Professor Geoffrey Hanks, Honorary President of the EAPC, Professor Emeritus of Palliative Medicine, University of Bristol, UK, and Professor, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway, explains the historical context to the EAPC recommendations on opioids for cancer pain.
The new (third) version of the ‘EAPC recommendations on the use of opioids for cancer pain’ was published earlier this year in the Lancet Oncology (Caraceni A et al. Lancet Oncol 2012; 13: e58-68). The new guidelines represent a different level of endeavour compared with the previous versions with respect to the considerable amount of work undertaken by the contributors, the number of contributors, the meticulous and comprehensive approach to the planning and execution of the project, the presentation of the final paper and the unique resource (20 systematic literature reviews) generated in associated publications (Palliative Medicine 2011; 25: 389-605 and Palliative Medicine 2012; 26: 305-312). The online version of the recommendations and the supporting papers can be downloaded from the EAPC website.
Two threads of palliative care history come together in the story of the EAPC and its opioid guidelines. Serendipity played a part, as did a cold bedroom in a convent at the top of a mountain in Sicily (once used by Pope John Paul), and the Pope’s bed.
Why were opioid guidelines necessary or interesting?
A discovery that caused great excitement in the pain world in the late 1970s was the identification of opioid receptors in the spinal cord. The excitement was because of the possibility of more or less immediate clinical applications with the potential, it seemed, to transform the management of patients with the most difficult cancer pain. Administration of morphine or other potent opioids by the intrathecal or epidural routes would require very much smaller doses of these drugs because they would be applied in direct contact with the spinal cord, avoiding systemic effects, with an anticipated improvement in efficacy and a reduction in unwanted effects.
Controversy quickly followed and there was much heated debate about the precise indications for these routes, particularly as the sophisticated drug delivery systems for continuous spinal infusions were expensive and highly invasive to use for long-term administration. There were wide variations in practice, sometimes in the same institution, and unsurprisingly there was insufficient high quality evidence to permit clear guidelines. This was one of several controversies in pain therapeutics.
The EAPC Research Network
Franco De Conno recognised in the early days of the EAPC that with its rapidly growing membership one of the possible activities of the new association was to participate in research. Thus, on 18 November 1992 he organised two expert groups of the EAPC Research Network in Palermo. The pain experts focused on routes of administration of opioids with the controversy about spinal routes high on the agenda. The other group discussed nutrition and hydration in palliative care. The subsequently published clinical guidelines were well received and widely influential.
Franco proposed that the board of directors of the EAPC should establish a Research Group to look into the possibility of undertaking research projects. The board strongly supported this proposal and in December 1995 the EAPC Research Network Steering Group was created, with Franco appointed as chairman. There were many difficulties to overcome, not least the need to find the funds to organise meetings of the group, and we were very fortunate to have the support of Sebastiano Mercadante and Giorgio Trizzino in Sicily who provided a suitable venue (the convent at the top of a mountain) and funded the early meetings.
It soon became clear that there were very few clinicians working in palliative care who had any experience of participating in multicentre clinical trials, thus we abandoned the idea of organising such studies. However, an alternative approach to tackling controversies in palliative care therapeutics, where there was a lack of high quality evidence, was to continue to bring together expert groups to achieve a consensus approach and publish clinical guidelines. The opioids paper is the only one to have achieved a third edition and full details are available on the EAPC website. This is now a continuing activity to which everyone can contribute. The guidelines and supporting papers must be widely disseminated and put into practice. Feedback is very important, both positive and negative, and can be channelled through the ‘Guidelines hotline’.
And the Pope’s bed in the convent in Sicily? I’ll save that for my next post.