[Treatment of constipation in palliative care patients is a challenge].

The evidence for treatment of constipation in palliative care patients is poor. The condition of these patients is often complex, and results from studies performed in other patient groups cannot be extrapolated unconditionally. However, macrogol (polyethylene glycol), lactulose and sodium picosulphate seem to be well tolerated, and methylnaltrexone could be used in opioid-induced constipation, if the patients are not at risk from gastrointestinal perforation. The patients should be offered quiet and private surroundings, and attention should be payed to securing an optimal body position for defecation.

[Cross-sectorial cooperation has improved palliative care]. / Gode erfaringer med en tværsektoriel samarbejdsmodel for palliativ behandling

Project Palliation in the Odsherred Municipality is concerned with testing of a cooperation model between Lynghuset, general practice and Pain Centre, Holbæk Hospital. The purpose was to improve the palliative care to people suffering from life-threatening diseases through development of interdisciplinary and cross-sectorial cooperation. The model has shown to contribute to improvements but it also leaves room for further qualification.

Barriers to cancer pain management in Danish and Lithuanian patients treated in pain and palliative care units.

The prevalence of cancer-related pain is high despite available guidelines for the effective assessment and management of that pain. Barriers to the use of opioid analgesics partially cause undertreatment of cancer pain. The aim of this study was to compare pain management outcomes and patient-related barriers to cancer pain management in patient samples from Denmark and Lithuania. Thirty-three Danish and 30 Lithuanian patients responded to, respectively, Danish and Lithuanian versions of the Brief Pain Inventory pain scale, the Barriers Questionnaire II, the Hospital Anxiety and Depression Scale, the Specific Questionnaire On Pain Communication, and the Medication Adherence Report Scale. Emotional distress and patient attitudes toward opioid analgesics in cancer patient samples from both countries explained pain management outcomes in the multivariate regression models. Pain relief and pain medication adherence were better in Denmark, and the country of origin significantly explained the difference in the regression models for these outcomes. In conclusion, interventions in emotional distress and patient attitudes toward opioid analgesics may result in better pain management outcomes generally, whereas poor adherence to pain medication and poor pain relief appear to be more country-specific problems.

Switching from high doses of pure µ-opioid agonists to transdermal buprenorphine in patients with cancer: a feasibility study.

BACKGROUND: Several myths on buprenorphine's pharmacology exist: possible analgesic ceiling effect, feasibility of combination with other opioid agonists, and the reversibility of side effects. Aim to evaluate: 1) if cancer patients receiving high doses of pure agonists could obtain adequate pain relief after switching to transdermal (TD) buprenorphine and 2) whether the numbers of breakthrough pain episodes after switching increased and whether they could be treated with the same doses of pure agonist as before switching. DESIGN: The prospective open multicenter study included outpatients with moderate-to-severe cancer pain satisfactorily controlled. SETTING: Patients were switched from the usual pure agonist to TD buprenorphine and were titrated to a stable dose. The assessments were: 1) daily self-assessment of pain intensity, numbers of rescue medications, and pain interference with sleep; 2) brief pain inventory; 3) pain relief and pain intensity; 4) quality of life; and 5) adverse events and symptoms. RESULTS: Eighteen patients receiving 150-516 mg of morphine/day were included. The buprenorphine dose at the end of the study varied between 52.5 and 140 µg/h. No difference in pain before and after switching was shown. The level of rescue doses was maintained. The patches were well tolerated. A significant decrease in fatigue and an increase in global health status were seen after the switch. CONCLUSION: It is feasible to switch cancer patients from high doses of pure µ-opioid agonists to TD buprenorphine without eliciting any antagonist effects, but the dose conversion factor is individual and the switching process should be tailored for the individual patient.

Psychological and behavioural predictors of pain management outcomes in patients with cancer.

To better understand the phenomenon of patient-related barriers to cancer pain management and address them more effectively in interventional studies, a theoretical model related to psychological aspects of pain experience and pain-related behaviours was elaborated. The aim of the study was to analyse the impact of patient-related barriers on cancer pain management outcomes following this model. Thirty-three patients responded to the Brief Pain Inventory Pain scale, the Danish Barriers Questionnaire II (DBQ-II), the Hospital Anxiety and Depression scale (HADS), the Danish version of Patient Perceived Involvement in Care Scale measuring the quality of patient-physician pain communication, and the Danish version of Medication Adherence Report Scale (DMARS-4). Statistical analysis was performed with SPSS 16.00. The results of the multivariable linear regression analyses showed that pain intensity was explained by patients' emotional distress (symptoms of anxiety and depression) and that pain relief was explained by cognitive barriers. In conclusion, interventions in emotional distress and patients' concerns may supposedly result in better cancer pain management outcomes.

