Lessons from the Literature

2021; Volume 22, No 5, May

Under My Microscope

Dr. Tania Pastrana. Used with permission.

By Dr. Tania Pastrana
IAHPC Research Advisor

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Switching Ratio from Parenteral to Oral Methadone 1:1.2 Is Safer Compared with Ratio 1:2 in Patients with Controlled Cancer Pain: A multicenter randomized-controlled trial (RATIOMTD-010810)

González-Barboteo J, Porta-Sales J, Nabal-Vicuña M, Díez-Porres L, Canal-Sotelo J, et al. J Palliat Med 2021: 382-390. DOI: 10.1089/jpm.2020.0244

Methadone is listed by the WHO as an essential medicine for the management of cancer pain1 and has good pharmacological characteristics. It is even used by specialist teams as first-line treatment in cancer control with good results.2 However, the lack of reliable switching ratios represents a challenge, particularly concerning patient safety: therefore, it is recommended for use by experts.

The study presented here was conducted by Spanish colleagues under the leadership of Dr. Eduardo Bruera. They compared the success and side effects of two ratios (1:2 versus 1:1.2) from parenteral to oral methadone in hospitalized patients with cancer pain, through a single-blind, multicenter, randomized-controlled trial. Thirty-nine patients (21 in one arm of the study, 18 in the other) with advanced cancer were included. Outcomes measured were pain intensity and opioid toxicity. Methadone dose pre switching was 24.5 mg ±13.5 and 49 mg ±27.3 for ratio 1:2, versus 23.3 mg ±9.4 and 28 mg ±11.3 for ratio 1:1.2.

The authors recommended a ratio of 1:1.2 when changing from parenteral to oral methadone, which resulted in lower toxicity and no difference in analgesia.

  1. World Health Organization Model List of Essential Medicines, 21st List, 2019.
  2. Peirano GP, Mammana GP, Bertolino MS, Pastrana T, Vega GF, et al. Methadone as first-line opioid treatment for cancer pain in a developing country palliative care unit. Support Care Cancer 2016; 24(8): 3551-6.

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Objective: To compare success and side effects with two ratios from parenteral to oral methadone: 1:2 versus 1:1.2 in hospitalized patients with cancer pain.

Design: A multicenter double-blind randomized clinical trial.

Settings/Participants: Inpatients with well-controlled cancer pain with parenteral methadone requiring rotation to the oral route.

Measurements: Outcomes included pain intensity (Brief Inventory Pain), opioid toxicity (Common Toxicology Criteria for Adverse Events), and methadone dose. Success was defined as no toxicity with good pain control at 72 hours.

Results: Thirty-nine of forty-four randomized patients were evaluable: 21 in ratio 1:2 and 18 in ratio 1:1.2. Seventy-one percent male. Median age 65 years. No significant differences in basal clinical characteristics between both groups. Median methadone dose pre/post switching was 24.5 mg ±13.5 and 49 mg ±27.3 for ratio 1:2, versus 23.3 mg ±9.4 (p: not significant) and 28 mg ±11.3 (p < 0.01) for ratio 1:1.2. Pain was well controlled without differences between both ratios. Drowsiness at day +1 (p < 0.017) and myoclonus at day +3 (p < 0.019) were more prevalent in group 1:2. Success was observed in 12 patients in ratio 1:2 versus 18 in ratio 1:1.2 (p < 0.001). Methadone side effects were observed in 12 patients in ratio 1:2 (mainly neurotoxicity symptoms) versus 2 in ratio 1:1.2 (p < 0.005).

Conclusion: Ratio 1:1.2 when changing from parenteral to oral methadone resulted in lower toxicity and no difference in analgesia. More conservative dose adjustment during methadone route change should be considered. European Clinical Trials Register (EudraCT No. 2010-024092-39).

Read Tania Pastrana’s bio here.

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Media Watch: Education

These articles on education in the context of clinical practice and improving public awareness are selected from recent issues of Barry R. Ashpole’s weekly report Media Watch.

Clinical Practice

Using Virtual Learning to Build Pediatric Palliative Care Capacity in South Asia: Experiences of implementing a teleteaching and mentorship program (Project ECHO)

JCO Global Oncology | Online – 8 February 2021 – In low- and middle-income countries, where 98% of the children needing palliative care (PC) reside, access to PC services is often very limited. Virtual learning, which brings training and mentorship directly to learners, can improve access to educational opportunities for staff in resource-limited settings. In this report, the authors describe the design, implementation, challenges, and subsequent modifications of a teleteaching and mentorship program, as well as the impact of the program for participants and for pediatric PC service delivery in South Asia. The program, Project ECHO (Extension for Community Healthcare Outcomes), consisted of biweekly videoconference sessions with didactic teaching and case-based discussions. It focused on engaging participants in meaningful learning by focusing on opportunities for participant interaction through teachings and case discussions. DOI: 10.1200/GO.20.00481

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Palliative care competencies for geriatricians across Europe: A Delphi consensus study

European Geriatric Medicine | Online – 1 February 2021 – The Delphi process described enabled development of a European specific core competency catalogue to improve competencies of geriatricians to enable them to guide their patients through the last period of life. DOI: 10.1007/s41999-020-00445-5

NB: The final version of core PC competences recommended by the European Geriatric Medicine Society included 35 competencies listed here.

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Public Education

The Hospice as a Learning Space: A death education intervention with a group of adolescents

BMC Palliative Care | Online – 7 April 2021 – The findings of this study confirm that death education does not produce negative consequences, but rather promotes existential reflection, as evidenced by previous literature. The participating students (from a town in Northern Italy) appreciated the different experiential and theoretical activities in the course and the warmth, humanity and competence conveyed by the hospice professionals and guests who held the meetings. Students highlighted the particular importance of the hospice experience, which reassured them about their capacity to manage the end of life. This protected space offered them the opportunity to face death as a natural and necessary event in life that can be managed with sensitivity, generosity and serenity. Participants’ responses in the qualitative part of the study revealed that they had discovered a deeper meaning in their lives and developed better coping skills to deal with loss, empowering them with more confidence to talk about the subject. DOI: 10.1186/s12904-021-00747-w

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Effectiveness of a Family-Caregiver Training Program in Home-Based Pediatric Palliative Care

Children | Online – 26 February 2021 – This descriptive pre-post educational intervention study shows that the provided intervention had a particularly positive effect in caretakers’ self-perception and their confidence about the outstanding caring skills they already had. Although the number of out-of-hours telephone calls from the caregivers to the pediatric palliative care (PC) team after the intervention did not decrease, they were more focused on the description of symptoms. Psycho-educational space emerged in the authors’ school for parents of children with complex healthcare needs in the setting of home-based PC that allowed them to share their experience of daily care for their children. DOI: 10.3390/children8030178

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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