Journal of palliative medicine
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The sublingual administration of opioid analgesics has been a mainstay in the pain management of homebound dying hospice patients who are no longer able to swallow. It is also a potentially useful route of administration in other situations in which the oral route is not available and other routes are impractical or inappropriate. Potential advantages of the sublingual route include rapid analgesic onset and avoidance of hepatic first-pass metabolism. ⋯ Other opioids have been less studied. Available data suggests limited sublingual availability of hydrophilic opioids (e.g., morphine, oxycodone, and hydromorphone) and superior absorption of the lipophilic opioids (e.g., methadone and the fentanils). Buprenorphine, a potent, lipophilic, partial mu-opioid receptor agonist, appears promising but awaits further study.
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Breakthrough pain is a highly prevalent and difficult to manage cancer pain problem. Current strategies are frequently ineffective, in part because of a mismatch between the sudden onset and brief duration of breakthrough pain and the slower onset and more prolonged duration of oral immediate-release opioids. Novel analgesic interventions are needed to provide a closer match between the temporal profile of the pain and the pharmacodynamics of the pain medication, and novel models of study of breakthrough pain are needed to evaluate them. ⋯ This model of assessment of breakthrough pain, whereby each episode of pain is treated as a separate data set and multiple discrete episodes of breakthrough pain are assessed every 5 minutes in each patient, appears to be feasible within the cancer pain population. Preliminary results suggest a very rapid onset of relief of breakthrough pain with sublingual methadone when administered at the optimal dose, consistent with a highly favorable early pharmacodynamic profile of methadone administered via this route. Further study is warranted.
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Comparative Study
Influence of patient and physician characteristics on percutaneous endoscopic gastrostomy tube decision-making.
Data are lacking to support percutaneous endoscopic gastrostomy (PEG) tube placement in advanced dementia, yet it is common, especially in the southeast United States and in African Americans. In a cross-sectional survey, we examine whether physicians recommend PEG placement more for African American than Caucasian patients and identify physician characteristics related to recommendation for PEG. ⋯ In this survey, recommendation for PEG tube feeding differed significantly by physician race and specialty, and not by race of the case patient. Additional research is needed to measure whether real-life treatment recommendations vary by physician race, physician-patient race concordance and physician specialty.
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Comparative Study
Pediatric palliative care offers opportunities for collaboration.
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Palliative care specialists are faced with extensive barriers to providing effective palliative care. We carried out a survey to identify existing barriers from the point of view of palliative care experts in Japan and determine the priorities for future actions to overcome these barriers. ⋯ We identified numerous barriers to providing effective palliative care, related to not only medical practitioners, but also economic factors and the general population. These findings suggest that to overcome these barriers, we need to take action on many fronts, including increasing social awareness and effecting political change, as well as addressing problems relating to practitioners. We prioritized the future actions. The most frequent urgent problems were identified. We hope that collaborative efforts by the relevant organizations will improve palliative care in Japan.