Laxative prescribing in relation to opioid use and the influence of pharmacy-based intervention

Adherence to coprescribing of laxatives with opioids and associated characteristics in general practices in the Netherlands

BACKGROUND

Guidelines recommend to prescribe a laxative with an opioid to prevent constipation. We aimed to determine the adherence by general practitioners (GPs) to this recommendation and to explore which GP- and patient related factors were associated with it from the perspective of the GP.  METHODS: We conducted an observational study using GPs' prescription data from the Nivel Primary Care Database combined with a questionnaire asking for reasons of non-adherence. The proportion of first opioid prescriptions prescribed together with a laxative was determined as primary outcome. Possible explanatory factors such as the quality of registration, the level of collaboration with the pharmacy, familiarity with the recommendation and use of a clinical decision support system were explored, as were the self-reported reasons for non-adherence (classified as either GP-related or patient-related). We assessed the association of factors with the primary outcome using univariable multilevel logistic regression analysis.

RESULTS

The recommendation was measured in 195 general practices. The median proportion of first opioid prescriptions prescribed together with a laxative in these practices was 54% (practice range 18-88%). None of the determinants was consistently associated with the primary outcome. GPs from 211 practices filled out the questionnaire and the most frequently mentioned reason not to prescribe a laxative was that the patient has laxatives in stock, followed by that the patient doesn't want a laxative; both were patient-related factors.

CONCLUSION

There was room for improvement in following the guideline on laxative prescribing in opioid use. A main reason seemed to be that the patient refuses a laxative. Improvement measures should therefore focus on communication between GPs and patients on the relevance of co-using a laxative with opioids. Future studies need to establish the effect of such improvement measures, and determine whether reasons for non-adherence to the guideline changed over time.

Laxative co-medication and changes in defecation patterns during opioid use

Introduction

Opioid-induced constipation is a clinically relevant side effect and a cause of potentially avoidable drug-related hospital admissions.

Objectives

To describe the presence of laxative co-medication, the reasons for not starting laxatives and to evaluate changes in stool patterns of opioid initiators.

Methods

In this observational study community pharmacists evaluated the availability of laxative co-medication in starting opioid users and registered reasons for non-use. Two opioid initiators per pharmacy were invited to complete questionnaires (‘Bristol stool form scale’ and ‘Rome III Diagnostic Questionnaire for the Adult Functional Gastrointestinal Disorders’) on their defecation prior to and during opioid use. Descriptive statistics and Chi square tests were used to analyse reasons for non-use of laxatives and changes in defecation patterns.

Results

Eighty-one pharmacists collected data from 460 opioid initiators. Of those, 344 (74.8%) used laxatives concomitantly. Main reason not to use laxatives was that either prescribers or patients did not consider them necessary. Sixty-seven (89.3%) of the 75 opioid starters with two questionnaires completed were not constipated at opioid start. Eleven of them (16%) developed constipation during opioid use (Chi square p=0.003). At follow-up within laxative users 10.6% were constipated compared to 20.7% in subjects without laxatives.

Conclusion

One in four opioid starters did not dispose of laxative co-medication, mainly because they were not considered necessary by either the prescriber or the patient. The prevalence of constipation doubled during opioid use. A watchful waiting strategy for the use of laxative co-medication might include a monitoring of defecation patterns with validated questionnaires.

Pharmacotherapeutic management of chronic noncancer pain in primary care: lessons for pharmacists

Purpose

Describe the pharmacotherapeutic management of primary-care patients with chronic noncancer pain, assess their satisfaction with pain treatment, and identify the determinants of their satisfaction.

Methods

A cohort study was conducted in Quebec (Canada). Patients reporting chronic noncancer pain with an average pain intensity of at least 4 on a 0–10 scale (10= worst possible pain) and having an active analgesic prescription from a primary-care physician were recruited. They completed a telephone interview and a self-administered questionnaire to document their pain, emotional well-being, satisfaction with treatment, and barriers/beliefs/attitudes about pain and its treatment. Information on pharmacotherapy was based on an administrative provincial database and pharmacies’ charts. Determinants of patients’ satisfaction were identified using multivariate linear regression models.

