WITHDRAWN: 

Opioid switching to improve pain relief and drug tolerability.

Quigley C.

Cochrane Database Syst Rev. 2013 Oct 18;

Source

Cochrane Pain, Palliative & Supportive Care Review Group, Pain Research Unit, The Churchill Hospital, Headington, Oxford, Oxfordshire, UK, OX3 7LJ.

Abstract

BACKGROUND:

Patients with cancer, and increasingly chronic non-cancer pain frequently require strong opioids for pain relief. Morphine is the first-line strong opioid of choice for these patients. While most achieve adequate analgesia with morphine, a significant minority either suffer intolerable side-effects, inadequate pain relief, or both. For these patients switching to an alternative opioid is becoming established clinical practice. However, the evidence for the effectiveness of opioid switching does not appear to be established.

OBJECTIVES:

The aim of this review was to investigate the usefulness of opioid switching for patients with pain.

SEARCH METHODS:

Randomised trials that assessed opioid rotation, switching, or substitution in adults or children with acute or chronic pain were sought through electronic databases and by handsearching relevant journals. 
Date of the most recent search: January 2003.

SELECTION CRITERIA:

The search strategy retrieved no randomised controlled trials, and therefore no studies were available to enable a quantitative synthesis that would assess the effectiveness of the strategy of opioid switching.

DATA COLLECTION AND ANALYSIS:

Given the lack of RCTs, the review examined all case reports, uncontrolled, and retrospective studies in an attempt to determine the current level of evidence.

MAIN RESULTS:

Fifty-two reports were identified, comprising 23 case reports, 15 retrospective studies/audits and 14 prospective uncontrolled studies. The majority of the reports used morphine as first-line opioid and the most frequently used second-line opioid was methadone. All reports, apart from one, concluded that opioid switching is a useful clinical manoeuvre for improving pain control and/or reducing opioid-related side-effects.

AUTHORS' CONCLUSIONS:

For patients with inadequate pain relief and intolerable opioid-related toxicity/adverse effects, a switch to an alternative opioid may be the only option for symptomatic relief. However, the evidence to support the practice of opioid switching is largely anecdotal or based on observational and uncontrolled studies. Randomised trials, including 'N of 1' studies, where a patient acts as their own control, are needed:  
firstly, to establish the true effectiveness of this clinical practice; 
secondly, to determine which opioid should be used first-line or second-line; and 
thirdly, to standardise conversion ratios when switching from one opioid to another.

Swallowing dysfunction and dysphagia is an unrecognized challenge for oral drug therapy.

Stegemann S, Gosch M, Breitkreutz J.

Int J Pharm. 2012 Jul 1;430(1-2):197-206. 

Source

Capsugel, Rijksweg 11, 2880 Bornem, Belgium. sven.stegemann@capsugel.com

Abstract

There is evidence that swallowing issues and dysphagia are an increasing problem of the aging population in the coming decades that is affecting oral medication administration. 

There is a variety of clinical expressions of swallowing dysfunction caused by aging, acute or chronic disease conditions, decline in physiological functions and adverse drug reactions. 

About one third of patients in long term care facilities experience serious difficulties with swallowing solid oral dosage forms (SODF). Manipulations of the solid oral drug products occur frequently in nursery homes leading to medication errors and potential changes in drug product performance.

 The alteration of the drug products is performed with the best intention of the care giver to help the patients but bears concerns about safety and lawfulness. Alternative SODF and drug delivery technologies should be considered in the development of new and generic products and their prescription to overcome medication administration problems in patients with swallowing difficulties of SODF.
Copyright © 2012 Elsevier B.V. All rights reserved.

Comment in

Comments on selected recent dysphagia literature. [Dysphagia. 2013]

Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms.

Eur J Clin Pharmacol. 2013 Apr;69(4):937-48.

Schiele JT, Quinzler R, Klimm HD, Pruszydlo MG, Haefeli WE.

Source

Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.

Abstract

PURPOSE:

We assessed the prevalence of difficulties in swallowing solid oral dosage forms in a general practice population. 
Reasons, nature, and characteristics of tablets and capsules causing such difficulties were investigated as well as general practitioners' (GP) awareness of these difficulties.

METHODS:

A questionnaire survey was conducted in 11 general practices and consecutive patients taking at least one solid oral dosage form for ≥4 weeks were invited to respond to a questionnaire at the practices and one at home. Physicians completed a short questionnaire for each included patient.

RESULTS:

Of all participants (N = 1,051), 37.4 % reported having had difficulties in swallowing tablets and capsules. 
The majority (70.4 %) of these patients was not identified by their GP. 
The occurrence of swallowing difficulties was related to gender (f>m), age (young>old), dysphagia [adjusted odds ratio (adOR): 7.9; p < 0.0001] and mental illness (adOR: 1.8; p < 0.05). 
By asking "Do you choke while eating or drinking?", affected patients could be identified with a sensitivity of 62.6 % and a specificity of 78.1 %.
 Because of these difficulties, 58.8 % of the affected patients had already modified their drugs in a way that may alter safety and efficacy and 9.4 % indicated to be non-adherent.

CONCLUSIONS:

One in 11 primary care patients had frequent difficulties in swallowing tablets and capsules while GPs grossly underestimated these problems. Therefore, physicians should rule out swallowing difficulties regularly to avoid non-adherence and inappropriate drug modifications. Special attention should be paid to specific patient groups (e.g. women and patients with dysphagia, dysphagia indicators, or mental illness).

