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(384) Pain and social processes for hospice cancer patients: an integrative review of the literature
Abstracts
secondary endpoints, including responder rate for achieving at least 30% improvement (p=0.020), changes from baseline to the DB endpoint in Brief Pain Inventory-Short Form (BPI-SF) Pain Intensity subscale (LS mean= -0.9; p=0.003) and Pain Interference subscale (LS mean; -1.1; p=0.006), change in BPI-SF least pain (p=0.004), and walking ability (p=0.003), were significant in the fulranumab treated patients vs. placebo. Patients with $ 2 point increase in BPI Pain Subscale (23% vs. 3%) and BPI Interference Subscale (26% vs. 6%) were more in placebo group vs. fulranumab. The most common adverse events (fulranumab vs. placebo) were asthenia (16% vs. 10%), decreased appetite (12% vs. 6%), fatigue (10% vs. 0%), and deaths due to malignant neoplasm progression (10% vs. 0%), with no differences in neurologic, autonomic, or joint related AEs. Although, adjunctive fulranumab therapy didn’t show significant improvement in average cancer pain intensity, greater responder rate and improvement in BPI-SF scales in fulranumab-treated group vs. placebo suggested the potential of anti-NGF therapy in cancer pain.
(383) Providing death with dignity M Cutbirth and D Bank; Seattle Children’s Hospital, Seattle, WA In 2008, the State of Washington became the second of five states to adopt the Death with Dignity Act, which provides a competent, terminally ill, adult resident, who are medically predicted to have six-months or less to live, the ability to request and self-administer lethal medication prescribed by a physician to end their own lives. Within the past few years, the State of Washington has had a consistent increase in the number of Death with Dignity cases, reaching more than 700 in total. One such case was a 20-year old male with progressive, metastatic osteosarcoma, rendering him with a prognosis of having less than 6 months to live. His disease caused severe bilateral leg pain that was difficult to control with conventional strategies. He expressed his goals of care to be pain control with minimal loss of function and the ability to interact with his family. In fear of having his wishes not be met, he applied for Death with Dignity. Over the 15-day application process, the inpatient pain consultation service implemented creative and innovative methods in an attempt to control his pain. In addition to high dose opioids, a methadone regimen, ketamine and benzodiazepine infusions, regional blocks, and other adjuncts and complimentary therapies were used. In his final days, challenges arose in the meeting of his goals due to the progression of his disease and treatment side effects. In collaboration with him and his family, for the rest of his days, his comfort and quality of life was ensured, ultimately providing him with death with dignity. We review the relationship between poorly controlled pain at the end of life, how it can lead to the decision to apply for Death with Dignity, and the moral components of physician aided death.
(384) Pain and social processes for hospice cancer patients: an integrative review of the literature O Ehrlich and R Walker; University of Massachusetts, Amherst, Amherst, MA Hospice cancer patients experience poorly-controlled pain. This review summarizes what is known about differing ways that members of the hospice caring triad (patients, caregivers, and nurses) interpret and respond to cancer pain. We searched the literature to retrieve 46 studies of pain meaning. Knowledge from these studies was then organized according to social roles and an established social processes framework. Pain meanings and related responses vary widely for persons with pain, their caregivers and nurses, as do pain goals. These differences can translate to pain management practices that may conflict with patients’ goals and impede pain control.
