Palliative medicine
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Palliative medicine · Jul 2011
ReviewA systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project.
Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative's opioid guidelines project. ⋯ RECOMMENDATIONS regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.
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Palliative medicine · Jul 2011
ReviewEvidence-based medicine: what is the evidence that it has made a difference?
Evidence-based medicine (EBM) has, over the past 20 years, made us all more critical in our thinking about the efficacy and safety of interventions. This is evident in the higher standards of our spoken and written work, formal and informal, and in our approach to the subject. The downside has been the coincidence of the squeeze on healthcare funding with the emergence of the EBM ideas - it has been all too easy to misuse the tools of EBM to deny patients access to treatment, and this, together with the off-putting political correctness of the EBM approach in some quarters, has made clinicians uneasy. ⋯ Tom Chalmers, a grandfather of the EBM movement, argued late in his career that the most important function of the EBM approach was to frame the research agenda. This we think is correct. The process of systematic review of a topic throws up the deficits in trial methods and the lacunae in the data, and this then can show the way forward.
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Palliative medicine · Jul 2011
ReviewA systematic review of oxycodone in the management of cancer pain.
Oxycodone is often used as an opioid analgesic for moderate to severe cancer-related pain, but its use varies across Europe. This systematic literature review forms the basis of guidelines for oxycodone use within the European Palliative Care Research Collaborative opioid guidelines project conducted on behalf of the European Association for Palliative Care. ⋯ There is no evidence from the included trials of a significant difference in analgesia or adverse effects between oxycodone and morphine or hydromorphone. The evidence was graded as high quality on the basis of a well-conducted meta-analysis, with no limitations likely to affect the outcome, in addition to consistency in the results of the other studies. The research was conducted using participants relevant to cancer and palliative care populations. Oxycodone can be recommended as an alternative to morphine or hydromorphone for cancer-related pain.
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Palliative medicine · Jul 2011
ReviewEuropean Palliative Care Research Collaborative pain guidelines: opioid switching to improve analgesia or reduce side effects. A systematic review.
According to a Cochrane review on opioid switching, sound evidence on the practice of substituting one strong opioid with another to improve pain control and reduce adverse effects was lacking in 2004. A systematic search strategy was developed to include studies after 2004, with adult cancer patients switching between strong opioids and reporting estimates of effect on pain and adverse effects. The search retrieved 288 publications (71 duplicates); 187 abstracts and 19 full papers were excluded. ⋯ Serious adverse effects were improved. Due to serious design limitations, the level of evidence was low (D). Randomized trials, with standardization of cohort classification, use of outcomes and analysis are warranted to establish the practice of opioid switching.
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Palliative medicine · Jul 2011
ReviewConversion ratios for opioid switching in the treatment of cancer pain: a systematic review.
In this paper we describe the results of a systematic search of the literature on conversion ratios during opioid switching. This is part of a project of the European Palliative Care Research Collaboration to update the European Association for Palliative Care recommendations for the use of opioid analgesics in the treatment of cancer pain. Studies were eligible for inclusion if they involved adult patients with chronic cancer pain, contained data on opioid conversion ratios, were prospective and were written in English. ⋯ When switching from different opioids to methadone the conversion ratio is highly variable, ranging from 5 : 1 to 10 : 1 and much higher in some studies. The derived ratios are influenced by several factors, including the reasons for switching and previous opioid doses. An individual treatment decision and strict monitoring is recommended for patients considered at risk.