[Patient-reported outcomes in chronic diseases under treatment with cannabis medicines : Analysis of the results of the Copeia survey]

BACKGROUND

The survey of Copeia captured early 2022 patient-reported outcomes (PRO) in Germany under cannabis medicinal product (CAM) therapy, with particular attention to symptoms, symptom changes, indications, side effects, dosages, and cost bearers.

GOAL

This study investigated the question of whether associations emerge from the results that could play a role in the indication and treatment monitoring of CAM in chronically ill patients.

MATERIALS AND METHODS

A standardized questionnaire was administered online nationwide in dialogue form over a 15-week period to collect itemized symptoms and PRO. Recruitment was supported by pharmacies, prescribing physicians, and patient associations. Inclusion criteria included physician-prescribed CAM therapy.

RESULTS AND DISCUSSION

Of 1582 participants, 1030 data sets (65%) could be completely analyzed. There was a heterogeneous patient population, whose common feature was disease chronicity. The frequency distribution of symptoms showed a homogeneous pattern for the respective indications, in which the most frequent six (pain 71%, sleep disturbance 64%, stress/tension 52%, inner restlessness 52%, depressive mood 44% and muscle tension 43%) seem to have a special significance. According to subjective assessment, quality of life improved significantly in 84% of all participating patients.

CONCLUSION

A symptom matrix (SMX) composed of different symptoms seems to play a special role in CAM therapy to improve the quality of life of chronically ill patients, regardless of the underlying disease. The SMX could contribute to the identification of an indication and to targeted treatment monitoring.

The Use of Tetrahydrocannabinol Is Associated with an Increase in Survival Time in Palliative Cancer Patients: A Retrospective Multicenter Cohort Study

Introduction

Tetrahydrocannabinol (THC) is often prescribed for ambulatory palliative patients to improve sleep quality and appetite and to reduce anxiety, stress, and pain. However, it is not known if THC has also an effect on the mortality of these patients.

Method

The objective was the impact of THC on mortality of ambulatory palliative patients. For this purpose, data from the palliative treatment documentation from 5 ambulatory palliative care teams in Brandenburg, Germany were used for this analysis. Survival time was calculated for 3 groups of patients: (1) without THC; (2) with THC in a low dosage (≤4.7 mg per day); and (3) THC in higher doses (≥4.7 mg per day). The analysis was done for 2 cohorts of patients. Cohort 1: all patients with a survival time of at least 7 days after inclusion in specialized ambulatory palliative care (SAPC) and cohort 2: a subgroup of patients with a survival time between 7 and 100 days. Kaplan-Meier curves were created, and multivariate analysis was done to investigate the impact of THC on mortality.

Results

A total of 9,419 patients with a survival time of at least 7 days after inclusion in SAPC were included in the analysis (cohort 1). 7,085 among them had a survival time between 7 and 100 days (cohort 2). In both cohorts, survival time was significantly prolonged by THC, but only when the daily THC dose was above the median of 4.7 mg. Survival time was 15 days longer in cohort 2 (40 vs. 25 days), when more than 4.7 mg THC were prescribed per day.

Conclusion

Use of THC is associated with a significant increase in survival time in ambulatory palliative patients which survive longer than 7 days the initiation of THC prescription and which use of THC >4.7 mg/day.

[Cannabis as medicine, aura and valebo - a new perspective on self-medication and medical support for chronic diseases]

BACKGROUND

It is known from medical practise that patients and physicians can have positive experiences with little-researched and unapproved interventions. Under certain circumstances, effects even go beyond the placebo effect.

METHOD

Based on casuistics of chronic pain patients, the question of whether self-medication in the context of a good doctor-patient relationship can optimize the efficacy of cannabinoids and reduce dose and undesirable side effects is investigated. Using medicinal cannabis as an example, a new view on self-medication and medical support is proposed.

RESULTS

The casuistics show that daily requirements (average of approximately 75 mg) for Δ⁹tetrahydocannabinol (THC) doses can be reduced. An unaccompanied and risky self-medication can be transformed into an effective therapy with significantly less medical cannabis. The approach consists of tracing the self-medication that has taken place to date and picking up the patient where he has "discovered" something for himself. The specific mode of action of cannabis in chronic diseases can be explained by mechanisms in the endocannabinoid system. Cannabinoids relieve patients in the context of stress, anxiety and depression, which are always involved in chronic diseases. In their physical as well as psychological sensations, patients are strengthened and eventually guided into self-efficacy.

CONCLUSIONS

If the patient has "discovered" cannabis as medicine for himself and can draw on positive experiences, something very powerful can emerge. In addition to the specific effects demonstrated by studies, there are non-specific effects or contextual factors at work that tend to be neglected in evidence-based medicine. These non-specific effects include, above all, those factors through which a patient gives a (subjective) meaning to a specific intervention. A new view on self-medication and medical support in chronic diseases is needed.

[Dronabinol in geriatric pain and palliative care patients : A retrospective evaluation of statutory-health-insurance-covered outpatient medical treatment]

BACKGROUND

Geriatric patients often suffer from a long history of pain and have a limited life expectancy. Cannabinoid receptor agonists like dronabinol may be an effective, low-risk treatment option for geriatric patients with chronic pain.

OBJECTIVES

The effectiveness and side effects of dronabinol therapy in geriatric patients are analyzed. The effects of the approval requirement are presented.

