Malene S. Davis

Alternative Routes to Oral Opioid Administration in Palliative Care: A Review and Clinical Summary

OBJECTIVE A major goal of palliative care is to provide comfort, and pain is one of the most common causes of treatable suffering in patients with advanced disease. Opioids are indispensable for pain management in palliative care and can usually be provided by the oral route, which is safe, effective, and of lowest cost in most cases. As patients near the end of life, however, the need for alternate routes of medication increases with up to 70% of patients requiring a nonoral route for opioid administration. In order to optimize patient care, it is imperative that clinicians understand existing available options of opioid administration and their respective advantages and disadvantages. METHODS We performed a literature review to describe the most commonly used and available routes that can substitute for oral opioid therapy and to provide a summary of factors affecting choice of opioid for use in palliative care in terms of benefits, indications, cautions, and general considerations. RESULTS Clinical circumstances will largely dictate appropriateness of the route selected. When the oral route is unavailable, subcutaneous, intravenous, and enteral routes are preferred in the palliative care population. The evidence supporting sublingual, buccal, rectal, and transdermal gel routes is mixed. CONCLUSIONS This review is not designed to be a critical appraisal of the quality of current evidence; rather, it is a summation of that evidence and of current clinical practices regarding alternate routes of opioid administration. In doing so, the overarching goal of this review is to support more informed clinical decision making.

Opioid Prescribing Practices Before and After Initiation of Palliative Care in Outpatients

CONTEXT Prescription Monitoring Programs (PMPs) are being developed and implemented in many states to deter abuse, diversion, and overdose, and physicians may use PMPs to help guide their treatment choices for individual patients. OBJECTIVES To evaluate the changes in prescribing practices and pain score outcomes in patients with cancer before and after an initial consult in an outpatient palliative care clinic. METHODS This is a retrospective study with a sample of 60 consecutive patients who had been referred by oncologists for difficult-to-manage pain and whose initial palliative care consult was with either of the two physicians in the outpatient palliative care clinic. For each patient, lists were compiled of all prescriptions for controlled medications and filled for the 90-day periods immediately before and after the initial consult. Data from patient charts were combined with information from the Virginia PMP, which included prescriptions written before and after the initiation of palliative care, written by prescribers both inside and outside the palliative care clinic. RESULTS After the palliative care consult, the proportion of patients on long-acting opioids increased from 45% to 73%. Self-reported pain outcomes, which were compiled for the subset of patients who continued palliative care for at least 60 days, showed a median decrease of two units on a 0-10 scale. A decrease was seen in the use of medications that compound acetaminophen with opioids. CONCLUSION Data from a PMP proved useful in understanding the changes in a population of patients. Favorable changes were observed in prescribing practices and pain outcomes.

An Evaluation of Time and Cost Variability in Hospice Interdisciplinary Group Meetings and Comparative Clinical Quality Outcomes

This study involved a community-based, multisite hospice program serving 7 distinct communities in the greater Washington, DC, metropolitan area. The objectives were to compare time and costs among hospice interdisciplinary group (IDG) meetings and resultant select clinical outcomes in order to establish a benchmark for best practices within a large multisite hospice provider. A standardized data collection tool was used at all practice sites during multiple team meetings to determine staffing by discipline and numbers, types and number of patient reviews (new patients, patient deaths, simple vs complex plan-of-care revisions), time involved, resultant costs, and clinical key quality-of-care outcome measures, including pain relief, patient and family satisfaction, and crisis prevention and rates of disruptions in care (unscheduled medical visits, transfers to emergency departments and/or hospital). A point system devised by the authors was used to normalize the data in order to account for differences in case mix (complexity, admissions, deaths). This novel approach has not been previously described, but was a necessary innovation in order to create apt comparisons among groups of patients and their respective interdisciplinary teams. Although all IDGs met Medicare Conditions of Participation standards, appreciable differences existed in all measured variables among the 7 community sites, leading to significant disparity in resultant costs associated with conducting IDG meetings across distinct communities served by this hospice agency. Significant increases in costs were not justified by commensurate improvements in clinical quality outcomes. In fact, the lowest-cost IDG also had as favorable or higher ratings on discrete clinical outcome measures as higher-cost IDGs. We conclude that IDGs differ substantially in performance, and through a comparative analysis, an optimal model was discerned, comprising lowest overall costs without compromising quality of care.