Results

Four hundred and eighty six patients participated. Their mean age was 58.4 years and they had had pain for a mean of 11.7 years (standard deviation, ±11.1) at an average pain intensity of 6.5 in the past week. Although 90% reported adverse gastrointestinal effects, 36.4% and 54.4% of these patients took no over-the-counter or prescribed medication for constipation or nausea, respectively. On a scale from 0–100, the mean overall satisfaction score was 64.7 (95% confidence interval [CI] =63.5–65.9). Patient satisfaction was low, particularly regarding the “information about pain and its treatment” (mean 50.6; 95% CI =47.6–53.7) and “treatment efficacy” (mean 53.6; 95% CI =51.5–55.6) subscales. The overall treatment satisfaction score decreased with more pain disability, probable depression and anxiety, more barriers to pain treatment, higher incidence of nausea, and use of over-the-counter analgesics.

Conclusion

In primary care, patients’ level of satisfaction with their pain treatment is not optimal. This study underlines how the expanded scope of practice of community pharmacists may allow them to play a pivotal role in providing information, discussing barriers to pain treatment, and monitoring pain disability, and by appropriately managing pharmacotherapy to optimize effectiveness while minimizing adverse effects.

Preventive medication use among persons with limited life expectancy

Persons with limited life expectancy (LLE) – less than 1 year – are significant consumers of health care, are at increased risk of polypharmacy and adverse drug events, and have dynamic health statuses. Therefore, medication use among this population must be appropriate and regularly evaluated. The objective of this review is to assess the current state of knowledge and clinical practice presented in the literature regarding preventive medication use among persons with LLE. We searched Medline, Embase, and CINAHL using Medical Subject Headings. Broad searches were first conducted using the terms ‘terminal care or therapy’ or ‘advanced disease’ and ‘polypharmacy’ or ‘inappropriate medication’ or ‘preventive medicine’, followed by more specific searches using the terms ‘statins’ or ‘anti-hypertensives’ or ‘bisphosphonates’ or ‘laxatives’ and ‘terminal care’. Frameworks to assess appropriate versus inappropriate medications for persons with LLE, and the prevalence of potentially inappropriate medication use among this population, are presented. A considerable proportion of individuals with a known terminal condition continue to take chronic disease preventive medications until death despite questionable benefit. The addition of palliative preventive medications is advised. There is an indication that as death approaches the shift from a curative to palliative goal of care translates into a shift in medication use. This literature review is a first step towards improving medication use and decreasing polypharmacy in persons at the end of life. There is a need to develop consensus criteria to assess appropriate versus inappropriate medication use, specifically for individuals at the end of life.

Stimulant laxatives and opioid-induced constipation

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Laxative management in ambulatory cancer patients on opioid therapy: a prospective, open-label investigation of polyethylene glycol, sodium picosulphate and lactulose

Constipation and the laxatives polyethylene glycol (PEG), sodium picosulphate (SPS) and lactulose (L) were investigated in outpatients with cancer and on opioid therapy. Randomly selected patients were enrolled in a prospective, controlled, open-label trial. Endpoints were number of patients taking laxatives >28 days, number of patients with a stool-free interval >72 h (sfi72), dosage, numerical rating scale (NRS) for constipation, and European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QoL) questionnaire scores. The 348 patients had comparable demographic and medical data. In this ambulatory population, mobility scores remained unaffected. Constipation incidence was 5.7%, with sfi72 42, mean NRS 2.3557 and mean QoL 2.1. A total of 53.2% discontinued their laxative medication. Laxative use correlated with higher opioid usage (morphine-equivalent mg/day: no laxative 98.2, SPS 128.2, PEG 139.9, L 154.5). PEG was the most frequently prescribed laxative (PEG 27.3%, SPS 10.3%, L 9.2%). PEG (sfi72 12.6%, NRS 2.2, QoL 2.1) and SPS (sfi72 11.1%, NRS 2.7, QoL 2.2) proved more effective than L (sfi72 15.5%, NRS 3.8, QoL 2.5). In spite of opioid therapy, the incidence of constipation was low in these ambulatory cancer pain patients at an early disease stage. For prevention of constipation, PEG or SPS is recommended instead of L.

The use of opioids at the end of life: the knowledge level of Dutch physicians as a potential barrier to effective pain management

BACKGROUND

Pain is still one of the most frequently occurring symptoms at the end of life, although it can be treated satisfactorily in most cases if the physician has adequate knowledge. In the Netherlands, almost 60% of the patients with non-acute illnesses die at home where end of life care is coordinated by the general practitioner (GP); about 30% die in hospitals (cared for by clinical specialists), and about 10% in nursing homes (cared for by elderly care physicians).The research question of this study is: what is the level of knowledge of Dutch physicians concerning pain management and the use of opioids at the end of life?