METHODS

In our retrospective monocentric cohort study, the study population comprised all geriatric patients over the age of 80 years who were treated in our office since the cannabis law came into effect on 10 March 2017 until 17 July 2018 (evaluation date). Geriatric, nonpalliative pain patients (group A) and geriatric palliative patients (group B) were investigated. The basis of the evaluation was a questionnaire sheet that we use in our office with details of dosages, pain intensity, treatment effects and side effects from dronabinol therapy.

RESULTS

By using dronabinol, 21 of the 40 geriatric patients (52.5%) achieved pain relief of more than 30%, 10% of the patients of more than 50%. On average, about four symptoms or side effects related to previous treatment were positively influenced. 26% of patients reported side effects. The rejection rates on the part of the health insurances were 38.7% (group A) and 10.3% (group B).

CONCLUSIONS

This study is one of the few analyses of the use of Dronabinol in geriatric patients. We show that cannabis-based drugs (in this case dronabinol) are an effective, low-risk treatment option that should be considered early in therapy. Regarding the indication spectrum, further clinical studies and an approval-free test phase are necessary.

[High-dose buprenorphine for outpatient palliative pain therapy]

The case of a 78-year-old patient with cancer-related pain and additionally mixed-pain syndrome is presented. Pain therapy with buprenorphine TTS 210 microg/h every 3 days was sufficient in the beginning, later the therapy was changed because of increasing problems of tape fixing during fever periods under chemotherapy to a continuous infusion of buprenorphine intravenously via an external medication pump. During the course of therapy it became necessary to increase the dose to 99.9 mg/day buprenorphine. Under this medication a sufficient pain reduction (median NRS 2-3) over a period of 135 days could be achieved. At the same time the patient was vigilant and cooperative without signs of intoxication until the end of life at home in the presence of his family.If no signs of intoxication occur under extreme opioid therapy and a sufficient pain therapy can be achieved, a rotation to another opioid is not necessary. However, outpatient palliative care requires a frequent adaptation to the individually varying opioid demand of the patient and time-consuming nursing care.

Risk factors for surgical site infections in a free-standing outpatient setting

BACKGROUND

More information about risk factors for surgical site infections in outpatient settings is necessary for creation of surveillance systems in this field.

OBJECTIVE

The aim of this study was to determine the incidence of surgical site infections (SSI) in an outpatient setting and to investigate whether the risk index of the National Nosocomial Infections Surveillance (NNIS) System is appropriate for outpatient settings.

METHODS

A retrospective cohort design was used to investigate SSI following all hernia repairs and varicose veins operations over a 9-year period in a freestanding outpatient setting. The exposure variables studied were age, sex, and American Society of Anesthesiologists (ASA) score of the patient; duration of operation; performing surgeon's name; type of operation; type of anesthesia; and follow-up period. An univariable and a multivariable analysis were performed to determine risk factors for SSI.

RESULTS

A total of 1095 operations were performed: 714 on varicose veins and 381 on hernia repairs. The median follow-up period was 43 days. The crude SSI rate was 1.2% (varicose veins operations, 1.5%; hernia repair operations, 0.5%). According to the results of the logistic regression model, only 1 factor remained significant: Patients with spinal anesthesia were 11 times as likely to develop a SSI as patients with any other type of anesthesia (95% CI, 2.15-200.5).

CONCLUSION

The NNIS risk index was not suitable for assessing SSI rates in this outpatient setting and for these specific procedures.

[Time used for outpatient tumor pain therapy]

OBJECTIVE

The insufficiency of pain therapy for cancer patients is a frequent complained. One reason for this deficit may be the great amount of time required for the management of patients with far advanced diseases. The objective of this paper is the calculation of time for this therapy.

METHODS

All relevant data on pain treatment of 126 patients were followed up in an anaesthesiology outpatient facility and their therapy was recorded retrospectively over a period of 52 months.

RESULTS

During a period of 18,798 observation days 1,634 pain therapy consultations were performed, on average 13 per patient (1 to 95). The mean duration of therapy was 149 days. The percentage of consultations at home was 46%, most of them (80%) were scheduled, the remaining 20% were emergency consultations that were immediately necessary, at night or on Sundays. Altogether, the mean time for therapy including travel time was about 7 h until the end of the therapy. Only 13.5% of patients died in a hospital.

CONCLUSION

Because of the great amount of time necessary for cancer pain therapy close collaboration of all physicians involved in analgesic/palliative care is essential. This requires a good basic knowledge of all colleagues about the specialties of cancer pain therapy as well as good commitment by the pain specialists.

[Pain therapy in cancer pain patients: control of therapy with the Potsdam pain questionnaire.]

154 cancer pain patients were treated from 1988 to 1990 according to the three-step analgesic ladder (TSAL) recommended by the WHO. The patients were assigned into 4 groups: WHO-I: patients were treated only with non-opioids, WHO-II: patients received a combination of non-opioid plus a weak opioid, WHO-III: patients were treated with strong opioids or a combination of a strong opioid plus a non-opioid; and the 4th group consisted of patients receiving a strong opioid epidurally. Our results, using the TSLA and comparing then to the pretreatment status, show complete or acceptable cancer pain relief among the patients as follows: in WHO-I: 44%, in WHO-II: 55%, in WHO-III: 63%, and in the 4th group 70%. The use of the TSAL resulted not only in a reduction of the pain level, but also in an increase of the quality of the life for these cancer pain patients. Also the mean duration of the patients' sleep was increased by more than one hour. An improvement of mood was observed, and the stabilisation of mood lasted longer.

[Pain therapy for urologic cancer patients at the Potsdam district hospital--initial results]

After two years the results of cancer pain treatment in urological patients at the district hospital Potsdam are presented. In 15 patients the WHO recommended three-stage analgesics plan was used successfully.