Update in Hospice and Palliative Care

1. Update in Hospice and Palliative Care Bob Arnold, University of Pittsburgh School of Medicine James Tulsky, Duke University School of Medicine Sonni Mun, Mount Sinai School of Medicine

2. Acknowledgments Daniel Fischberg Karl Lorenz Nathan Cherney Rosanne Leipzig Staff of AAHPM

3. 2004: A Banner Year • NIH State the Science • (http://consensus.nih.gov/ta/024/endoflifeintro.html) • National Consensus Project • (http://www.nationalconsensusproject.org)

4. 2004: A Banner Year • Review of Pediatric Palliative Care in NEJM • Himelstein B. P., Hilden J.M., Boldt A., Weissman D., 350: 1752-1762, April 22, 204 • Review of Palliative Care in NEJM • Morrison, R.S., Meier, D., 350:2582-2590, June 17, 2004

5. Objectives • Summarize seven important peer-reviewed articles from the last year • Critically analyze their methodologies and understand their conclusions • Determine if the findings are relevant to the care of your patients

6. Key Issues to Be Considered • Is the question important? • What are the results? • Are the results valid? • Can I apply the results to my patients

7. Methods • Key Word search of evidence-based reviews • Nathan Cherney database (www.cherneydatabase.org) • State of Science database

8. Methods • Hand search of leading journals • Selection criteria • Quality of science • Represent breadth of domains • Appeal to breadth of interest • Potential for impact

9. Relief of Suffering One breakthrough of the last year stands out above all others….

11. Case 1: Jerrold R • Recently diagnosed stage IV lung cancer • Presents to internist with chest wall pain • Has not taken any analgesics as “not sure what to take?”

12. Is it appropriate to start with a strong opiate? • WHO therapeutic ladder for the treatment of cancer pain • Data supporting WHO guidelines are weak Pain Severe Strong Opioid Moderate Weak Opioid Mild Non-Opioid

14. Starting With Strong Opioids • Study Design: Randomized controlled trial • Source of funding: Unknown • Participants: 100 patients • Inclusion Criteria: • Cancer • Not eligible for disease oriented treatment • Home palliative care • >6/10 on VAS for last week

15. Starting With Strong Opioids • Exclusion Criteria: • Impaired sensory or cognitive function • Predominately neuropathic pain • Previous opiates • Intervention: • Grp A: WHO pain ladder • Grp B: Start with strong opioids • Both groups can get adjuvants

16. Starting With Strong Opioids • Measurement • Daily • Pain diary-intensity, general condition, side effects • Once a week • Pain relief • Satisfaction with pain relief Y/N • Quality of life • Side effects • Analysis: chi-square and t-tests

18. Starting With Strong Opioids QOL change Pain Score change Nausea A-16.55 -1.92 315 B-16.05 -2.61 437 Pns p=0.041 p=0.0001 * There was no significant difference in vomiting, constipation, GI bleeding, or mental confusion

19. Starting With Strong Opioids

20. Key Issues • Is the question important? • Common clinical problem • What are the results? • All patients had significant pain reduction • Quicker pain relief with starting with non-opiates

21. Key Issues • Are the results valid? • Small study • Unclear about analgesic use • No controlling for co-morbidities • Poor measures

22. Key Issues • Can I apply the results to my patients? • Non-neuropathic, cancer pain • Young

23. Bottom Line • In selected cancer patients presenting with severe pain, starting with strong opioids will lead to better pain relief.

25. Case 2: Jerrold R (continued) • Stage IV lung cancer • Presents to internist six months later with persistent left arm pain (4/10) • Has received radiation to the arm • Is currently on long acting morphine, monthly bisphosphonates, steroids, and a NSAID • What can you do?

26. Background • What is the role of co-analgesics in pain relief? • NSAID • Steroids • Acetaminophen • Does adding acetaminophen to opiates improve pain relief in cancer patients?

28. Adding Acetaminophen • Study Design: RCT, placebo, crossover • Source of Funding: Au Cancer Council Janssen • Participants: 34 patients

29. Adding acetaminophen • Exclusion Criteria: • Recent XRT • New chemotherapy • Neuropathic pain • Severe liver disease .

30. Adding acetaminophen .

31. Adding acetaminophen • Primary outcome measure: • Pain as measured by 0-10 verbal scale and a 10-cm VAS • Daily rating and at end of study preference • Secondary measures • Breakthrough opiates • Well-being • Side effects

32. Adding acetaminophen • Sample size • Analysis: ANOVA • If not normal distribution then logit transformation

34. Adding acetaminophen-Visual scale-pain

35. Adding acetaminophen-Verbal scale - pain

36. Adding acetaminophen-visual scale-well being

37. Key Issues • Is the question important? • Common clinical problem • What are the results? • Consistent decrease in pain and increase in QOL if add acetaminophen • 30% had >1 point change on 0-10 scale for both pain and well-being

38. Key Issues • Are the results valid? • Small study • Problematic intervention • Short duration • Poor measures

39. Key Issues • Can I apply the results to my patients? • Consistent with other studies • Cheap and easy • Can stop if does not help

40. Clinical Bottom Line “Acetaminophen improved pain and well-being without major side-effects in people with cancer and persistent pain despite a strong opioid regimen.” It can be tried in patients with persistent pain

41. “His final wish was that all his medical bills be paid promptly.”

42. Case 3: Mary R • 74 year old with severe COPD • Has dyspnea at rest • Current medications • Albuterol/Atrovent • Oxygen • Steroids

43. Mary R’s Case: continued • Frustrated because dyspnea has made her life “miserable • Is there anything else besides her current regimen that will help alleviate her dyspnea?

44. Opioids for Dyspnea: Background • Dyspnea is a common symptom • Dyspnea is subjective • Can impair functional status • Particularly difficult for caregivers to observe

45. Opioids for Dyspnea: Background • Concern over adverse reactions • Conflicting consensus guidelines • Not enough good studies • Small sample numbers • Difficult to blind

47. Opioids for Dyspnea: Methods • 8 day RCT crossover • 20 mg of sustained release morphine versus placebo • Primary outcome variable: dyspnea on day #4

48. Opioids for Dyspnea: Methods continued Participants were recruited from outpatient clinics for respiratory, cardiac, general, and palliative medicine • Inclusion criteria • Adults with dyspnea at rest despite “optimal treatment of reversible factors” • Opioid naive • Exclusion criteria • Recent use of opioids • Confusion • Obtundation • Adverse reactions to opioids • History of substance misuse

49. Opioids for Dyspnea: Demographics

50. Opioids for Dyspnea: Results • 104 screened - 87 eligible • 48 consented - 39 refused or too sick • 10 withdrew - 5 in each group