METHODS

A written questionnaire was sent to a random sample of physicians of specialties most often involved in end of life care in the Netherlands. The questionnaire was completed by 406 physicians, response rate 41%.

RESULTS

Almost all physicians were aware of the most basal knowledge about opioids, e.g. that it is important for treatment purposes to distinguish nociceptive from neuropathic pain (97%). Approximately half of the physicians (46%) did not know that decreased renal function raises plasma concentration of morphine(-metabolites) and 34% of the clinical specialists erroneously thought opioids are the favoured drug for palliative sedation.Although 91% knew that opioids titrated against pain do not shorten life, 10% sometimes or often gave higher dosages than needed with the explicit aim to hasten death. About half felt sometimes or often pressured by relatives to hasten death by increasing opioiddosage.The large majority (83%) of physicians was interested in additional education about subjects related to the end of life, the most popular subject was opioid rotation (46%).

CONCLUSIONS

Although the basic knowledge of physicians was adequate, there seemed to be a lack of knowledge in several areas, which can be a barrier for good pain management at the end of life. From this study four areas emerge, in which it seems likely that an improvement can improve the quality of pain management at the end of life for many patients in the Netherlands: 1)palliative sedation; 2)expected effect of opioids on survival; and 3) opioid rotation.

Fixed combination of oxycodone with naloxone: a new way to prevent and treat opioid-induced constipation

Morphine and other opioids increase tone and reduce propulsive motility in several segments of the gut, enhance absorption of fluids, and inhibit secretion. This opioid-induced bowel dysfunction may present as infrequent stools, hard stools, difficult defecation, bloating, and sense of incomplete emptying of the bowels, but also dry mouth, gastroesophageal reflux, epigastric fullness, and abdominal cramping. It afflicts about one-third of patients on opioid treatment. Lifestyle measures, such as regular toilet visits, physical activity, and fiber-rich diet, are very unlikely to be successful. Laxatives, such as bisacodyl, sodium picosulfate, sennosides, macrogols, and prucalopride, may relieve opioid-induced constipation (OIC) in a proportion of patients only. A new approach to counteract OIC is the coadministration of an opioid antagonist devoid of the potential to penetrate the brain. In the EU, an oxycodonenaloxone combination has been approved for this purpose. Both components are included in an oral extended-release preparation. Following its release, naloxone acts locally on the gut and antagonizes the inhibitory effect of the opioid. After being absorbed in parallel with oxycodone, naloxone is rapidly and completely inactivated by a high first-pass effect in the liver. In a 2:1 dose ratio it may improve OIC without interfering with the analgesic effect.

Adherence to medication guideline criteria in cancer pain management

The medication-assessment tool for cancer pain management (MAT-CP) is a novel tool for measuring the quality of drug use in chronic pain management in relation to guideline standards. MAT-CP has recently been revised and validated for use in the U.K. clinical setting. This article presents a measure of the adherence of current practice to specific cancer pain guideline criteria in two palliative care settings. Adult patients with malignant disease experiencing pain and/or receiving analgesics were identified by clinical pharmacists at two hospitals and five hospices in Scotland, United Kingdom. The MAT-CP was applied to data extracted from case notes. Results were quantified in terms of applicability and adherence to guideline criteria and the presence of insufficient data. MAT-CP was applied to 192 cancer patients experiencing pain; 103 (54%) were males and the mean (standard deviation) age was 68.5 (13.0) years. Overall guideline adherence was 75% (confidence interval [CI]: 74%, 77%; n=3460 applicable criteria). Low adherence (<50%) was seen for nine criteria, whereas 21 criteria were considered high-adherence criteria (>75%). Overall adherences for 56 (29%) hospitalized patients and 136 (71%) hospice patients were 65% (CI: 62%, 68%) and 79% (CI: 78%, 81%), respectively. Although good overall guideline adherence was found, there were gaps in both the hospice and hospital palliative care settings in the implementation of certain treatment recommendations, particularly in relation to pain assessment. The application of the tool has highlighted issues for feedback to health care providers and for further study.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Prophylaxis for opioid-induced constipation in elderly long-term care residents: A cross-sectional study of medicare beneficiaries

BACKGROUND

Opioid analgesics are effective therapeutic agents for malignant and nonmalignant pain, but their use is often compromised by unwanted adverse effects on the central nervous system and gastrointestinal (GI) tract. These adverse effects include sedation, respiratory depression, nausea and vomiting, reduction in biliary and pancreatic secretions, decreased GI motility, increased GI transit time, and subsequent constipation.