The Danish Barriers Questionnaire-II: preliminary validation in cancer pain patients.

OBJECTIVE: The objective of this study was to examine the psychometric properties of the Danish version of the Barriers Questionnaire-II (DBQ-II). METHODS: The validated Norwegian version of the DBQ-II was translated into Danish. Cancer patients for the study were recruited from specialized pain management facilities. Thirty-three patients responded to the DBQ-II, Hospital Anxiety and Depression Scale, and Brief Pain Inventory pain severity scale. RESULTS: A factor analysis of the DBQ-II resulted in six scales. Scale one, Fatalism, consisted of three items addressing fatalistic beliefs regarding cancer pain management. Scale two, Immune System, consisted of three items addressing the belief that pain medications harm the immune system. Scale three, Monitor, consisted of three items addressing the fear that pain medicine masks changes in one's body. Scale four, Communication, consisted of five items addressing the concern that reports of pain distract the physician from treating the cancer, and the belief that "good" patients do not complain. Scale five, Addiction, consisted of two items addressing the fear of becoming addicted to pain medication. Finally, scale six, Tolerance, consisted of three items addressing the fear of getting tolerant to analgesic effect of pain medicine. Items related to medication side effects were analyzed as separate units. The DBQ-II total had an internal consistency of 0.87. The DBQ-II total score was related to measures of pain relief and anxiety. CONCLUSIONS: The DBQ-II seems to be a reliable and valid measure of the barriers to pain management among Danish cancer patients.

The Danish version of the Medication Adherence Report Scale: preliminary validation in cancer pain patients.

OBJECTIVE: To examine the psychometric properties of the Danish version of the Medication Adherence Report Scale (DMARS-4) adapted to measure adherence to analgesic regimen among cancer patients. METHODS: The validated English version of the Medication Adherence Report Scale was translated into Danish following the repeated back-translation procedure. Cancer patients for the study were recruited from specialized pain management facilities. Thirty-three patients responded to the DMARS-4, the Danish Barriers Questionnaire II, The Danish version of Patient Perceived Involvement in Care Scale measuring the quality of patient-physician pain communication, and the Danish Brief Pain Inventory pain severity scale. RESULTS: A factor analysis of the DMARS-4 resulted in one factor. Mean (SD) score on the cumulative scale ranging from 4 to 20, with higher scores indicating better medication adherence, was 17.8 (0.42). The DMARS-4 scores were related to the measures of patients' concerns about pain management and patients' pain communication. The internal consistency of the DMARS-4 was 0.70. CONCLUSIONS: The DMARS-4 seems to be a valid and reliable measure of self-reported adherence to analgesic regimen in the context of cancer pain.

[Differences in the prescription of analgesics in the treatment of cancer pain in six Danish pain treatment units]. / Forskelle på ordinationsmønstret af analgetika ved behandling af cancersmerter på seks danske smertebehandlingsenheder.

30-40% of cancer patients suffer from pain at diagnosis while 70-80% of patients at progressed stages of the disease suffer from pain. Background pain is treated with long-acting opioids. Breakthrough pain can be treated with shorter acting non-opioid analgesics or opioids. The aim of this study was to describe the medical treatment of pain in cancer patients in connection with six Danish hospital units with special expertise in pain treatment. Differences in the prescription of analgesics were studied. The study was performed as a cross section study of prescribed analgesics. Data was collected by reviewing medical records. The study included 347 patients. A total of 278 patients out of 347 were treated with opioids for background pains. A significant difference was found (P < 0.001) in the frequency of prescribing morphine, oxycodone and fentanyl. For the treatment of background pain secondary analgesics were prescribed for 40% of the patients while 50% of the patients were treated with paracetamol and/or NSAID. According to the medical records 79% of the patients were prescribed analgesics for breakthrough pain. 73% of the 347 patients had strong opioids prescribed for breakthrough pain. For the treatment of background pain opioids were prescribed for the majority of the cancer patients. Morphine and oxycodone were prescribed most frequently. Secondary analgesics and paracetamol and/or NSAID were also prescribed for background pain. The strong opioids were prescribed for the treatment of breakthrough pain. Differences in the prescription of analgesics between the six hospital units were observed in this study.