Opioid misuse in patients with cancer pain: an integrative systematic review of the literature

Introducción: los opioides son ampliamente utilizados para el control del dolor oncológico y no oncológico. Existe mucha información sobre el uso inadecuado de opioides (UIO) en pacientes no oncológicos, sin embargo en pacientes oncológicos existe menos evidencia. Objetivos: identificar, analizar y sintetizar la evidencia disponible sobre la epidemiología, los factores de riesgo, instrumentos clínicos y evolución del UIO en pacientes con dolor oncológico. Material y métodos: revisión sistemática integradora de la literatura con extracción de datos y síntesis narrativa. Las fuentes utilizadas para buscar artículos publicados hasta el 31 de diciembre de 2017 fueron las bases de datos PubMed, Web of Science y PsychINFO. Se eligieron aquellos artículos que siguieran los siguientes criterios de inclusión: 1) publicados en lengua inglesa, española o francesa, y 2) que incluyesen información sobre la prevalencia o incidencia del UIO en pacientes con dolor oncológico, o/y 3) que aportasen información sobre factores de riesgo, mortalidad, duración del UIO y su remisión. Resultados: De la búsqueda surgieron 3520 artículos, de los cuales 40 cumplieron los criterios de inclusión. Se identificaron cuatro áreas temáticas: 1) epidemiología, 2) factores de riesgo, 3) opinión de pacientes y profesionales, y 4) políticas específicas. Los resultados obtenidos fueron muy heterogéneos, identificándose una prevalencia que oscila entre el 0 y el 26 % en el UIO y entre el 12 y el 85 % en las conductas aberrantes relacionadas con opioides. Se identificaron diferentes factores de riesgo de UIO, destacando la edad joven y la presencia de antecedentes psiquiátricos o de abuso de sustancias, y se describieron diferentes instrumentos dirigidos a la evaluación del riesgo o bien al diagnóstico del UIO. En cuanto a la opinión de los profesionales, parece haber un incremento de la sensibilización al respecto, pero las políticas de los centros en relación con esta problemática suelen ser casi inexistentes. Conclusiones: A pesar de que existe una mayor sensibilización de los profesionales acerca del UIO en pacientes oncológicos, la información de que disponemos es muy heterogénea y no nos permite extraer conclusiones claras. Por esta razón será necesaria la realización de nuevos estudios intentando homogeneizar criterios y establecer mejores protocolos y políticas de detección e intervención frente al UIO

Have we improved pain control in cancer patients? A multicenter study of ambulatory and hospitalized cancer patients

Background: Pain in cancer patients is recognized as a major health problem, yet few studies of both inpatient and outpatient populations have been carried out. Objective: The study objective was to assess the frequency, type, and characteristics of pain in adult cancer patients, including both inpatients and outpatients. Methods: This cross-sectional study involved 1064 adult cancer patients (437 outpatients and 627 inpatients) from 44 hospitals and/or long-term-care centers in Catalonia, Spain. Cancer patients suffering from pain of any etiology for >_2 weeks and/or under analgesic treatment >_2 weeks were enrolled. Demographic and pain data were collected. The Spanish version of the Brief Pain Inventory was used to assess pain. Results: Pain frequency was 55.3%. Pain was less frequent in outpatients than inpatients (41.6% versus 64.7%; p<0.001), although median pain duration was longer in outpatients (20 versus 6 weeks; p<0.001). Pain was assessable in 333 patients, and intensity was similar in both out- and inpatients; however, outpatients reported less improvement, less pain interference with daily life, and less pain related to the cancer per se. In both groups, patients with multiple myeloma (73%), breast (65%), and lung cancer (61%) were most likely to report pain. Conclusions: Pain in cancer patients, both ambulatory and hospitalized, remains a challenge for health care professionals, health administrators, and stakeholders. Our study reveals the high level of pain and distress that cancer patients continue to suffer, a problem that is particularly notable in outpatients due to the intensity and duration of the pain

Quality improvement in palliative care services and networks: preliminary results of a benchmarking process in Catalonia

Background: a wide range of palliative care services has been implemented in Catalonia over the past 20 years. Quantitative and qualitative differences in the organization of palliative care services between districts and settings can result in wide variability in the quality of these services, and their accessibility. Methods: we implemented a benchmark methodology to compare dimensions of care and organization, to identify aspects requiring improvement, and to establish indicators to measure progress. The overall aim was to generate a consensus document for submission to the Department of Health (DoH) of the Government of Catalonia. Results: a Steering Committee convoked a meeting in Barcelona (Catalonia, Spain) and representatives (n = 114) of all the 37 districts within our health care remit (rural, urban, intermediate, and metropolitan) and settings of the health care system (hospitals, social health centers, community, and nursing homes) attended and took part in plenary sessions and workshops to define areas that, in their experience, were considered weak. Twenty-one consensus recommendations achieving high levels of consensus were generated for submission to the DoH. These included the formal definition of the model of care and organization of palliative care services at all levels in the region, the implementation of measures for improvement in different settings and scenarios, systems for continuous care, and facilities for the continuing training of health care personnel. These proposals have since been implemented in a trial region and, depending on the outcomes, will be applied throughout our health service. Conclusion: we conclude that benchmark methodology is valuable in acquiring data for use in improving palliative care organization for patients' benefit

