EAPC - ipac

424 EAPC Abstracts
Background: Evidence based medicine incorporates best available evidence
with clinical experience. Randomized controlled trials (RCT) are the
gold standard for evaluating therapy. The Cochrane Collaboration performs
systematic reviews of RCT evidence. EAPC guidelines are based upon
available evidence and expert opinion. Our objective is to review the RCT
evidence for EAPC pain management guidelines. Methods: Qualitative
appraisal of systematic reviews from the Cochrane Collaboration. Selected
reviews evaluate cancer or neuropathic pain and opioid or adjuvant analgesics.
Results: RCTs support efficacy of fentany, hydromorphone, morphine,
methadone and nonsteroidal anti-inflammatories in cancer. RCTs do
not support EAPC guidelines of morphine as first line opioid, nor recommendations
to titrate only with immediate release. Limited evidence is
available for long term methadone. Only oral transmucosal fentanyl citrate
has been evaluated for breakthrough pain. RCTs refute a predictable relationship
between breakthrough and around the clock opioid dose. No RCTs
evaluate opioid switching for side effects or analgesia. No reviews and very
few RCTs have been performed in neuropathic cancer pain.
Bisphosphonates, radiotherapy and radioisotopes are effective for painful
bony metastases. Single and multiple fraction radiotherapy schedules are
eqianalgesic. Systematic reviews are hampered by heterogeneity of trial
design, pain definition and evaluation, short study duration, lack of pain
classification and limited side effect reporting. Conclusions: Limited RCT
evidence supports EAPC cancer pain management guidelines. RCT evidence
refutes guidelines on breakthrough dosing and morphine titration.
Evidence gaps exist comparing opioids (efficacy, adverse effects, pain syndromes)
and guiding management of breakthrough and neuropathic pain.
Strategies to improve RCT evidence in palliative medicine are needed.
Formal criteria for evaluating observational evidence are needed.
83 Oral Presentation
Pain 1
Genetic variation in the Catechol-O-Methyltransferase (COMT)
gene and morphine requirements in cancer pain patients
Authors: Trude Rakvåg Faculty of medicine Cancer research and molecular
medicine NORWAY
Stein Kaasa Norwegian University of Science and Technology and St. Olavs
Hospital Trondheim NORWAY
Frank Skorpen Norwegian University of Science and Technology
Trondheim NORWAY
Joy Ross St Joseph’s Hospice London UNITED KINGDOM
Hiroe Sato Imperial College London UNITED KINGDOM
Pål Klepstad Norwegian University of Science and Technology and
St. Olavs Hospital Trondheim NORWAY
Background: Genetic variation contributes to differences in pain sensitivity
and response to different analgesics. Catecholamines are involved in the
modulation of pain. Catecholamines are partly metabolized by the catechol-
O-methyltransferase (COMT) enzyme. Therefore genetic variability in the
COMT gene may contribute to differences in pain sensitivity and response
to analgesics. It is shown that a polymorphism in the COMT gene, Rs4680
(Val158Met), influence pain sensitivity in human experimental pain and the
efficacy for morphine in cancer pain treatment. In this study we wanted to
investigate if variability in other regions in the COMT gene also contributes
to interindividual variability in morphine efficacy. Methods: We genotyped
11 single nucleotide polymorphisms (SNPs) throughout the COMT gene,
and constructed haplotypes from these 11 SNPs, which were in Hardy-
Weinberg equilibrium. We compared both genotypes and haplotypes against
pharmacological, demographical and patient symptoms measurements in a
Caucasian cancer patient cohort (n=197) receiving oral morphine treatment
for cancer pain. Results: Multivariate analyses showed that the most frequent
haplotype (34.5 %) was associated with lower morphine dose requirements
(p=0.005). Conclusions: This study suggests that genetic variability
in the COMT gene contributes to the efficacy of morphine in cancer pain
patients, and that increased understanding of this variability is reached by
evolving from analyses of a single SNP with haplotype analyses.
84 Oral Presentation
Pain 1
Trends in the use of opioids at the end of life and the expected
effects on hastening death
Authors: Mette Rurup Department of Public and Occupational Health VU
University Medical Center NETHERLANDS
Bregje D Onwuteaka-Philipsen VU University Medical Center, EMGO
institute, Department of Public and Occupational Health Amsterdam
NETHERLANDS
Agnes van der Heide Erasmus MC, Department of Public Health Rotterdam
NETHERLANDS
Sander D Borgsteede VU University Medical Center, Department Clinical
Pharmacology and Pharmacy Amsterdam NETHERLANDS
Paul J van der Maas Erasmus MC, Department of Public Health Rotterdam
NETHERLANDS
Background: Research aims: To study (trends in) opioid use and perceptions
of having hastened the end of life of a patient. Methods: A death
certificate study was done in the Netherlands in 2005 which was similar to
studies done in 2001 and 1995. In 2005, a questionnaire was sent to
6860 physicians who had attended a death. Response rate: 78%. Results:
Physicians in the Netherlands less often administered opioids with the
intention to hasten death in 2005 (3.1% of the non-sudden deaths) than in
2001 and in 1995 (resp. 7% and 10% of the non-sudden deaths). Physicians
gave similar dosages of opioids in each of the study years (79–82% gave
less than 200 oral morphine equivalents when taking into account hastening
the end of life in 1995, 2001 and 2005), but physicians in 2005 less often
thought that life was actually shortened than in 2001 and 1995 (37% in
2005, 50% in 2001, 53% in 1995). Of the physicians in 2005 who did think
the life of the patient was shortened by opioids (regardless of whether it was
intended or merely taken into account), 94% did not give higher dosages
than were in their own opinion required for pain– and symptommanagement.
Physicians in 2005 more often took hastening death into
account when they gave higher dosages of opioids, when the patient experienced
more severe symptoms and with female patients. In older patients
(≥80 years) physicians took the hastening of death into account more often,
but the actual dosages of opioids were lower. Conclusions: Physicians in
2005 less often thought that death was hastened by opioids and they less
often gave opioids with the intention to hasten death than in 2001 and 1995.
Main source of funding: ZonMW.
85 Oral Presentation
Pain 1
Effectiveness of Knowledge Translation Interventions to
Improve Cancer Pain Management: A Systematic Review
Authors: Greta Cummings Faculty of Nursing University of Alberta CANADA
Susan Armijo-Olivo University of Alberta Edmonton CANADA
Patricia Biondo Tom Baker Cancer Center Calgary CANADA
Alison Connors University of Alberta Edmonton CANADA
Neil Hagen Tom Baker Cancer Board, University of Calgary Calgary
CANADA
Lesa Chizawsky University of Alberta Edmonton CANADA
Robin Fainsinger University of Alberta Edmonton CANADA
Carla Stiles Tom Baker Cancer Center Calgary CANADA
Rashmi Dhaubhadel University of Alberta Edmonton CANADA
Background: Despite widespread interest in determining how to implement
best practices in cancer care, no systematic reviews of implementation of
knowledge transfer interventions for cancer pain management were found.
The study purpose was to examine the research literature to determine the
effectiveness of knowledge translation (KT) interventions for changing
behavior, beliefs and knowledge in healthcare practitioners, patients and
family, with the goal of improving clinical outcomes in cancer pain management.
Methods: Extensive electronic database searches (e.g. MEDLINE,
CINAHL, EMBASE, and others), along with manual and website searches,
were performed. Studies that evaluated the effect of KT interventions on