- How well do so-called "bridge" programs work? These are the home-care programs for patients who qualify but whose goals do not align with hospice, or who have serious illness but a prognosis outside of the hospice criteria (e.g. 1 year rather than 6 months). I have heard rumors that bridge programs may drop patients who do not "cross the bridge" to hospice, or who do not have profitable insurance. Does anyone know of any studies desribing these programs, and critically evaluating the quality of their services? This seems to be a potentially important avenue of research.
- Problems with VA hospice contracts for residential hospice. A number of area SNF/nursing homes are not accepting the VA hospice contract, or prioritizing it so low as to effectively not accept it. The fact that the VA will pay for residential hospice care (including room and board) for veterans has always struck me as a very important benefit for this population. So many veterans lack informal caregivers to provide for their daily needs, and lack the financial resources to hire private help. Hospice alone - generally a few visits a week - is not nearly enough. They need the custodial care that the residential benefit provides. I hope our area issue is not a sign of a national trend toward making placement of veterans in a residential hospice difficult, or (worse) impossible.
- Opioid analgesia in patients with liver failure. Does anyone have a good reference? I read this one and this one, but wasn't particularly impressed. There doesn't seem to be a fast fact on the topic.
by: Alex Smith
Comments
As with all palliative services, patient admission/discharge decisions are regularly made using many criteria, including insurance coverage.
http://pain-topics.org/opioid_rx/safety.php#RenalHepatic. Hope this helps. -- Stew Leavitt
David-appreciate your story. It sounds like we have more work to do to understand the reasons for the problems with the SNFs and VA hospice contracts, and work to repair those relationships.
Tim-completely agree we need more information about the quality and services offered by bridge programs. They fill an important niche, but what exactly are they? What do they do? What is the impact on patient outcomes? How are patients enrolled and disenrolled?
Stew - the pain topics paper is a great reference! Very practical. One issue - the pain topics paper recommends against the use of methadone in patients with hepatic dysfunction (citation is a package insert). The article in Mayo Clinic Proceedings by Chandok I linked to above actually touts methadone (along with fentanyl) as one of the safest drugs to use in hepatic dysfunction. For support, they note the many patients who use methadone without problems for opioid replacement therapy (history of substance abuse). Anecdotally, we've used methadone in patients with hepatic dysfunction without issue. Methadone is metabolized in the liver, however, so I understand there are reasons for caution, and we've generally dose-reduced when used for analgesia.
Considering methadone as "safe" with any degree of hepatic dysfunction seems like a 'stretch.' And, using MMT (Methadone Maintenance Treatment) settings as a support of this might not be appropriate. There are many challenges in adequately dosing MMT patients with methadone if they have HCV, cirrhosis, or other liver ailments; the potential for overdose is significant, but they need the methadone to maintain addiction recovery (it's not an analgesic application of the drug).
Anyway, that was the opinion of our authors and peer reviewers when the paper was originally developed. I hope the above doesn't sound defensive.
I believe Howard Smith has updated his article from the Mayo Clinic Proceedings in 2009. Smith HS. The Metabolism of Opioid Agents and the Clinical Impact of their Active Metabolites. Clin J. Pain 2011; 27(9): 824-838.
James
Stew - not at all defensive, thank you for the explanation! You're right, 'safe' is not the right word for using methadone in the setting of liver failure. Extreme caution is probably better. My take away from this is that for dose finding and breakthrough, oxycodone at a reduced dose and spaced out interval is probably best. For patients with a stable requirement, the fentanyl patch is safest. Or in settings where IV administration is feasible, IV fentanyl may be used.
James - thanks for the reference, just flipped through it. Nice summary - not as practical for the practicing clinician, as it doesn't say what to do and not do, but great background about the metabolism of each opioid.
The reference 17 is: http://www.uptodate.com/contents/management-of-pain-in-patients-with-cirrhosis/abstract/17
Maybe safe isn't such a stretch of a word after all?
For many patients, sometimes the most ill patients, methadone seems to work when all other analgesics have failed. Yet, I've been a "student" of methadone for almost 20 years and it still has me mystified at times. Research regarding its actions, and interactions, really needs to be examined critically, as so much of it is of low quality, of questionable validity, and hasn't been adequately replicated. I suppose the old advice is still most suitable for any clinical situation with methadone: start low and go very slow.
http://www.ncbi.nlm.nih.gov/pubmed?term=rhee%20palliation%20and%20liver%20failure
Rhee & Broadbent Palliation of liver failure: palliative medication dosage guidelines 2007 J Palliat Med
Greg Phelps MD
UT Hospice