opioids, prescription of >100 defined daily doses per year of benzodiazepines, physical inactivity, reports of strong pain intensity, and prescription of drugs from 8 or more Anatomical Therapeutic Chemical groups. The study showed that most people having chronic nonmalignant pain are not using opioids, even if the pain is strong or very strong. However, the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment.

A pharmacoepidemiological cohort study of subjects starting strong opioids for nonmalignant pain: a study from the Norwegian Prescription Database.

Clinical studies of short duration have demonstrated that strong opioids improve pain control in selected patients with chronic nonmalignant pain. However, high discontinuation rates and dose escalation during long-term treatment have been indicated. The aim of the present study was to determine discontinuation rates, dose escalation, and patterns of co-medication with benzodiazepines. The Norwegian Prescription Database provides complete national data at an individual level on dispensed drugs. A complete national cohort of new users of strong opioids was followed up for 5 years after initiation of therapy with strong opioids. Of the 17,248 persons who were new users of strong opioids in 2005, 7229 were dispensed a second prescription within 70 days and were assumed to be intended long-term users. A total of 1233 persons in the study cohort were still on opioid therapy 5 years later. This equals 24% of the study cohort who were still alive. Of the participants, 21% decreased their annual opioid dose by 25% or more, whereas 21% kept a stable dose (± 24%) and 34% more than doubled their opioid dose from the first to the fifth year. High annual doses of opioids were associated with high annual doses of benzodiazepines at the end of follow-up. It is an issue of major concern that large dose escalation is common during long-term treatment, and that that high doses of opioids are associated with high doses of benzodiazepines. These findings make it necessary to question whether the appropriate patient population receives long-term opioid treatment.

Attitudes, beliefs and self-reported competence about postoperative pain among physicians and nurses working on surgical wards.

AIMS: To investigate attitudes, beliefs and self-reported competence with regard to pain management in nurses and physicians on surgical wards. Interprofessional differences between physicians and nurses were also examined. METHODS: A total of 795 physicians and nurses from different surgical departments in Norway were invited to complete a questionnaire measuring attitudes, beliefs and self-reported competence about postoperative pain. FINDINGS: In total, 128 physicians and 407 nurses completed the questionnaire (response rate 68%). Of these, 77% of physicians and 57% of nurses reported more than 4 years' work experience with postoperative pain. Most of the physicians (95%) and nurses (86%) reported that patients 'often' or 'very often' achieved satisfactory pain relief. Overall, 69% of the sample evaluated themselves as being highly competent or competent in treating nociceptive pain, while only 16% reported they were highly competent or competent in treating neuropathic pain. There were no statistically significant differences between the professions regarding their self-reported competence in pain management, and nurses and physicians only differed on three out of 18 conditions regarding their appraisal of conditions related to postoperative pain management after controlling for years of experience. Only 20% of respondents were satisfied with the annual updates for staff about pain relief for patients with postoperative pain. CONCLUSIONS: Even though the majority of physicians and nurses described themselves as competent in management of nociceptive pain, and thought that patients often or very often achieved satisfactory pain relief, the respondents reported dissatisfaction with the annual updates in pain management and poor competence in treatment of neuropathic pain.

Reimbursement of analgesics for chronic pain.

BACKGROUND: The prevalence of chronic non-malignant pain in Norway is between 24% and 30%. The proportion of the population using opioids for non-malignant pain on a long-term basis is around 1%. The purpose of our study was to investigate how many were prescribed analgesics on reimbursable prescription under reimbursement code -71 (chronic non-malignant pain) in 2009 and 2010, which analgesics were prescribed and whether prescribing practices were in accordance with national guidelines. MATERIAL AND METHOD: We retrieved pseudonymised data from the National Prescription Database on all those who received drugs with reimbursement code -71 in 2009 and 2010. The data contain information on drug, dosage, formulation, reimbursement code and date of issue. RESULTS: 90,731 patients received reimbursement for drugs indicated for chronic non-malignant pain in 2010. Of these, 6,875 were given opioids, 33,242 received paracetamol, 25,865 non-steroid inflammatory drugs (NSAIDs), 20,654 amitryptiline and 16,507 gabapentin. Oxycodone was the most frequently prescribed opioid, followed by buprenorphine, tramadol and codeine/paracetamol. Of those who were prescribed opioids, 4,047 (59%) received mainly slow-release opioids, 2,631 (38%) also received benzodiazepines and 2,418 (35%) received benzodiazepine-like sleep medications. CONCLUSION: The number of patients who received analgesics and opioids on reimbursable prescriptions was low compared to the proportion of the population with chronic pain and the proportion using opioids long-term. 38% of those reimbursed for opioids also used benzodiazepines, which is contrary to official Norwegian guidelines.

Opioid switching to methadone: a pharmacoepidemiological study from a national prescription database.

BACKGROUND: Opioid switching to methadone is reported frequently to improve pain control in patients with an unacceptable balance between pain control and side effects during treatment with first line opioids, but carries a risk of drug accumulation and respiratory depression. To justify this risk it is required that less risky treatments are tried beforehand and that a sufficiently large proportion of patients experience a long-lasting improvement in pain control. RESEARCH QUESTIONS: How large was the proportion of patients remaining on long term methadone treatment after a switch from a strong opioid to methadone? How long had the patients been treated with opioids before the switch to methadone? METHODS: Longitudinal pharmacoepidemiological study from the complete national Norwegian Prescription Database. RESULTS: One hundred and thirty (77%) cancer patients received more than one dispensed prescription of methadone. Forty-nine (40%) chronic non-malignant pain (CNMP) patients continued to have methadone prescriptions dispensed more than 6 months after the switch. Of 168 cancer patients, 48 (29%) had tried two strong opioids prior to the switch to methadone whereas 21 (12.5%) had tried three or more strong opioids. Similar numbers for 124 CNMP patients were 26 (21%) and 34 (27%), respectively. INTERPRETATION: Opioid switching to methadone appears to provide a long lasting improvement in pain control in a significant proportion of patients. However, the study raises concerns that treatment options with less risk are not being exhausted prior to switching to methadone.