Clinical governance and appropriateness of opioid-prescribing practices in cancer pain: a retrospective single center cohort study in primary care setting

Abstract

Background: Although many educational programs and guidelines had been published during last decades, only 50% of cancer pts receive adequate pain control. General Practitioner (GP) has an increasingly recognized role in the care of these pts, especially in end-of-life care. Thus, we aimed to investigate GPs' opioids prescribing adherence to guidelines in terminally ill cancer pts admitted to Integrated Home Care Services (IHCS). Then, we evaluated the impact of specialist home palliative care team (HPCT) in the management of cancer pain. Methods: A retrospective cohort study enrolling all cancer pts listed by the Local Health Authority No. 5, Veneto Region, as admitted to IHCS in 2013, with at least one opioids' prescription. For each patient, demographics (age and gender), clinico-pathological data, length of stay in home care, access to HPCT and opioids treatment have been obtained from medical and administrative records. In this preliminary report, descriptive statistics was used. Results: A total of 163 pts were included, median age was 69 years (range 12-91), 39,9% were women. Median length of stay in home care was 72 days; 138 pts (84,7%) died before 31/12/2013. The most common cause of cancer-related death were colon and lung cancer (21% and 19% respectively). Of the cohort considered, 41 pts had been taken into care only by GPs whereas 122 pts (74.9%) had been taken into care also by HPCT. Pts followed by GPs were more likely to receive only weak opioids as analgesic therapy (24,3% vs 5,7%). Regarding strong opioids management, pts followed only by GPs were more likely to start with transdermic route (29% vs 20,9%) and with morphine sulphate (38,7% vs 17,4%), whereas pts followed also by PHCT were more likely to start with oxycodone/naloxone (43,5% vs 13%). GPs' prescription of rescue therapy (immediate release opioids and rapid onset opioids) was less common when pts were not enrolled for the palliative care program (19,4% vs 73,9%). Conclusions: Access to palliative care could improve cancer pain management and GPs' knowledge about some key issues, such as timely appropriate administration of strong opioids, oral route as first-choice opioid administration, prescription of immediate release formulation for pain exacerbation and awareness of new drugs which could help to prevent and treat opioids induced constipation. A stronger integration of palliative care to standard oncologic care and primary care could be useful and improve our clinical practice.