Development of a Guide to Multidimensional Needs Assessment in the Palliative Care Initial Encounter (MAP)

Ensuring patient-centered palliative care requires a comprehensive assessment of needs beginning in the initial encounter. However, there is no generally accepted guide for carrying out this multidimensional needs assessment as a first step in palliative intervention. To develop an expert panel-endorsed interview guide that would enable proactive and systematic Multidimensional needs Assessment in the Palliative care initial encounter (MAP). A preliminary version of the MAP guide was drafted based on a published literature review, published semistructured interviews with 20 patients, 20 family carers, and 20 palliative care professionals, and a nominal group process with palliative care professionals and a representative of the national patient's association. Consensus regarding its content was obtained through a modified Delphi process involving a panel of palliative care physicians from across Spain. The published systematic literature review and qualitative study resulted in the identification of 55 needs, which were sorted and grouped by the nominal group. Following the Delphi process, the list of needs was reduced to 47, linked to six domains: Clinical history and medical conditions (n = 8), Physical symptoms (n = 17), Functional and cognitive status (n = 4), Psycho-emotional symptoms (n = 5), Social issues (n = 8), and Spiritual and existential concerns (n = 5). MAP is an expert panel-endorsed semi-structured clinical interview guide for the comprehensive, systematic, and proactive initial assessment to efficiently assess multiple domains while adjusting to the needs of each patient. A future study will assess the feasibility of using the MAP guide within the timeframe of the palliative care initial encounter

Proactive and systematic multidimensional needs assessment in patients with advanced cancer approaching palliative care: a study protocol

Introduction: The benefits of palliative care rely on how healthcare professionals assess patients' needs in the initial encounter/s; crucial to the design of a personalised therapeutic plan. However, there is currently no evidence-based guideline to perform this needs assessment. We aim to design and evaluate a proactive and systematic method for the needs assessment using quality guidelines for developing complex interventions. This will involve patients, their relatives and healthcare professionals in all phases of the study and its communication to offer clinical practice a reliable approach to address the palliative needs of patients. Methods and analysis: To design and assess the feasibility of an evidence-based, proactive and systematic Multidimensional needs Assessment in Palliative care (MAP) as a semistructured clinical interview guide for initial palliative care encounter/s in patients with advanced cancer. This is a two-phase multisite project conducted over 36 months between May 2019 and May 2022. Phase I includes a systematic review, discussions with stakeholders and Delphi consensus. The evidence gathered from phase I will be the basis for the initial versions of the MAP, then submitted to Delphi consensus to develop a preliminary guide of the MAP for the training of clinicians in the feasibility phase. Phase II is a mixed-methods multicenter feasibility study that will assess the MAP's acceptability, participation, practicality, adaptation and implementation. A nested qualitative study will purposively sample a subset of participants to add preliminary clues about the benefits and barriers of the MAP. The evidence gathered from phase II will build a MAP user guide and educational programme for use in clinical practice. Ethics and dissemination: Ethical approval for this study has been granted by the university research ethics committee where the study will be carried out (approval reference MED-2018-10). Dissemination will be informed by the results obtained and communication will occur throughout

An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

Background: The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD. Methods: Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy. Findings: All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD. Conclusions: This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention

Herramientas para la evaluación multidimensional de uso para médicos de cuidados paliativos: proyecto ICO-Tool Kit

Introducción: el paciente y su familia presentan una serie de necesidades físicas, emocionales, sociales y espirituales que requieren ser evaluadas. Estas necesidades han de quedar registradas ya que han de permitir la fijación de objetivos asistenciales, la revisión de los resultados y su reevaluación posterior. La evaluación de estas necesidades con instrumentos comunes facilita la transmisión de la información entre los distintos profesionales sanitarios implicados en el proceso de atención. Objetivo: consensuar distintos instrumentos para una evaluación multidimensional en el paciente oncológico avanzado que deberían incluirse en cualquier valoración médica de equipo de cuidados paliativos de la red asistencial del Institut Català d'Oncologia. Material y método: técnica de consenso entre los distintos participantes mediante grupo de discusión. Acuerdo interobservador en grupo de discusión basado en la valoración tanto de la bibliografía existente sobre los instrumentos analizados, como de la experiencia práctica diaria de los miembros de los equipos en su empleo. El equipo de trabajo estuvo formado por una muestra representativa de los 3 centros participantes y constituida por 5 médicos, 4 psico-oncólogos y 4 trabajadores sociales. Todos con experiencia en cuidados paliativos y dedicación completa. De los distintos instrumentos analizados, se empleó para su valoración tanto la bibliografía existente de los mismos, así como la experiencia práctica de los equipos con su empleo. Se obtenía una puntuación y un grado de acuerdo que sirvió para la elección de los instrumentos que se consideraban más útiles y formarían parte del kit de evaluación. Resultado y conclusiones: tras discusión y análisis de los resultados, se seleccionaron los instrumentos que se consideraron más adecuados para la evaluación. Se definió un conjunto de instrumentos para la evaluación de las 3 dimensiones exploradas: física (antecedentes, estado funcional, dependencia, listado de síntomas y supervivencia), emocional (síntomas emocionales, incluyendo espiritualidad y cuidados al final de la vida) y social mostrando el porcentaje de acuerdo alcanzado para cada una de ellas