Latest Australian research

Wojnar R, Sulistio M, Gorelik A, Michael N.

Background: Therapeutic drug monitoring of methadone for opioid replacement therapy in the management of opioid dependence is well-described. However, only a few studies have described the correlation between serum methadone concentration and cancer pain during palliative care.

Methods: Patients were recruited from an exploratory randomized controlled trial (RCT) comparing methadone rotation with other opioid rotations for refractory cancer-induced bone pain. Serum methadone trough levels and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) levels on day 14 of the rotation were analyzed using validated liquid chromatography-mass spectrometry. The average and worst pain intensities were rated at baseline and on day 14, preceding the recorded methadone levels. The Common Terminology Criteria for Adverse Events composite score was used to determine the adverse effects of methadone. The Spearman ρ was used to examine the correlation between methadone trough levels and pain reduction.

Results: Among the 20 patients who were randomized to receive methadone in the RCT, eight consented to this substudy. The mean (SD) steady-state 24-hour methadone dose was 11.6 (2.6) mg, whereas the mean (SD) serum methadone trough concentration was 93.7 (45.6) ng/mL with an acceptable adverse effect profile. All patients had an EDDP concentration of <0.01 mg/L, suggesting good metabolite clearance.

Conclusion: The reported methadone concentration required for therapeutic benefit was significantly lower than that reported previously. The study highlights that further appropriately powered studies are required to establish the role of routine trough methadone monitoring in patients newly rotated for the management of refractory cancer pain.

Jeong SY, Cleasby P, Ohr SO, Barrett T.

Abstract: Although advance care planning (ACP) has been widely promoted to enhance future provision of end-of-life care, there continues to be a need to better understand the ways in which individuals engage with ACP processes and their perceptions of resultant documentation (e.g. completed advance care directives (ACDs)). The aim of the study was to shed light on the views of patients participating in an RN-led ACP service. Data were collected from 85 completed ACDs and 43 surveys completed by patients and their carers. Diversity was demonstrated across the choice of substitute decision makers, preferred place of care, impact of future limitations, storage and communication of completed documentation. The findings provide clinicians, researchers and policy makers with insights into what matters to people in life and at the very end of life, and how to orientate services towards the preferences for care documented in ACDs. REGISTRATION: The study was retrospectively registered on 8/10/2018 with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246).

Ley Greaves L, Willmott L, Feeney R, White BP.

Abstract: Legalization of voluntary assisted dying (VAD), is increasingly being considered in many countries worldwide. Some regimes have a designated implementation period, after the law has passed but before it comes into force, to develop processes and systems required for VAD to be integrated within existing healthcare. This study is the first qualitative analysis of semi-structured interviews with 31 medical practitioners holding no in-principle objection to VAD, who may go on to provide VAD, during an implementation phase. It looks to understand perspectives on implementation and expectations of participating in VAD. Thematic analysis conceptualized four major themes: a new practice with many unknowns, perspectives on implementation, practicalities of the law, and clinical considerations. Findings highlight appropriate consideration is needed during the implementation phase to prepare the workforce in a sustainable way. Involvement of palliative care physicians in education and support for those involved in all end-of-life care would also be beneficial.