Toward evidence-based prescribing at end of life: a comparative analysis of sustained-release morphine, oxycodone, and transdermal fentanyl, with pain, constipation, and caregiver interaction outcomes in hospice patients.

OBJECTIVE: The primary goal of this investigation was to examine selected outcomes in hospice patients who are prescribed one of three sustained-release opioid preparations. The outcomes examined include: pain score, constipation severity, and ability of the patient to communicate with caregivers. PATIENTS AND SETTINGS: This study included 12,000 terminally ill patients consecutively admitted to hospices and receiving pharmaceutical care services between the period of July 1 and December 31, 2002. DESIGN: We retrospectively examined prescribing patterns of sustained-release morphine, oxycodone, and transdermal fentanyl. We compared individual opioids on the aforementioned outcome markers, as well as patient gender, terminal diagnosis, and median length of stay. RESULTS: Patients prescribed a sustained-release opioid had similar average ratings of pain and constipation severity, regardless of the agent chosen. Patients prescribed transdermal fentanyl were reported to have more difficulty communicating with friends and family when compared with patients prescribed either morphine or oxycodone. On average, patients prescribed transdermal fentanyl had a shorter length of stay on hospice as compared with those receiving morphine or oxycodone. CONCLUSION: There was no difference in observed pain or constipation severity among patients prescribed sustained-release opioid preparations. Patients receiving fentanyl were likely to have been prescribed the medication due to advanced illness and associated dysphagia. Diminished ability to communicate with caregivers and a shorter hospice course would be consistent with this profile. Further investigation is warranted to examine the correlation between a patient's ability to interact with caregivers and pain control achieved.

Initial Selection of Antiemetics in End-of-Life Care: A Retrospecitve Analysis.

The purpose of this study was to compare the relative severity of nausea and vomiting scores before and after initiation of treatnment regimens in end-of-life cancer patients, and secondarily to evaluate the efficacy of a combination antiemetic preparation (ABHR; lorazepam [Ativan], diphenhydramine [Benadryl], haloperidol [Haldol], and metoclopramide [Reglan] in this patient population. A retrospective analysis of antiemetic use was performed through a systematic chart review of patients with an end-of-life diagnosis of lung, pancreatic, or colorectal cancer whose medications were provided through Hospice Pharmacia. Information collected included patient age and sex; terminal diagnosis; pre- and post-antiemetic nausea and vomiting scores; and initial antiemetic choice. A total of 584 patient records were examined, and the most widely used antiemetics used were prochlorperazine, metoclopramide, and ABHR. The most prevalent diagnosis was lung cancer. All of the agents and preparations were determined to be effective as intial therapy for the management of nausea and vomiting in the end-of-life cancer patient; therefore use of these agents as first-line therapy options in this population appears to be justified. ABHR appears to be at least as efficacious as other first-line monotherapy options investigated. Despite a lack of information on the absolute bioavailability of alternative ABHR dosage forms such as suppositories and topical gels, these also appear to be efficacious and therefore are viable options in the treatment of nausea and vomiting in end-of-life cancer patients.

Methadone and the hospice patient: prescribing trends in the home-care setting.

OBJECTIVE: To identify frequency and utilization patterns of methadone by hospice patients in the home-care setting. PATIENTS AND SETTING: All hospice patients admitted to a North American palliative care specialty pharmacy and dispensed methadone from November 1, 2001 to October 31, 2002 were analyzed. We also analyzed all hospice patients dispensed long-acting opioids during that same time period. DESIGN: A retrospective analysis of the pharmacy database was performed for patients dispensed methadone. Data was compared to the long acting opioid cohort to be able to identify any difference in terminal diagnoses present, and the presence of neuropathic pain in both groups. Methadone daily dosage was also analyzed during this study. RESULTS: Four hundred sixteen hospice patients were dispensed methadone over a twelve-month period of time. For comparison, 21,219 patients were prescribed a long-acting opioid preparation (sustained-release morphine, sustained-release oxycodone, or transdermal fentanyl). The most common terminal diagnosis for both groups was lung carcinoma. The distribution of terminal diagnoses was similar in both groups. The group prescribed methadone was found to have a higher incidence of neuropathic pain (30.5% of patients) when compared to the long-acting opioid group (16.9%). Most patients (61.3%) were prescribed daily methadone doses of 100 mg or less. CONCLUSIONS: Despite its potential clinical and economic benefits, methadone is not commonly prescribed for the hospice patient in the home-care setting. Clinicians may be more aware of the usefulness of methadone in the treatment of neuropathic pain.