OBJECTIVE

The goal of this study was to determine national estimates of laxative use, with and without concurrent opioids, in the long-term care (LTC) population and to determine factors associated with laxative underuse among elderly LTC residents receiving opioids.

METHODS

This cross-sectional study was conducted in LTC facilities in the United States. Medicare beneficiaries participating in the Medicare Current Beneficiary Survey (MCBS) aged >or=65 years residing at least 1 month in a nursing home or assisted living facility in 2001 were considered eligible. Monthly and annual measures of laxative and opioid use were developed to estimate prevalence of drug use in the LTC population. Multivariable logistic regression was used to determine factors associated with the use of laxatives.

RESULTS

Among our sample of 867 MCBS beneficiaries (mean [SD]age, 85.0 [7.7] years), 281 (32%) received at least 1 opioid at some time during 2001. Of these 281 patients, 186 (66%) were administered at least 1 laxative at any time of the year. We found that the mean monthly prevalence of concurrent opioid and laxative use was 55% (476/867). There was a low prevalence of as-needed laxative and opioid use; 96% of resident-months were identified as scheduled bowel regimen administrations, and 89% of resident-months with opioid use had >or=3 opioid administrations. The results of the multivariable analysis showed that white, female, and currently married patients spend 227% (P < 0.007), 52% (p < 0.008), and 39% (P < 0.02), respectively, more months with at least 1 administration of a laxative and an opioid than their counterpart nonwhite, male, unmarried patients, Comorbidities were not associated with laxative prophylaxis.

CONCLUSION

Although laxatives are widely recommended in patients taking opioids, only 66% of elderly LTC residents in this study received this standard of care.

Clinical risk management in Dutch community pharmacies: the case of drug-drug interactions

BACKGROUND

The prevention of drug-drug interactions requires a systematic approach for which the concept of clinical risk management can be used. The objective of our study was to measure the frequency, nature and management of drug-drug interaction alerts as these occur in daily practice of Dutch community pharmacies.

METHODS

In total, 63 Dutch pharmacies collected all drug-drug interaction alerts during 153 research days (on average 2.4 days/pharmacy), as well as variables related to these alerts, such as involved medicines, first time or recurrent drug-drug interaction, same or different prescribers, patient data (age, sex) and information about the management of drug-drug interactions by the pharmacy. The latter was discriminated into internal procedures only and external action, such as communication with the patient, the prescriber or the anticoagulation clinic and prescription modification. All drug-drug interactions were classified into categories of clinical relevance (A-F) and available evidence (0-4).

RESULTS

A total of 43,129 prescription-only medicines were dispensed during the study period. On average, 16.8 interaction alerts per day per pharmacy were collected. Approximately 6% of all prescriptions generated a drug-drug interaction alert. Of all alerts (n = 2572), 31.1% occurred for the first time and with 21% two different prescribers were involved. The 20 most frequently occurring drug-drug interaction alerts accounted for approximately 76% of all alerts. Cardiovascular drugs, NSAIDs, oral contraceptives and antibacterials were most frequently involved. External action was taken in response to 27.3% of the alerts, meaning either a modification of one of the concerned prescriptions (n = 65; 9.3%), communication with the prescriber or anticoagulation clinic (n = 90; 12.8%) or communication with the patient or a relative (n = 547; 77.9%). Where there was no external action (n = 1860; 72.3%), pharmacists concluded in about two-thirds of cases that the drug-drug interaction had been managed in the past. Other reasons not to intervene externally were for instance: incorrect alert; acceptable drug-drug interaction; or outcome of the interaction considered irrelevant. Adjusted for several variables, a first alert was found to be a main determinant for external action. After stratifying for first alerts no other significant determinants were found.