Challenges of treating patients with chronic pain with dysphagia (CPD): physician and patient perspectives.

Pergolizzi JV Jr, Taylor R Jr, Nalamachu S, Raffa RB, Carlson DR, Varanasi RK, Kopecky EA.

Curr Med Res Opin. 2013 Oct 28.

 Source

Johns Hopkins University School of Medicine, Baltimore, MD, USA, Georgetown University School of Medicine, Washington, DC, USA, and Temple University School of Medicine , Philadelphia, PA , USA.

Abstract

Abstract Objective: 
Dysphagia-difficulty eating and swallowing-can significantly impair a patient's ability to maintain adequate nutritional and medication intake. There are a large number of patients with chronic pain, including pediatric, geriatric, and palliative care patients, who suffer from dysphagia and, therefore, have difficulty achieving optimal pain management with solid, oral formulations. The objective of this study was to survey physicians and patients in the US to understand their knowledge, attitudes, and clinical management/analgesic usage patterns in the treatment of patients with chronic pain with dysphagia (CPD).

 Research design and methods: Two separate surveys were administered to physicians and patients. The physician survey design was qualitative; physicians participated in a semi-structured phone interview. The patient survey design was quantitative; patients participated in a structured online survey. Purposive sampling was used to recruit participants into both studies. Physician participants were identified based on their specialty, prescribing practices, and geographic location. Patient participants were recruited through a consumer panel of pre-identified individuals who, for 3 months or longer, had chronic pain and were taking opioids. 


Results: Thirty-four physicians and 1021 patients were surveyed. Physicians indicated that 5-20% of their patients had difficulty swallowing. Treatment for CPD consisted of the fentanyl patch, immediate-release opioids, methadone liquid, or extended-release morphine products. 
Physicians were not satisfied with currently available treatment options. 
 Twenty-nine per cent of patients surveyed had trouble swallowing or disliked swallowing pills. 
Eighty per cent of patients were not asked about their ability to swallow solid, oral dosage forms by their physician. 
To circumvent swallowing difficulties, some patients (16%) cut/crush/grind their medication to facilitate swallowing. Most of these patients (65%) did not know that altering tablets could potentially change the drug release (pharmacokinetic) characteristics of the tablet and lead to serious adverse events. 
Limitations: Qualitative survey research can be influenced by responder bias as well as selection bias. The number of survey participants for both the physician and patient surveys was small, thus responses may not reflect those in the general population. 


Conclusion: A proportion of patients with chronic pain have dysphagia and cannot swallow solid, oral dosage forms, which creates a serious treatment challenge for pain specialists and other healthcare providers. Currently available treatment options have limitations; new treatment options would be welcomed by both physicians and patients. Physician and patient education should be enhanced in order to promote awareness of the deleterious consequences associated with altering currently available analgesic formulations. Facilitating patient-physician communication on this topic may help to improve treatment outcomes.

حال الإنسانية

روز زياده

4 كانون الأول 2013

تعليقاً على مقال المطران خضر ("النهار" 21 ايلول 2013) بعنوان "الشيخوخة والعتاقة"، نسأل: لماذا الناس في بلدنا ماديّون الى درجة الصنمية؟ في كل الاديان يعظوننا بالمحبة التي يوصي بها الله. ولكن لا احد يحاول تجربة نوعية هذه المحبة. عشنا الحروب اللبنانية والمذلات وضيق المعيشة ونحن نصبر، ونقول: "غداً سيكون أحسن". سيأتي يوم وتنتهي الحرب. لم يكن عند أحد من الناس ادنى فكرة ان نهاية الحرب بعيدة وستدخل عليها حروب اخرى بكل عناصر الهدم الاخلاقي والتربوي والاقتصادي وآداب المعاشرة "Savoir Vivre" وتصاعدت قيمة الشتيمة لتتدنى قيمة الانسان واضمحلت الانسانية. هكذا مثلما جرى لـ"فوعة" الدولار الاميركي مقابل الليرة اللنانية. منذ عقود، ونحن ننتظر لأن الامر ليس بيدنا. وقد نسينا أننا شخنا وأن مجالات الحياة اصبحت قليلة لنا. نمنا لنستفيق على تعريب الناس مثلما يعربون "كومة من التفاح أو البطاطا". نعم كبار السن يُستبعدون عن كل شيء. عن السهرات، عن التفسح. عن السؤال عنهم ليشعروا بالحياة.

كبار السن بين ليلة وضحاها يهدد تاريخ نضالهم وتمحى معه تعابير وجوههم حَمَلة عقلية قديمة لا تتماشَى مع الحياة العصرية التحررية حيث عمّت المُساكنات اغلب العائلات والطبقات وهجر الازواج والزوجات بيوتهم بعد سنوات كثيرة من العيش معاً وتأسيس عائلة، بحجة لم يعد لديهم طاقة للاحتمال، تاركين اولاداً كل ذنبهم ان الله اختارهم هدية لهؤلاء العائلات. إن اعتبرنا الدعاية التي نراها على التلفزيون " كل سنة في ولد بيخسر اهلو وبيخسر معن الروحة عالمدرسة" فنجد ان العدد الاكبر هم من يخسرون اخلاقية اهاليهم ليخسروا معهم كل معنى قيّم للحياة.

قال المطران خضر "الانسان لا يعتق". صحيح، هو لا يعتق انما المجتمع اللبناني العتيد الخالي من الانسانية "يحسسه" بأنه اصبح عتيقاً وغير مؤهل لاي شيء.