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A Pilot study using a case study approach of the effectiveness and managebality of continuous subcutaneous infusion drug administration for patients with chronic malignant pain Beddard-Hyber, Elizabeth Anne

Abstract

The prevalence and complexity of unrelieved pain remains high among cancer patients, posing a challenge for health care providers to provide effective pain management. This becomes particularly challenging when the patient can no longer tolerate oral medications. Although continuous subcutaneous infusion (CSCI) via a low-technology syringe driver is commonly used as an alternative modality to oral administration in other countries, it has not been used much in Canada. The aim of this pilot study was to assess the feasibility of using a case study approach to gain insight into the decision to initiate CSCI via syringe driver and to test the effectiveness of CSCI related to pain and pain-related symptoms, and its comfort and manageability for use by patients who cannot tolerate oral medications and are experiencing severe or unstable pain. Both quantitative and qualitative approaches were used to gather information from the patient, family/caregiver, physician and community health care nurse. Data pertaining to levels of pain and pain-related symptoms were collected daily for two weeks and at a follow up point two weeks later using the Brief Pain Inventory and the Edmonton Symptom Assessment Scale plus questions related to frequency of breakthrough doses given and medication dosage. Questions were also asked about comfort and manageability in using CSCI via syringe driver. Although the plan was to include four case studies, only one case was included because of difficulty with recruitment of people who met the study criteria. In the case examined, CSCI via syringe driver was initiated after other modalities (transdermal fentanyl patch and intermittent subcutaneous injections) were found to be ineffective or labour intensive. Syringe drivers were accessible in the community where the study was conducted and health care providers were competent in their use. The patient's wife was willing and able to manage the modality and to assess her husband's pain accurately, provide bolus doses appropriately and report difficulties in administration of CSCI or in management of her husband's pain. In terms of effectiveness in managing pain, the administration of continuous and bolus doses of hydromorphone in increasing amounts was able to maintain the patient's average daily pain levels between 1 and 3.5 (on a numeric scale of 0-10). When pain levels reached a 4, the patient's wife administered a bolus dose. Least pain levels ranged from 0 and 0.5 daily, during the first two weeks. Two weeks following the main study period, the pain had increased considerably with average daily pain rated as 4 and worst pain rated as 9. Total hydromorphone administered increased from 114 mg to 204 mg during the first two weeks to a total of 378 mg per day (180 mg as continuous dose plus 11 breakthrough doses each of 18 mg) in the follow-up period. At that point, although better pain control would likely have been achieved by switching to methadone, switching would require patient hospitalization for medication adjustment. Neither the patient nor family wanted the patient to be hospitalized so the patient continued on CSCI at home until his death shortly after. In terms of pain-related symptoms, the main symptoms experienced related to elevated anxiety and tiredness. In terms of manageability, the patient's wife managed CSCI via syringe driver and the administration of bolus doses with relative ease and reported changes in her husband's condition when necessary. Although limitations pertain to the small sample and the use of proxy pain assessments by the wife, the findings suggest that CSCI via syringe driver is generally effective in administering an opioid that could be quickly titrated to meet the individual needs of the patient and easily managed in the home. A case study approach is appropriate and feasible. Implications for theory, practice, education and research are suggested.

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