When oral morphine fails in cancer pain: the role of the alternative routes

[Cancer pain management]

Pain is a significant and alarming symptom of cancer seriously affecting the activity and quality of life of patients. Recent research proved that inadequate analgesia shortens life expectancy. Therefore, pain relief is not only a possibility but a professional, ethical and moral commitment to relieve patients from suffering, as well as ensure their adequate quality of life and human dignity. Proper pain relief can be achieved with medical therapy in most of the cases and the pharmacological alternatives are available in Hungary. Yet medical activity regarding pain relief is far from the desired. This paper gives a short summary of the guidelines on medical pain management focusing particularly on the use of opioids.

Symptom control in advanced cancer: twenty principles

In Palliative Medicine, symptom management is a clinical priority and one of the key skill sets of the palliative specialist. Symptom control principles have been derived from clinical practice in cancer pain management. They can also be applied to other cancer symptoms, and systematic application will help improve quality of life (QOL). They require a diagnosis of the underlying etiology, individualization of symptom therapy, a systematic approach to management, and therapeutic clarity and simplicity. There are 20 principles that have been identified as helpful to guide the clinical practice of symptom control in advanced cancer.

A Multiple-Dose Phase I Study of Intranasal Hydromorphone Hydrochloride in Healthy Volunteers

We evaluated the pharmacokinetics, tolerability, and safety of 1 and 2 mg of intranasal hydromorphone hydrochloride in an open-label, single- and multiple-dose study. This Phase I study was conducted in 24 healthy volunteers (13 men and 11 women). Intranasal doses were delivered as 0.1-mL metered-dose sprays into one or both nostrils for 1- and 2-mg doses, respectively. Venous blood samples were taken serially from 0 to 12 h after the first single dose and the last (seventh) multiple dose. Plasma hydromorphone concentrations were determined by liquid chromatography/mass spectrometry/mass spectrometry. Noncompartmental analysis was used to estimate pharmacokinetic variables. After 7 intranasal doses of 1 and 2 mg (once every 6 h), mean +/- sd peak plasma concentrations of 2.8 +/- 0.7 ng/mL and 5.3 +/- 2.3 ng/mL, respectively, were observed. The median time to peak concentration was 20 min for both single and multiple doses. Dose proportionality was observed for the 1- and 2-mg doses. Adverse events included somnolence, dizziness, and bad taste after dose administration. Intranasal hydromorphone hydrochloride was well tolerated and demonstrated rapid nasal drug absorption and predictable accumulation. These results support clinical investigation of hydromorphone hydrochloride nasal spray for use as an alternative to oral and IM administration.

Morphine is not the only analgesic in palliative care: literature review

BACKGROUND

No comprehensive review has been published to date, which provides information for nurses on pharmaceutical alternatives to morphine in palliative care. As nurses are often the health professional most involved with terminally ill patients, there is a clear need for a review of current practices which is accessible to nurses.

AIM

The aim of this review is to examine the pharmaceutical alternatives to morphine use in palliative care that are currently available.

METHODS

Searches were made of the CINAHL and MEDLINE databases for articles published between 1990 and 2000, using the keywords 'pain management', 'cancer pain' and 'morphine'.

FINDINGS

Most evidence on the use of pharmaceutical alternatives to morphine is anecdotal, demonstrating a need for more research to be conducted in this field. Evidence presented in this review shows encouraging results following the administration of methadone, fentanyl or ketamine to patients with difficult pain problems.

CONCLUSION

Nurses need to be aware of treatment options that may benefit patients with difficult pain problems. Although positive experiences have been documented when using alternatives to morphine, more research must be conducted to allow practitioners to add more pharmaceutical alternatives to their pain management armouries.

Continuous subcutaneous infusion practices of United States hospices

In hospice organizations, continuous subcutaneous infusion (CSI) is a common medication delivery modality for pain management. Nonetheless, little is known regarding the practices of hospice organizations in their utilization of this technique. We surveyed 3,930 hospice organizations to describe indication, diluents, medications, and other variable factors associated with CSI utilization. Of the 3,930 surveys sent, 907 were returned, yielding a response rate of 24%. Seventy-three percent of hospice organizations surveyed indicated they utilized CSI. The average daily census (ADC) of these hospices was 38.6 +/- 61.0. The most common indication for CSI use was palliative management (95%). The most common medication used in CSI was morphine sulfate (97%). These results indicate that CSI utilization may be widespread in hospices and further study regarding this delivery system is warranted.

The use of transdermal fentanyl in pediatric oncology palliative care

Transdermal fentanyl offers a noninvasive approach to the management of patients with opioid dependent and stable, chronic cancer pain. The transdermal delivery system offers distinct advantages where oral administration of opioids is difficult as a consequence of progressive disease and in patients whose compliance with oral medications is poor. Thirteen patients ranging in age from three years and nine months to 18 years and seven months were treated with transdermal fentanyl for between six hours and 112 days. All had previously been receiving oral morphine prior to the commencement of fentanyl and were transferred to fentanyl because of oral opioid side effects and poor oral compliance. Fentanyl was well tolerated and provided effective pain relief for 11 of 13 patients. Overall, patients and parents experienced satisfaction with fentanyl, both in terms of pain relief and improvement in quality of life.