The pattern of change in opioid and adjuvant prescriptions for cancer pain before and after referral to a comprehensive program in the Palliative Care Center in Kuwait

Abstract

Background Cancer-related pain is a complicated symptom that often coincides with fatigue, depression, and anxiety. Although many safe treatments are available, inadequate control of Cancer-related pain continues to lead to suffering in cancer patients. This study’s aim is to describe pain control, and the pattern of change in opioid and adjuvant medication prescriptions, before and after referral to the Palliative Care Center. Methods We conducted a prospective cohort study in adult cancer patients the Palliative Care Center between January 1, 2016 and December 30, 2017. We measured pain intensity and other associated symptoms via the Revised Edmonton Symptom Assessment System (ESAS-r) and documented detailed analgesics and adjuvant medication history before starting any palliative care and on days 0, 3, 6, and 14. Results The analysis included 240 patients whose cancer-related pain, anxiety, and depression scores meaningfully improved by day 6. The changes in the median (interquartile ranges) of Cancer-related pain, anxiety, and depression scores from day 0 to day 6 were: 6 (4–8) to 3 (1–4); 6 (4–9) to 2 (1–4); and 3 (2–6) to 2 (1–4), respectively, with p < 0.001 for all. Morphine was the most common opioid administered; the percentage using it increased from 20.4% (n = 49) before referral to 49.6% (n = 119) on day 6 (p < 0.001). The median morphine equivalent daily dose decreased from a median (interquartile ranges) of 60(31–93) mg/day before referral to 34(22–66) mg/day on day 6 (p < 0.001). There was also a statistically significant increase in the percentage of patients taking adjuvant medications, from 38.8% before referral to 84.2% on day 6 (p < 0.001). Comparing D0 to D6, the number of patients using Gabapentinoids significantly increased from 57(23.75%) to 79(32.9%) (p < 0.001), amitriptyline dramatically increased from 14 (5.8%) to 44 (18.3%) (p < 0.001), and other antidepressant drugs increased from 15 (6.2%) to 34 (14.1%) (p < 0.001). Conclusion After referral to the Palliative Care Center, patients’ pain and other symptoms scores decreased significantly, even with lower median morphine equivalent daily doses, arguably through more appropriately directed opioid use. This is evidence for the effectiveness of the comprehensive program at the Palliative Care Center in Kuwait.

Does cancer type and adjuvant analgesic prescribing influence opioid dose?—a retrospective cross-sectional study

“…Consistent with international guidelines (3,20,21) on cancer pain management which support the use of adjuvant analgesics, our centre had a 73% adjuvant analgesic co- prescription rate for those with cancer pain who were on opioids. This is concordant with other studies examining adjuvant analgesic use for cancer pain in the hospital setting which found a similar majority (>80%) of patients being co-prescribed adjuvant analgesics (22,23). These studies had gabapentin as the most commonly prescribed adjuvant analgesic whereas pregabalin was the commonest gabapentinoid prescribed in the current study, possibly relating to local government rebates favouring pregabalin for neuropathic pain.…”

Caregiver Burden Correlates With Complexity of Drug Regimen in Non-oncological Palliative Medicine

“…20,21 Unwanted and untoward effects of drug interactions create additional anxiety in a person without medical training such as the caregiver. 21,22 The scores obtained by the assessment of administration routes do not correlate with the family caregiver's burden, as parenteral drugs are administered by professionals, which represents a support of the caregiver. However, the therapeutic regimen including numerous drugs, significantly more for noncancer patients, with complicated timetables, pill fractioning, administration before or after meals, according to different assessment scales increase the caregiver's responsibility and are associated with heavier burden.…”

“…Prescription of opioids increases statistically significantly at the first assessment or after admission (P , 0.001), and also does neurological and antidepressant drugs for associated analgesic purposes. 22,23 Another class of drugs used more frequently in cancer patients are corticosteroids. According to literature, one third of patients may have secondary digestive toxicity, which is underdiagnosed because of under-reporting.…”

Investigation of the Relationship between Pain Level and General Comfort in Palliative Care Patients

“…Palyatif bakım hastalarında ağrının değerlendirildiği çalışmalarda; hastaların ağrı şiddetini kötü ve ağrı düzeyini şiddetli olarak değerlendirdikleri, hareket etmekle beraber ağrılarının daha çok arttığını ve en çok baş, ekstremite bölgesinde ağrı yaşadıklarını belirttikleri bildirilmektedir. 15,16,[22][23][24] Çalışmamızda, hastaların bildirdiği ağrının nitelikleri literatür ile uyum göstermektedir.…”