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.

"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.

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.

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.

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.

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.

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.

[Post-operative pain management in hospitals]. / Behandling av postoperativ smerte i sykehus.

BACKGROUND: Relief of post-operative pain has a bearing on the patient's well-being, mobilisation and time confined to bed. The article discusses indications, contraindications and the efficacy of the various treatment modalities. MATERIAL AND METHOD: We have examined review articles, meta-analyses and randomised controlled trials, identified through literature searches in PubMed. RESULTS: The use of several medicines and techniques (multimodal pain treatment) is necessary to achieve a good balance between pain relief, side effects and risk. Systemic administration of paracetamol, NSAIDs, opioids and glucocorticoids is effective for post-operative pain. The same applies to epidural analgesia, peripheral nerve blocks and local anaesthetic wound infiltration. Subanaesthetic doses of ketamine have an opioid-sparing effect, but the optimal dosing regimen is uncertain. Gabapentinoids have an effect on post-operative pain, but the effect appears to vary depending on the type of operation and analgesic regimen. The effect of one analgesic will depend on which other drugs are used in multimodal pain treatment. Epidural analgesia, peripheral nerve blocks or extensive local infiltration analgesia is often necessary to relieve movement-related pain. INTERPRETATION: Many treatment modalities are effective for post-operative pain. It is crucial that the treatment is well organised and that it includes routines for systematic pain assessment, efficacy and side effects of the pain management.

[Postoperative pain in patients admitted to Norwegian hospitals]. / Postoperativ smerte hos pasienter innlagt i norske sykehus.

BACKGROUND: Postoperative pain management is important for patients' well-being and mobility. It also reduces the length of hospital stays and prevents complications. Based on our own clinical experience, data on pain in cancer patients from Norway and on postoperative pain from other countries, we expected that a substantial proportion of patients staying in Norwegian hospitals would report postoperative pain of high intensity. MATERIAL AND METHODS: 215 in-patients from 14 Norwegian hospitals participated in a study of pain during the first 24 hours after operations. The study was based on medical records and data reported by the patients themselves. RESULTS: On an 11-point numerical scale, the mean intensity of pain was 3.0 (SD 2.1) during the first 24 hours. 8 % of patients reported that the intensity of even the weakest pain during rest had been ≥ 4, 38 % reported a mean intensity ≥ 4 and 11 % reported a mean ≥ 6. The medical records contained information about the intensity of postoperative pain for only 22 % of the patients. Reports from patients indicated that 52 % had been asked to report the intensity of pain on a scale as part of the hospital routine, while 78 % and 74 % had been asked about the need for additional pain alleviation and whether the medication was effective. INTERPRETATION: Many patients reported pain of strong intensity during the first 24 hours after operations. There is a great potential for improved documentation and treatment of pain.

Prescriptions of opioids to children and adolescents; a study from a national prescription database in Norway.

BACKGROUND: Analgesics are among the groups of drugs most frequently prescribed to children and adolescents. The prevalence of opioid use in children and adolescents is, however, not known. AIM: The primary aim was to determine the 1-year periodic prevalence of opioid dispension in Norwegian children and adolescents below 18 years of age. The secondary aim was to determine to which extent children and adolescents receive opioids for acute or chronic pain. METHODS: All pharmacies in Norway submit data electronically to the Norwegian Prescription Database on all dispensed prescriptions. All prescriptions to any individual are identified with a pseudonym. All Norwegians who were dispensed opioids from 2004 to 2007 are included in the study. RESULTS: In 2004, 6386 children and adolescents received opioid dispensions, a number which had increased by 35% to 8607 in 2007. These numbers correspond to an increase in 1-year periodic prevalence from 0.59 to 0.79%. Each year during the study period, approximately 95% of the patients received only one or two opioid dispensions. Only 262 Norwegian children and adolescents below 18 years of age received opioid dispensions in three successive years from 2005 to 2007. About 93-95% of children and adolescents receiving opioids each year received the weak opioid codeine. CONCLUSIONS: The 1-year periodic prevalence of opioid use in Norwegian children and adolescents is only one-sixteenth of the previously reported prevalence in the Norwegian adult population. Children and adolescents primarily receive opioids for acute pain.

[Morphine or oxycodone tablets for pain?]. / Morfin eller oksykodon tabletter mot smerter?

The opioids morphine and oxycodone are potent analgesics that are available as extended-release and immediate-release tablets. Indications are the same for both; i.e. severe acute pain and chronic pain (non-malignant or malignant). Few clinical studies have compared morphine and oxycodone directly. There is no evidence to support that one is superior over the other.

[Treatment of acute pain during drug-assisted rehabilitation]. / Behandling av akutte smerter under legemiddelassistert rehabilitering.

Patients on drug-assisted rehabilitation have the same right to pain relief as others. Techniques that reduce the need for opioids should be used when possible in opioid-dependent individuals who need treatment of acute and post-operative pain. Substitution treatment should always be continued. In some situations a switch to a different opioid or route of administration is required. Higher doses of opioids than those needed in other patients may be required for analgesia. Well-designed clinical studies are lacking in this field.