Palliative Care Physicians' Practice in the Titration of Parenteral Opioids for Dyspnea in Terminally Ill Cancer Patients: A Nationwide Survey

Mori, Masanori; Matsunuma, Ryo; Suzuki, Kozue; Matsuda, Yoshinobu; Watanabe, Hiroaki; Yamaguchi, Takashi

doi:10.1016/j.jpainsymman.2019.04.007

Cited by 15 publications

(13 citation statements)

References 9 publications

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“…The topic presented in this article was included in the questionnaire regarding the management of dyspnoea in ambulatory patients with cancer. The results for the other topics we surveyed have been presented elsewhere 7–9…”

Section: Methodsmentioning

confidence: 99%

Benzodiazepines for cancer dyspnoea: a nationwide survey of palliative care physicians

Matsuda

Matsunuma

Suzuki

et al. 2019

BMJ Support Palliat Care

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ObjectivesIt is unclear whether patients with non-specific dyspnoea are suitable candidates for studies investigating the effectiveness of benzodiazepines against dyspnoea. The objective of this survey was to investigate suitable subjects for studies of benzodiazepines for cancer dyspnoea.MethodsA nationwide questionnaire survey was conducted among 536 Japanese-certified palliative care physicians. We randomly selected 268 physicians and inquired about their approach to dyspnoea management in patients with cancer, with and without anxiety, as follows: (1) Administration of a benzodiazepine. (2) Administration or titration of an opioid. We also asked them to consider their approach in the following situations: (1) Opioid-naïve. (2) Low-to-moderate baseline opioid dose. (3) High baseline opioid dose. We assessed the use of specific benzodiazepines separately.ResultsOverall, 192 physicians responded to the questionnaire (71.6%). For patients without anxiety, the proportion of participants reporting that they frequently or very frequently ‘administer a benzodiazepine’ increased with baseline opioid dose (opioid-naïve: 5.2%, low-to-moderate: 11.5%, high: 26.0%). The proportion of participants reporting that they frequently or very frequently ‘administer or titrate an opioid’ decreased with baseline opioid dose (opioid-naïve: 83.3%, low-to-moderate: 73.4%, high: 41.1%). The pattern was similar for patients with anxiety, although more respondents said they prescribe benzodiazepine for these patients (naïve: 22.4%, low-to-moderate: 34.4%, high: 45.8%) and fewer prescribed an opioid. Alprazolam and lorazepam are frequently used.ConclusionPatients with anxiety or receiving a high baseline opioid dose could be potential candidates for future studies investigating the effectiveness of benzodiazepines against cancer dyspnoea.

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Section: Methodsmentioning

confidence: 99%

Benzodiazepines for cancer dyspnoea: a nationwide survey of palliative care physicians

Matsuda

Matsunuma

Suzuki

et al. 2019

BMJ Support Palliat Care

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“…20 Furthermore, clinician lack of knowledge, education and training, in relation to opioid use for breathlessness and lack of experience of the use of opioids for breathlessness was shown to be a barrier across several studies, all of which had high MMAT totals. 30,37,41 A perceived lack of evidence for the use of opioids for breathlessness was found to reduce clinician confidence. 37 Patient lack of knowledge was also shown to affect the use of opioids for breathlessness, in particular the mixed or poor information and communication patients received from clinicians.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

Professionals’, patients’ and families’ views on the use of opioids for chronic breathlessness: A systematic review using the framework method and pillar process

et al. 2021

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Background: In combination with non-pharmacological interventions, opioids may safely reduce chronic breathlessness in patients with severe illness. However, implementation in clinical practice varies. Aim: To synthesise the published literature regarding health professionals’, patients’ and families’ views on the use of opioids for chronic breathlessness, identifying issues which influence implementation in clinical practice. Design: Systematic review and synthesis using the five-stage framework synthesis method. Data sources: Three electronic databases (MEDLINE, Embase via OVID, ASSIA via Proquest) were searched (March 2020) using a predefined search strategy. Studies were also citation chained from key papers. Papers were screened against a priori eligibility criteria. Data were extracted from included studies using the framework synthesis method. Qualitative and quantitative data were synthesised using the pillar process. Included studies were critically appraised using the Mixed-Methods Appraisal Tool. Results: After de-duplication, 843 papers were identified. Following screening, 22 studies were included. Five themes were developed: (i) clinician/patient characteristics, (ii) education/knowledge/experience, (iii) relationship between clinician/family, (iv) clinician/patient fear of opioids and (v) regulatory issues. Conclusions: There are significant barriers and enablers to the use of opioids for the symptomatic reduction of chronic breathlessness based on the knowledge, views and attitudes of clinicians, patients and families. Clinicians’ interactions with patients and their families strongly influences adherence with opioid treatment regimens for chronic breathlessness. Clinicians’, patients’ and families’ knowledge about the delicate balance between benefits and risks is generally poor. Education for all, but particularly clinicians, is likely to be a necessary (but insufficient) factor for improving implementation in practice.

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“…In addition, these studies included only cognitively competent patients with cancer with breathlessness. In clinical practice, morphine is widely used in various forms including continuous intravenous/subcutaneous infusion to ensure timely titration, rapid breathlessness relief and the avoidance of unnecessary adverse events in the setting of clinical deterioration and organ dysfunction during the last weeks to days of life 32 36 37. Thus, it is uncertain whether these results can be applied to patients with cancer who are very close to death.…”

Section: Current Evidence Supporting Treatment For Terminal Breathlesmentioning

confidence: 99%

“…This lack of evidence results in a wide variability in the practice of treating patients with terminal breathlessness among palliative care specialists 32 37. A number of important clinical questions have yet to be answered.…”

Section: Unanswered Research Questions In Terminal Breathlessnessmentioning

confidence: 99%

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

Mori

Yamaguchi²,

Matsuda

et al. 2020

ESMO Open

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Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.

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Palliative Care Physicians' Practice in the Titration of Parenteral Opioids for Dyspnea in Terminally Ill Cancer Patients: A Nationwide Survey

Cited by 15 publications

References 9 publications

Benzodiazepines for cancer dyspnoea: a nationwide survey of palliative care physicians

Benzodiazepines for cancer dyspnoea: a nationwide survey of palliative care physicians

Professionals’, patients’ and families’ views on the use of opioids for chronic breathlessness: A systematic review using the framework method and pillar process

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

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