2011; Volume 13, No 3, March

 
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IAHPC BOARD MEMBERS’ REPORTS

Making those over 50 count? Palliative care and the aged
by Dr. Faith Mwangi-Powell

At the recent International Conference on AIDS and STIs in Africa, held in Addis Ababa Ethiopia in December 2011, a pre-conference on HIV and aging brought together the old, the young, policy makers, partners from governments, technical agencies, academia, civil society and donors.

The purpose of the pre-conference was to discuss the impact of the HIV epidemic on older people aged 50 and above who are either living with HIV or are affected by the epidemic in their role as carers. Clear recommendations to guide a future response to HIV and ageing in Africa was the primary aim of the pre-conference, organized by Help Age International, the UN Joint Programme on HIV/AIDS (UNAIDS), the World Health Organization, the Sidney School of Public Health, University of Sidney, Australia. The meeting was in recognition of that needs of older people living with HIV/AIDS are largely unmet. For example, at a high level meeting on HIV held in June 2011, UN member states produced a political declaration that made bold commitments to redouble efforts geared towards universal access to HIV prevention, treatment, care and support by 2015, and to have 15 million people living with HIV receive antiretroviral treatment by the same year (2). The declaration, though bold, had several omissions. It failed to recognize that people are living longer with HIV leading to a new cohort of older people living with HIV.  Indeed statistic projections indicate that by 2015 more than 50% of people living with HIV in the developing world will be aged 50 years and above. In sub-Saharan Africa over 3 million people living with HIV are above 50 years old and account for13% of those living with HIV in the continent (3). This means that the population dynamics of those living with HIV is changing and existing policies need to recognize the unique needs that come with these changes.

Speaking at one of the meetings, George Were, a 70 year old man looking after orphans said, "We as older people need to be seen more than just caregivers, sometimes we are also sick too and we need help, why do they not count us?� Indeed, a study conducted by the African Palliative Care Association (APCA) reviewing the palliative care needs for the elderly in two African countries found that their needs are largely neglected on the continent (1).

The survey found that while many aged try to lead active lives, the lives of many are characterized by inactivity, dependency and social isolation. Central to the problems that can compound a sense of social isolation is poverty, a financial destitution that impacts negatively upon people’s ability to access the health services they need. These financial problems are exacerbated for those aged who look after orphans and vulnerable children. Even where siblings exist as potential care givers to the aged, offering support can be problematic. Vulnerability to the actions of family members and family circle members can sometimes be compounded by competition over land rights. For some aged, functional impairment is marked by unmanaged pain.

In view of these finding, there is a critical need to ensure that HIV and AIDS response is comprehensive and fully integrated in order to meet the needs of all those affected, including patients and caregivers over 50 years of age.

References
1 APCA Bridging the Gap Report, APCA 2009, www.africanpalliativecare.org/resources
2 Political Declaration on HIV/AIDS Intensifying our efforts to Eliminate HIV/AIDS, Resolution  adopted by the UN general assembly on 10th June 2011. www.un.org
3 UNAIDS, (2009) HIV/AIDS statistics.

Dr Faith Mwangi-Powell is a board member of the IAHPC since 2007 and the Executive Director of the African Palliative Care Association, a post she has held since January 2005.


Opioids in palliative care: safe and effective prescribing of strong opioids for pain in palliative care of adults.
by Dr. Michael I. Bennett

Recently the National Institute for Clinical Excellence (NICE) in the UK undertook a review of evidence to produce prescribing guidance on opioids for use in palliative care. The guidance is aimed at prescribers who are not specialists in palliative care (e.g. family doctors or internal medicine specialists) and is for first line opioid therapy only. The guidance will be formally published in May 2012 but I have summarized the main recommendations to date.

The guidance was based on a thorough review of evidence of efficacy, adverse effects and health economic modeling. This revealed important clinical evidence that will be published in detail alongside the guidelines. For example, morphine is as effective or superior to oxycodone, fentanyl and buprenophine in terms of pain relief. In general, there were no overall differences found in adverse effects between opioids though transdermal preparations do result in reduced constipation, but not other adverse effects when compared to morphine. However, the health economic modeling demonstrated that transdermal preparations were not cost effective for first line therapy. In addition, for breakthrough pain, although fast acting fentanyls produced improvements in pain control compared to oral morphine the magnitude of the additional benefit was not cost-effective. For example, 47.3% of patients on morphine achieved a clinically meaningful improvement at 15minutes compared to 55.4% on fentanyl spray. Therefore morphine was recommended for first line therapy for breakthrough pain.

Communication
When offering a patient pain treatment with strong opioids, ask them about concerns such as addiction, tolerance, side effects and fears that treatment implies the final stages of life. Provide verbal and written information on opioid therapy to patients and carers, including when and why opioids are used to treat pain, how effective they are likely to be, how, when and how often to take opioids for background and breakthrough pain side effects and signs of toxicity, information on who to contact out of hours, particularly during initiation of treatment.

First-line treatment – titration
When starting treatment with strong opioids, offer patients with advanced and progressive disease regular oral sustained-release or immediate-release preparations (depending on patient preference and clinical presentation), with rescue doses of oral immediate-release preparations for breakthrough pain.

First-line maintenance therapy
Offer oral sustained-release morphine as first-line maintenance therapy to patients with advanced and progressive disease who require strong opioids. Do not routinely offer transdermal patch formulations as first-line maintenance therapy to patients in whom oral opioids are suitable. If pain remains inadequately controlled despite optimising first-line maintenance therapy, review analgesic strategy and consider seeking specialist advice.

First-line treatment with opioid patches if oral opioids are not suitable
Consider initiating transdermal opioids with the lowest acquisition cost for patients in whom oral opioids are unsuitable and analgesic requirements are stable, supported by specialist advice where needed. Consider subcutaneous delivery of opioids for patients in whom pain is unstable. 

Breakthrough pain
Offer immediate-release oral morphine for the first-line rescue medication of breakthrough pain. Do not offer fast-acting fentanyl as first-line rescue medication.

Management of side effects
Inform patients that constipation affects nearly all patients receiving strong opioid therapy. Prescribe laxative therapy (to be taken regularly at an effective dose) for all patients initiating strong opioids. Optimise laxative therapy for the management of constipation before considering switching opioids. Advise patients that nausea may occur when starting opioid therapy or at dose increase, but that it is likely to be transient. If nausea persists, prescribe and optimise anti-emetic therapy before considering switching opioids.

Advise patients that mild drowsiness or impaired concentration may occur when starting opioid therapy or at dose increase, but that it is often transient. In patients with either persistent or moderate-to-severe central nervous system side effects: consider dose reduction if pain is controlled, consider switching opioids if pain is not controlled.

If side effects remain uncontrolled despite optimising therapy, consider seeking specialist advice.

Dr Michael Bennet Professor at the University of Leeds and member of the NICE guidelines group, is a board member of the IAHPC since 2010.

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