F03 Cancer Pain - Pharmacological Treatment (385) Opiate adherence in African Americans being treated for cancer pain K Yeager, S Meghani, H Cooper, T Quest, B Williams, J Kweon, S Haight, and D Bruner; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
African Americans (AA) experience a disproportionate burden of cancer pain. The purpose of this study is to describe adherence to around the clock (ATC) oral opiates for AAs being treated for cancer
The Journal of Pain
S71
pain. Using a cross sectional descriptive approach, self-identified AAs (n=85) 21 years or older, diagnosed with cancer, and taking an oral ATC opiate were recruited from a tertiary cancer center and a safety net hospital in Atlanta. Mean age was 56 years (range 3587), 58% were women, and 48% had at least some college education. Participants had various cancer diagnoses, with 75% receiving cancer treatment in the last month (57% chemotherapy, 11% radiation, and 32% both). Mean pain at its worst, average, and least was 6.1, 4.8 and 2.9 respectively; all in the last 24 hours and on a 0-10 scale. Patients were prescribed either extended release Morphine (62%), extended release Oxycodone (34%) or Methadone (4%). Self-reported adherence showed that 54%, 56%, 59%, and 51% reported taking the ATC opiates as prescribed (correct dose at the correct time) for the past 1, 2, 3, 4 days respectively. They reported last skipping a dose in the last week (37%), last month (17%), or last 2 to 3 months (13%). Only 33% said they never skipped a dose. Of those who reported skipping a dose, the most common reasons included not feeling like they needed it (33%), sleeping through dose time (27%), not being at home (25%) and being busy (25%). Other concerns for not taking opiates as prescribed included, concerns about relying on medicines, not wanting to take medicines unless the pain was severe, and drowsiness. Findings from this study enhance understanding of how ATC opiates are taken by AA and provide information on which to develop interventions to improve cancer pain management. Supported by NINR 1K01NR014673.
(386) The influence of age and gender on opioid dosage in cancer pain clinic patients N Moryl, V Dave, P Glare, V Malhotra, A Gulati, J Hung, V Puttanniah, Y Griffo, R Tickoo, A Wiesenthal, C Johnson, S Horn, and C Inturrisi; Memorial Sloan-Kettering Cancer Center, New York, NY
The Memorial Sloan-Kettering Cancer Center (MSKCC) Pain Registry database contains patient characteristics, treatments, and outcomes on 1534 cancer pain patients who were seen at the MSKCC Pain Medicine outpatient clinics from November 1, 2010 until December 12, 2014. Ages 45-64 comprised 50% and were followed by age >=65 at 35%. Fifty-seven % were female and 43% male. Eighty-three % of females and 89% of males received an opioid at one on more clinic encounters. The median daily opioid dose in morphine equivalents (MEQs) was 109 with a range from 0.4 to 3960 MEQs. As the opioid dose increases from the 1st quartile to the 4th quartile, the % of females receiving the higher doses decreases from 35 to 22% while the % males receiving the higher doses increases from 22 to 28% (p<0.001). As the opioid dose increases, the % of patients age 4564 receiving the higher doses increases from 25 to 30% while the % of patients age >=65 receiving the higher doses decreases from 36 to 16% (p<0.001). The patients that received an opioid report greater mean % Pain Relief (Brief Pain Inventory, BPI) than those that did not (56% compared to 35%) and this increased to 60% for those receiving the highest dose. However, the mean Pain Interference (BPI) subscale and mean Condensed Memorial Symptom Assessment Scale (CMSAS) Physical subscale scores were increased slightly as a function of opioid quartile dose. We find that males and patients aged 45-64 receive higher opioid doses than females and patients aged >=65. For these cancer patients, the patient-reported pain relief and adverse effects are opioid dose dependent. Supported in part by DA028928 and a grant from Purdue Pharm, Ltd.
