Healthcare professionals' views of the use of oral morphine and transmucosal diamorphine in the management of paediatric breakthrough pain and the feasibility of a randomised controlled trial: A focus group study (DIPPER)
Breakthrough pain; diamorphine; focus groups; opioids; paediatrics; pain management; palliative care; terminal care
Background: Oral morphine is frequently used for breakthrough pain but the oral route is not always available and absorption is slow. Transmucosal diamorphine is administered by buccal, sublingual or intranasal routes, and rapidly absorbed. Aim(s): To explore the perspectives of healthcare professionals in the UK caring for children with life-limiting conditions concerning the assessment and management of breakthrough pain; prescribing and administration of transmucosal diamorphine compared with oral morphine; and the feasibility of a comparative clinical trial. Design/ participants: Three focus groups, analysed using a Framework approach. Doctors, nurses and pharmacists (n = 28), caring for children with life-limiting illnesses receiving palliative care, participated. Result(s): Oral morphine is frequently used for breakthrough pain across all settings; with transmucosal diamorphine largely limited to use in hospices or given by community nurses, predominantly buccally. Perceived advantages of oral morphine included confidence in its use with no requirement for specific training; disadvantages included tolerability issues, slow onset, unpredictable response and unsuitability for patients with gastrointestinal failure. Perceived advantages of transmucosal diamorphine were quick onset and easy administration; barriers included lack of licensed preparations and prescribing guidance with fears over accountability of prescribers, and potential issues with availability, preparation and palatability. Factors potentially affecting recruitment to a trial were patient suitability and onerousness for families, trial design and logistics, staff time and clinician engagement. Conclusion(s): There were perceived advantages to transmucosal diamorphine, but there is a need for access to a safe preparation. A clinical trial would be feasible provided barriers were overcome. Copyright © The Author(s) 2021.
Jamieson L; Harrop E; Johnson M; Liossi C; Mott C; Oulton K; Skene SS; Wong ICK; Howard RF
Palliative Medicine.
2021
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1177/02692163211008737" target="_blank" rel="noreferrer noopener">10.1177/02692163211008737</a>
Documentation of breakthrough pain in narrative clinical records of children with life-limiting conditions: Feasibility of a retrospective review
life-limiting conditions; child; Breakthrough pain; data collection/instrumentation; retrospective review
This study explored the feasibility of generating reliable information on the frequency, nature and management of breakthrough pain (BTP) in children with life-limiting conditions and life-threatening illnesses (LTIs) from narrative clinical records. In the absence of standardized ways for documenting BTP, we conducted a consensus exercise to develop a glossary of terms that could denote BTP in the records. Thirteen clinicians who contributed to the records reached consensus on 45 terms which could denote BTP, while emphasizing the importance of contextual information. The results of this approach together with guidance for improving the reliability of retrospective reviews informed a data extraction instrument. A pilot test of this instrument showed poor agreement between raters. Given the challenges encountered, we do not recommend a retrospective review of BTP using narrative records. This study highlighted challenges of data extraction for complex symptoms such as BTP from narrative clinical records. For both clinical and research purposes, the recording of complex symptoms such as BTP would benefit from clear criteria for applying definitions, a more structured format and the inclusion of validated assessment tools. This study also showed the value of consensus exercises in improving understanding and interpretation of clinical notes within a service.
Oostendorp LJ; Rajapakse D; Kelly P; Crocker J; Dinsdale A; Fraser L; Bluebond-Langner M
Journal of Child Health Care
2018
<a href="http://doi.org/10.1177/1367493518807312" target="_blank" rel="noreferrer noopener">10.1177/1367493518807312</a>
Barriers to the use of buccal and intranasal fentanyl for breakthrough pain in paediatric palliative care: an exploratory survey
palliative therapy; letter; pediatrics; human; child; breakthrough pain; fentanyl
We recently administered a survey to investigate the prescribing of buccal and intranasal fentanyl for breakthrough pain in paediatric palliative care in the UK.
Harrop E; Jamieson L; Choy T H; Ho WHP; Wong ICK
BMJ supportive & palliative care
2018
<a href="http://doi.org/10.1136/bmjspcare-2017-001413" target="_blank" rel="noreferrer noopener">10.1136/bmjspcare-2017-001413</a>
A cross-sectional study on prevalence of pain and breakthrough pain among an unselected group of outpatients in a tertiary cancer clinic
adolescent; Cross-Sectional Studies; Female; Humans; Male; Young Adult; Neoplasms; Pain Measurement; Cohort Studies; Adult; Prevalence; Aged; Middle Aged; Comorbidity; Ambulatory Care Facilities; Breakthrough Pain; Norway; Outpatients
PURPOSE: Systematic knowledge about the prevalence and the treatment effects of cancer pain in patients attending a general oncology outpatient department is limited. The purpose of this study was to investigate the prevalence of pain in a large representative cohort of patients attending a general oncology outpatient department in order to guide further screening, classification, and treatment of pain. MATERIAL AND METHODS: A cross-sectional study among patients visiting the outpatient clinic with histologically verified cancer, age≥18 years, adequate cognitive function, and no surgical procedures last 24 h were included. Pain was assessed by the Brief Pain Inventory and the Alberta Breakthrough Pain Assessment Tool. RESULTS: Three hundred five patients were included. The mean age was 60 years, 94% had a WHO performance status of 0-1 and 59% received oncological treatment with a curative intent. The mean score for average pain last 24 h (numerical rating scale, 0-10) and current pain was 1.84 and 1.08, respectively. Twenty-two percent reported pain score of ≥4 as their average pain in the previous 24 h. Twenty-one percent reported breakthrough pain (BTP). In multivariate analyses, sleep, BTP, age, treatment intent, and comorbidity was significantly associated with mean average pain in the previous 24 h and explained 29% of the variability of average pain in the previous 24 h. CONCLUSION: Of the patients at an oncology outpatient clinic, 22% reported clinically significant pain. These findings indicate that all patients are candidates to be screened for pain and, if present, a more detailed pain diagnosis should be established before any interventions can be recommended.
2014-07
Raj Sunil X; Thronaes M; Brunelli C; Hjermstad MJ; Klepstad P; Kaasa S
Supportive Care In Cancer : Official Journal Of The Multinational Association Of Supportive Care In Cancer
2014
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1007/s00520-014-2178-3" target="_blank" rel="noreferrer">10.1007/s00520-014-2178-3</a>