High opioid dosage rapid detoxification of cancer patient in palliative care with the Raffaeli model.

BACKGROUND: Chronic opioid administration can induce adverse drug-dependent events and tolerance and/or hyperalgesia development. Opioid rotation is the treatment option in this case; however, it can expose patients to long periods of ineffectiveness and/or development of withdrawal syndrome, overdose, or adverse events. To overcome this issue, a method of rapid detoxification from opioids has been developed. AIMS: To assess feasibility and efficacy of our opioid detoxification protocol in patients affected from chronic cancer pain. SETTINGS/PATIENTS: We studied 15 patients, with chronic cancer pain, who were afferent to Hospice of Rimini, Italy, were in therapy with high doses of opioid and needed opioid rotation or a therapeutic variation because of opioid toxicity, inefficacy, tolerance, or hyperalgesia. Each patient received a fixed dose of endovenous morphine and clonidine plus oral ketoprofen or ibuprofen, and oral lorazepam, if required, for at least 3 days, suspending the previous opioid therapy. We monitored withdrawal symptoms, pain intensity, type, and intensity of adverse events. RESULTS: Withdrawal symptoms were experienced by four (26.6 percent) patients. The average Numerical Rating Scale for pain decreased significantly (p < 0.05) from 8.3 ± 1.57 to 3.6 ± 1.4 at the end of the detoxification and to 2.4 ± 1 at the end of the rotation or therapeutic adjustment. Average duration of the detoxification was 6.86 ± 6.4 days (range 3-22). CONCLUSIONS: The results suggested that the detoxification protocol may be effective in preventing withdrawal signs in patients needing a therapeutic change because of opioid-induced tolerance, hyperalgesia, or toxicity.

Qualitative pain classification in hospice and pain therapy unit.

In this study, we investigated patient's meaning attribution to pain in hospice and pain therapy unit, using a qualitative approach: narrative-based medicine. The data presented here were related to patients (n = 17) hospitalized in Rimini Hospice (Italy). These data were compared to those of patients (n = 21) with noncancer pain (control sample). The interviews were then analyzed according to the technique of thematic narrative analysis. The results of our research identified a differential process in pain processing in relationship to the meaning that the patient attributed to pain. The thematic analysis of the interviews allowed the inductive construction of a specific network of pain dimensions, which were summarized in "the pain chronogram."

Death representation of caregivers in hospice.

In this study, we investigated caregiver's death representation in hospice. The results presented here are a further analysis of the data collected in our previous study, concerning the evaluation of the caregiver in hospice. The data analysis of 24 caregivers of patients hospitalized in Rimini Hospice (Italy) underlined that caregivers avoiding death representation of the patient admitted to hospice had fewer protective factors (52.3%) and more risk factors (47.7%) than caregivers nonavoiding (66.5% and 33.5%, respectively). Caregivers avoiding death representation, moreover, experienced a greater distress (58%) than those nonavoiding (42%).

Ziconotide: A rapid detoxification protocol for the conversion from intrathecal morphine--the Raffaeli Detoxification Model.

OBJECTIVES: To assess the efficacy and the safety of our rapid detoxificationprotocol in preventing signs and symptoms of withdrawal and pain severity. DESIGN: Prospective, open-label case series study. SETTINGS: Public primary care at the Pain and Palliative Care Unit of the Infermi Hospital of Rimini, Italy. PATIENTS: The authors studied 10 consecutive patients suffering from chronic noncancer pain who were refractory to intrathecal (IT) morphine, and hence indicated for ziconotide therapy. INTERVENTIONS: IT pump was refilled with saline solution, and each patient received endovenous morphine, oral clonidine, ketoprofen, and lorazepam for the first 3 days, and slow-release tramadol, oral clonidine, and ketoprofen for 10 days. Ziconotide therapy was started at the end of the 2-week detoxification treatment. MAIN OUTCOME MEASURES: The observer-rated opioid withdrawal scale (OOWS) was used for the assessment of withdrawal signs, visual analogue scale was used for pain intensity assessment, and also adverse events were recorded. RESULTS: Withdrawal symptoms were experienced by 3 patients (30 percent). Their average OOWS decreased significantly (p < 0.05) from 4.3 +/- 2.5 to 1.7 +/- 0.6 at days 3 and 14 of protocol, respectively, with no increment of pain intensity. Withdrawal symptoms were resolved in 4 days on average without the need of adjuvant medications. One patient with high morphine dosage (20 mg/d), interestingly, did not show any withdrawal symptoms. CONCLUSIONS: The detoxification protocol was effective in preventing withdrawal signs without increasing pain severity, allowing to rapidly convert IT morphine to ziconotide monotherapy in patients who are refractory to morphine.

Caregiver evaluation in hospice: application of a semi-structured interview.

In this study we report the results of construction and administration of a semi-structured interview for the evaluation of caregivers in hospice. The results presented here are related to interviews (n = 25) that were administered at Rimini Hospice. According to the interview coding system, it was possible to identify thematic areas of the interviews where the caregiver's distress was mainly concentrated. As concerning the care burden, greater distress was detected in areas relating to the change in the rhythm of life (38%) and in social network (26%); whereas, as concerning the psychological burden, a greater distress was detected in the area related to the caregiver role (51%). In conclusion, a singular element identified as a source of distress in, our study, is that of social network.

Illness awareness in hospice: application of a semi-structured interview.

This study describes the results of a semi-structured interview to assess the illness awareness of cancer patients in Hospice. The results of this study are based on the interviews made in Rimini and Savignano sul Rubicone Hospices (n = 51). Psychologists evaluated illness awareness of the participants interviewed independently from the code system that is provided for the interview. According to the psychologists, 18 patients (35%) were aware, 11 patients (22%) were unaware, and 22 patients (43%) were aware with defense mechanisms. According to the code system of the interview, the results were the following: 18 patients (35%) were aware, 2 patients (4%) were unaware, and 29 patients (57%) were aware with defense mechanisms. Two participants had to be reassessed because of inconsistency in some factors. In conclusion, the data analysis underlined that the congruence of the 2 assessment methods was found in 33 of the 51 patients examined (65%) and that the degree of concordance was rather low (kappa = .46; 95% CI = 0.24-0.68).