F04 Cancer Pain - Other (387) Effectiveness of splanchnic nerve neurolysis for targeting location of cancer pain: using the pain drawing as an outcome variable D Novy, M Engle, E Lai, C Cook, E Cox-Martin, L Trahan, L Feng, and D Koyyalagunta; UT MD Anderson Cancer Center, Houston, TX The effectiveness of splanchnic nerve neurolysis (SNN) for cancerrelated abdominal pain has been investigated using numeric pain intensity rating as an outcome variable. The outcome variable in this study used the grid method for obtaining a targeted pain drawing score on 60 patients with pain from pancreatic or gastro-intestinal primary cancers or metastatic disease to the abdomen. Using the Wilcoxon signed rank test and associated effect sizes, results show
secondary endpoints, including responder rate for achieving at least 30% improvement (p=0.020), changes from baseline to the DB endpoint in Brief Pain Inventory-Short Form (BPI-SF) Pain Intensity subscale (LS mean= -0.9; p=0.003) and Pain Interference subscale (LS mean; -1.1; p=0.006), change in BPI-SF least pain (p=0.004), and walking ability (p=0.003), were significant in the fulranumab treated patients vs. placebo. Patients with $ 2 point increase in BPI Pain Subscale (23% vs. 3%) and BPI Interference Subscale (26% vs. 6%) were more in placebo group vs. fulranumab. The most common adverse events (fulranumab vs. placebo) were asthenia (16% vs. 10%), decreased appetite (12% vs. 6%), fatigue (10% vs. 0%), and deaths due to malignant neoplasm progression (10% vs. 0%), with no differences in neurologic, autonomic, or joint related AEs. Although, adjunctive fulranumab therapy didn’t show significant improvement in average cancer pain intensity, greater responder rate and improvement in BPI-SF scales in fulranumab-treated group vs. placebo suggested the potential of anti-NGF therapy in cancer pain.
(383) Providing death with dignity M Cutbirth and D Bank; Seattle Children’s Hospital, Seattle, WA In 2008, the State of Washington became the second of five states to adopt the Death with Dignity Act, which provides a competent, terminally ill, adult resident, who are medically predicted to have six-months or less to live, the ability to request and self-administer lethal medication prescribed by a physician to end their own lives. Within the past few years, the State of Washington has had a consistent increase in the number of Death with Dignity cases, reaching more than 700 in total. One such case was a 20-year old male with progressive, metastatic osteosarcoma, rendering him with a prognosis of having less than 6 months to live. His disease caused severe bilateral leg pain that was difficult to control with conventional strategies. He expressed his goals of care to be pain control with minimal loss of function and the ability to interact with his family. In fear of having his wishes not be met, he applied for Death with Dignity. Over the 15-day application process, the inpatient pain consultation service implemented creative and innovative methods in an attempt to control his pain. In addition to high dose opioids, a methadone regimen, ketamine and benzodiazepine infusions, regional blocks, and other adjuncts and complimentary therapies were used. In his final days, challenges arose in the meeting of his goals due to the progression of his disease and treatment side effects. In collaboration with him and his family, for the rest of his days, his comfort and quality of life was ensured, ultimately providing him with death with dignity. We review the relationship between poorly controlled pain at the end of life, how it can lead to the decision to apply for Death with Dignity, and the moral components of physician aided death.
(384) Pain and social processes for hospice cancer patients: an integrative review of the literature O Ehrlich and R Walker; University of Massachusetts, Amherst, Amherst, MA Hospice cancer patients experience poorly-controlled pain. This review summarizes what is known about differing ways that members of the hospice caring triad (patients, caregivers, and nurses) interpret and respond to cancer pain. We searched the literature to retrieve 46 studies of pain meaning. Knowledge from these studies was then organized according to social roles and an established social processes framework. Pain meanings and related responses vary widely for persons with pain, their caregivers and nurses, as do pain goals. These differences can translate to pain management practices that may conflict with patients’ goals and impede pain control.