CONCLUSIONS

A high frequency of drug-drug interaction alerts was found. Most concerned recurrent alerts, which were the main reason not to act externally. Concerning the assessment phase in the risk-management process, drug-drug interactions with no or low evidence/relevance should be reconsidered. Concerning the management of drug-drug interactions in pharmacies, the opportunity to actively suppress alerts for a certain period of time should be studied in more detail. There are indicators that the management of patient-orientated advice could be improved and a greater degree of consistency developed for the management of first and recurrent interaction alerts.

Pharmacologic Management of Constipation in the Critically Ill Patient

STUDY OBJECTIVE

To compare the effectiveness of common laxatives in producing a bowel movement in patients admitted to a medical intensive care unit (MICU).

DESIGN

Retrospective medical record review.

SETTING

MICU of an academic medical center.

PATIENTS

Ninety-five patients admitted to the MICU from July 1-October 31, 2004.

MEASUREMENTS AND MAIN RESULTS

Fifty patients satisfied the inclusion criteria. Patient-specific data such as age, weight, sex, length of MICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) II score, dietary intake, opioid intake, laxative intake, and bowel movements were recorded during the first 96 hours of admission. Logistic regression analysis was used to compare patients who did and did not have a bowel movement. Of the 50 patients, 25 did not have a bowel movement during the first 96 hours of MICU admission. Patients given a stimulant laxative (senna, bisacodyl) and/or an osmotic laxative (lactulose, milk of magnesia) were more likely to have a bowel movement (odds ratio [OR] 26.6, 95% confidence interval [CI] 3.2-221, p=0.002). Opioid intake, expressed as logarithmic morphine equivalents, was negatively associated with occurrence of a bowel movement (OR 0.76, 95% CI 0.59-0.97, p=0.027). Disease severity, as determined by APACHE II score, was also negatively associated with a bowel movement (OR 0.84, 95% CI 0.7-0.99, p=0.04).

CONCLUSION

Critically ill patients have a high frequency of constipation, and opioid therapy is a significant risk factor. Routine administration of stimulant or osmotic laxatives should be considered for this patient population.

Sodium picosulfate in opioid-induced constipation: results of an open-label, prospective, dose-ranging study

Identification of a safe and effective dose of the laxative sodium picosulfate was investigated in a single-centre, open-label study of 23 patients (age 40-81 years) receiving > or =60 mg/day morphine sulphate and experiencing constipation. A starting dose of 5, 10 or 15 mg sodium picosulfate (1 mg/mL solution) was administered, based on the patient's clinical status at entry and recent requirements for laxatives. Dose titration was permitted (+/-2.5 or 5 mg increments), to a maximum daily dose of 60 mg. Bowel movements, concomitant medication and need for suppositories or enemas were recorded in daily diaries. Sixteen patients withdrew before the end of the planned 14-day treatment period because of deterioration of the underlying condition. Sodium picosulfate was well-tolerated. Serious adverse events were all related to the underlying condition. A satisfactory response (normal stool consistency, not requiring enemas, suppositories or manual evacuation, no significant adverse event) was achieved in 15/20 evaluable patients. The median daily dose to achieve this was 15 mg (range: 5-30 mg) and the median time to first bowel movement after dosing was 11.75 hours (range: 6-22.5 hours). There was no clear relationship between the opioid dose and the optimum dose of sodium picosulfate, confirming that individual dose titration is necessary.

Disease and intolerability documentation in electronic patient records

BACKGROUND

Documentation of diseases and intolerabilities in electronic patient records (EPRs) in pharmacies is needed to produce an alert in case a contraindicated medicine is prescribed. Limited research is available concerning EPRs in pharmacies.

OBJECTIVE

To study the prevalence and quality of documentation of diseases and intolerabilities in EPRs in a sample of Dutch community pharmacies.

METHODS

Each participating pharmacy (N = 79) collected data on one day in May 2003 for each patient enrolled into the study (N = 687) concerning demographics, drug use, and documentation of diseases and intolerabilities.

RESULTS

In 57.4% of the EPRs, at least one disease and, in 7.9%, at least one intolerability was documented. Higher age, number of drugs used, and chronic disease score were associated with any documentation of a disease/intolerability in the EPR. The highest sensitivity scores (completeness) were found for diabetes (84.7%), asthma/chronic obstructive pulmonary disease (strict definition: 75.9%), and hypothyroidism (75.0%). Rather low values were found for prostatic hyperplasia (55.6%) and heart failure (29.4%). The positive predictive value (reliability) was high for hypothyroidism (100%) and diabetes (87.1%).

