Oxycodone overused in palliative care
By Joanna Lyford, Senior medwireNews Reporter
20 March 2013
Eur J Hosp Pharm 2013; 20: 125–128

medwireNews: Oxycodone is being inappropriately prescribed in a substantial portion of palliative care patients in the UK, a prospective study indicates.

Healthcare professionals with a generalist role were the most frequent inappropriate prescribers of oxycodone, leading the authors to call for greater collaboration with specialist teams when managing patients with complex pain.

Under all regional, national, and international guidelines, morphine is the recommended first-line drug for the management of moderate-to-severe pain, with other opioids such as oxycodone being reserved for second-line use.

Despite this, use of oxycodone has more than doubled in the UK in the past 5 years.

In this study, Adam Todd (Wolfson Research Institute, Stockton-on-Tees, UK) and colleagues evaluated oxycodone use among patients at a tertiary care center (hospice) over a 6-month period.

In all, 50 patients were taking oxycodone. The drug had been initiated by the general practitioner in 44% of patients and by specialist palliative care nurses in 22% of patients; other prescribers included palliative care consultants (18%), hospital doctors (14%), and a site-specific nurse specialist (2%).

The researchers considered use of the drug to be inappropriate in 17 (34%) individuals.

The most common reason for classifying oxycodone use as inappropriate was that the patient had not first tried morphine. Other reasons included not uptitrating morphine adequately before switching to oxycodone, believing that oxycodone would be better tolerated than morphine, patient unwillingness to take morphine, and prescribers feeling that patients were "unsafe" to take morphine.

Hospital doctors and general practitioners were most likely to prescribe oxycodone inappropriately, note Todd et al, whereas no palliative care consultant initiated the drug inappropriately.

Writing in the European Journal of Hospital Pharmacy, the authors note that "oxycodone has been heavily marketed over the years" and call for a "larger investigation examining oxycodone prescribing."

Among patients classified as taking oxycodone appropriately, the most frequent reason was renal impairment. "Although we considered this an appropriate use, clinical evidence for the use of opioids in renal impairment is lacking and something of a grey area; recommendations are based on pharmacokinetic and pharmacodynamic data," write Todd and colleagues.

They conclude: "Oxycodone is initiated inappropriately in a significant number of palliative care patients and should only be used as a second-line strong opioid or if morphine is not suitable or cannot be tolerated. The specialist palliative care team should be consulted for advice in cases of complex pain management."

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