F03 Cancer Pain - Pharmacological Treatment (385) Opiate adherence in African Americans being treated for cancer pain K Yeager, S Meghani, H Cooper, T Quest, B Williams, J Kweon, S Haight, and D Bruner; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
African Americans (AA) experience a disproportionate burden of cancer pain. The purpose of this study is to describe adherence to around the clock (ATC) oral opiates for AAs being treated for cancer
The Journal of Pain
S71
pain. Using a cross sectional descriptive approach, self-identified AAs (n=85) 21 years or older, diagnosed with cancer, and taking an oral ATC opiate were recruited from a tertiary cancer center and a safety net hospital in Atlanta. Mean age was 56 years (range 3587), 58% were women, and 48% had at least some college education. Participants had various cancer diagnoses, with 75% receiving cancer treatment in the last month (57% chemotherapy, 11% radiation, and 32% both). Mean pain at its worst, average, and least was 6.1, 4.8 and 2.9 respectively; all in the last 24 hours and on a 0-10 scale. Patients were prescribed either extended release Morphine (62%), extended release Oxycodone (34%) or Methadone (4%). Self-reported adherence showed that 54%, 56%, 59%, and 51% reported taking the ATC opiates as prescribed (correct dose at the correct time) for the past 1, 2, 3, 4 days respectively. They reported last skipping a dose in the last week (37%), last month (17%), or last 2 to 3 months (13%). Only 33% said they never skipped a dose. Of those who reported skipping a dose, the most common reasons included not feeling like they needed it (33%), sleeping through dose time (27%), not being at home (25%) and being busy (25%). Other concerns for not taking opiates as prescribed included, concerns about relying on medicines, not wanting to take medicines unless the pain was severe, and drowsiness. Findings from this study enhance understanding of how ATC opiates are taken by AA and provide information on which to develop interventions to improve cancer pain management. Supported by NINR 1K01NR014673.
(386) The influence of age and gender on opioid dosage in cancer pain clinic patients N Moryl, V Dave, P Glare, V Malhotra, A Gulati, J Hung, V Puttanniah, Y Griffo, R Tickoo, A Wiesenthal, C Johnson, S Horn, and C Inturrisi; Memorial Sloan-Kettering Cancer Center, New York, NY
The Memorial Sloan-Kettering Cancer Center (MSKCC) Pain Registry database contains patient characteristics, treatments, and outcomes on 1534 cancer pain patients who were seen at the MSKCC Pain Medicine outpatient clinics from November 1, 2010 until December 12, 2014. Ages 45-64 comprised 50% and were followed by age >=65 at 35%. Fifty-seven % were female and 43% male. Eighty-three % of females and 89% of males received an opioid at one on more clinic encounters. The median daily opioid dose in morphine equivalents (MEQs) was 109 with a range from 0.4 to 3960 MEQs. As the opioid dose increases from the 1st quartile to the 4th quartile, the % of females receiving the higher doses decreases from 35 to 22% while the % males receiving the higher doses increases from 22 to 28% (p<0.001). As the opioid dose increases, the % of patients age 4564 receiving the higher doses increases from 25 to 30% while the % of patients age >=65 receiving the higher doses decreases from 36 to 16% (p<0.001). The patients that received an opioid report greater mean % Pain Relief (Brief Pain Inventory, BPI) than those that did not (56% compared to 35%) and this increased to 60% for those receiving the highest dose. However, the mean Pain Interference (BPI) subscale and mean Condensed Memorial Symptom Assessment Scale (CMSAS) Physical subscale scores were increased slightly as a function of opioid quartile dose. We find that males and patients aged 45-64 receive higher opioid doses than females and patients aged >=65. For these cancer patients, the patient-reported pain relief and adverse effects are opioid dose dependent. Supported in part by DA028928 and a grant from Purdue Pharm, Ltd.
F04 Cancer Pain - Other (387) Effectiveness of splanchnic nerve neurolysis for targeting location of cancer pain: using the pain drawing as an outcome variable D Novy, M Engle, E Lai, C Cook, E Cox-Martin, L Trahan, L Feng, and D Koyyalagunta; UT MD Anderson Cancer Center, Houston, TX The effectiveness of splanchnic nerve neurolysis (SNN) for cancerrelated abdominal pain has been investigated using numeric pain intensity rating as an outcome variable. The outcome variable in this study used the grid method for obtaining a targeted pain drawing score on 60 patients with pain from pancreatic or gastro-intestinal primary cancers or metastatic disease to the abdomen. Using the Wilcoxon signed rank test and associated effect sizes, results show