CONCLUSIONS

In a selection of Dutch pharmacies, at least one documented disease and/or intolerability was found in the EPR of almost 60% of the patients. Certain diseases were documented to a relatively high degree; others had poorer levels of documentation. For optimal surveillance of drug-disease interactions in pharmacies, the frequency and quality of disease and intolerability documentation need further improvement.

Pharmaceutical care in community pharmacy: practice and research in the Netherlands

OBJECTIVE

To describe the pharmaceutical care activities and research in community pharmacy in the Netherlands.

FINDINGS

Pharmaceutical care is well advanced in Dutch pharmacy practice. This is largely due to the fact that clinical pharmacy was already an integrated part of community pharmacy practice by the end of the 1980s. Activities of the International Pharmaceutical Federation (FIP), some wholesale companies, and influential individuals in the Netherlands stimulated universities and the Royal Society for the Advancement of Pharmacy to advance the implementation of pharmaceutical care.

DISCUSSION

Not all pharmacies in the Netherlands provide pharmaceutical care at the same level, although medication surveillance (concurrent and prospective medication analysis) is part of everyday practice. Implementation of quality assurance systems in community pharmacy practice could be helpful in assuring high levels of care. Similar to those in other countries, Dutch pharmacists are torn between the wish to provide pharmaceutical care and economic considerations, although the financial status of most pharmacies is still (very) healthy. New entrants into the market, such as supermarket and pharmacy chains, seem to put little emphasis on care provision.

CONCLUSIONS

Pharmaceutical care has been implemented in many Dutch community pharmacies, but not everywhere to the same extent. Due to excellent automated medication surveillance; structured, high-quality medication counseling; and the fact that patients usually visit the same pharmacy, Dutch patients are well protected against many drug-related problems.

Evaluation of the clinical value of pharmacists' modifications of prescription errors

AIMS

Our objective was to examine the clinical value of pharmacists' interventions to correct prescription errors.

METHODS

In this study, we reviewed a random sample of prescriptions that had been modified in pharmacies. These prescriptions were collected on one predetermined day between 25th February and 12th March 1999 from 141 Dutch community pharmacies. Each prescription modification was evaluated by a panel of reviewers, including representatives of five groups of health care professionals. After generally rating each modification as positive, negative, or neutral, the reviewers assessed its outcome (in terms of prevention of an adverse drug reaction [ADR], an improvement in effectiveness, both, or other), the probability and importance of improvements in effectiveness and/or the probability and seriousness of an ADR in the case of a nonintervention. Our analyses included 144 interventions from the first general assessment and a selection of 90 consistently rated 'positive' interventions (from all assessments).

RESULTS

On average, one in 200 prescriptions (0.49%) was found to have been positively modified by Dutch community pharmacists. About half of these interventions (49.8%) were aimed at preventing ADRs; 29.2% were rated as a positive modification in the effectiveness of pharmacotherapy and 8.6% affected both effectiveness and ADR. Reviewers' ratings varied widely between different categories of drug-related problems (DRPs). The impact of individual interventions (n = 83) varied, and for 53% of these interventions it was estimated to be relatively high.

CONCLUSIONS

Pharmacists' interventions led to modification of prescriptions for an array of DRPs. Such interventions can contribute positively to the quality of pharmacotherapy. By extrapolating our data, we estimated a daily occurrence of approximately 2700 positive interventions in all Dutch pharmacies (1.6 per pharmacy per day). Reviewers rated the impact of interventions on a patient's health as significant in a substantial number of cases.

The lived experience of constipation in cancer patients in palliative hospital-based home care

Constipation is a common and well-studied symptom in palliative care. Most previous studies have focused on the frequency and management of constipation. The current study aimed to investigate the lived experience of constipation among cancer patients in palliative hospital-based home care. Eleven cancer patients admitted to a hospital-based home care unit in Sweden who had experienced constipation participated in this study. Semi-structured interviews were conducted and a qualitative, phenomenological approach was used. Three themes emerged: bodily suffering; mental preoccupation and a reminder of death; and avoidance and social isolation. The experience of constipation was described as an extensive complete person-experience that must be prevented. To prevent unnecessary suffering nurses need to be proactive in the assessment of constipation.