Intravenous morphine for emergency treatment of cancer pain

The Use of Parenteral Opioids in Cancer Pain Management

Opioids should be offered to patients with moderate-to-severe pain related to cancer or active cancer treatment unless contraindicated. Although oral administration of opioids is generally preferable, a parenteral route may be advisable and mandatory in some clinical circumstances. Parenteral administration of opioids may accelerate the achievement of analgesia. The intravenous route fits the need of rapid achievement of analgesia in patients poorly responsive to other opioids and provides a fast analgesia in patients with breakthrough pain, that has a specific temporal pattern requiring a rapid analgesic effect. When the oral route is unavailable for the presence of nausea, vomiting, or dysphagia. the parenteral route is one of the principal options. Opioids have different pharmacokinetic and pharmacodynamic characteristics and should be chosen according to the individual needs. Thus, the knowledge and experience with these routes of administration are mandatory for anesthesiologists committed to cancer pain management.

Rapid Titration With Intravenous Oxycodone for Severe Cancer Pain and Oral Conversion Ratio

CONTEXT

to assess a dose titration with intravenous oxycodone to achieve rapid pain relief of cancer pain of severe intensity. The second objective was to provide a conversion ratio with the oral route.

METHODS

Cancer patients admitted for severe pain were prospectively assessed. At admission (T0) previous opioid doses were recorded. Edmonton symptom assessment scale (ESAS) was collected from T0 until the conclusion of the observation. Intravenous boluses of oxycodone were given until the initial signs of significant analgesia were detected. The effective dose was multiplied for six and given as intravenous continuous infusion. When the patient was considered stabilized the intravenous daily dose was converted to oral oxycodone using an initial ratio of 1:2. Subsequently, doses of oral oxycodone were changed according to the clinical situation.

RESULTS

Twenty-nine patients were examined. A mean effective bolus dose of oxycodone was 9.5 mg (SD 8.0) allowed to achieve a meaningful pain relief in a mean of 10.4 minutes (SD 3.3). The mean initial and the final infusion doses were 51.0 mg/day (standard deviation 40.9) and 69.7 mg/day ( standard deviation76.6), respectively. A significant change in pain intensity was observed at the different time intervals (P<0.0005). Conversion to oral route occurred after a mean of 2.7 days (standard deviation1.2) of intravenous oxycodone. The final mean conversion ratio was 1:2,12 ( standard deviation0.36).

CONCLUSION

Rapid intravenous oxycodone dose titration resulted in rapid pain relief. The intravenous-oral conversion ratio of 1:2 is reliable. Further studies are necessary to confirm this preliminary observation.

Effectiveness of rapid titration with intravenous administration of oxycodone injection in advanced cancer patients with severe pain

Some cancer patients suddenly develop severe, excruciating pain that requires rapid management using opioid medication. This study aimed to evaluate the effectiveness of rapid titration using oxycodone injection. Study subjects were advanced cancer patients who experienced severe pain (numeric rating scale ≥7) and needed prompt pain relief. Primary endpoint was (i) time required for the initial sign of significant analgesia to become evident. Secondary endpoints were (ii) pain relief stabilization success rate and (iii) adverse effects. Groups treated with oxycodone (oxycodone group) and morphine (morphine group) were retrospectively compared. The oxycodone group had 33 cases and the morphine group had 32 cases: (i) 15.6 ± 4.3 min in the oxycodone group and 19.3 ± 4.7 min in the morphine group (P = 0.001); (ii) 70 and 63% within 24 hours, and 88 and 84% within 48 hours in the oxycodone group and the morphine group, respectively (P = 0.36, 0.48). Although (iii) adverse effects appeared in both groups in the form of respiratory suppression, etc., the effects were mild. Rapid titration using oxycodone injections may be considered a beneficial choice.

Acute pain in advanced cancer: An opioid dosing strategy and illustration

Opioid dosing strategies for acute pain differ from strategies for chronic pain management. The basic principles of effective, safe dosing are rapid titration to the onset of analgesia followed by maintenance infusions based upon the titrated dose. This article presents guidelines and case histories for safe and effective dosing.

Starting step III opioids for moderate to severe pain in cancer patients: dose titration: a systematic review

The European Association for Palliative Care recommendation for starting morphine for cancer pain is dose titration with immediate release (IR) oral morphine given every 4 h with additionally doses for breakthrough pain. As part of a EU 6th framework programme to revise the guidelines we review the evidence regarding starting treatment and dose titration of opioids in adult patients with moderate to severe cancer pain. Relevant papers were identified though a systematic search in Medline for papers published until the end of 2009. We identified 15 relevant papers. Thirteen papers were descriptive papers reporting the results from starting treatment with oral morphine (six studies), starting treatment with intravenous morphine (two studies) and starting treatment with transdermal fentanyl (four studies). All treatment strategies resulted in acceptable pain control and were well tolerated. Two randomized controlled trials were identified. One study compared starting opioid treatment with intravenous morphine versus IR oral morphine and one study compared IR oral morphine versus sustained release oral morphine.

Opioid titration in cancer pain: a critical review

Initiation of therapy with strong opioids is a challenging phase to obtain the maximum benefit and to gain the patient's compliance. The approach could be different, depending on the clinical situation and type of opioid regimen. Substantially, the need to titrate the dose of strong opioids emerges in different conditions: (a) in opioid-naive patients who require an opioid treatment; (b) in patients no longer responsive to weaker drugs requiring strong opioids; (c) in patients already receiving strong opioids requiring higher doses because of an increase in pain intensity or a new acute pain problem; (d) in patients who are severely suffering and need an intensive as well as rapid intervention, due to previous persistent undertreatment. Whilst there is a vast literature confirming the effectiveness of most opioid drugs for the treatment of chronic pain, there is a lack of information regarding opioid titration. This review assesses the principal titration methods and outcomes regarding the different opioid drugs and their modalities of administration, in different clinical contexts.

Death, dying, and last wishes

Issues regarding patient care near the end of life can be challenging and rewarding for emergency physicians. Knowledge of the patient's wishes is essential, and may be accomplished by advance directives or communication with patients and surrogates. Resuscitative efforts are appropriate for many patients, but inappropriate for others. The goals of medicine remain the following: providing optimal health care, provision of the best possible symptom control, communication, empathy, and caring. As death approaches, provision of the best possible medical care, in accordance with the patient's wishes, can be rewarding for patients, families, and health care providers.

Intravenous versus Subcutaneous Morphine Titration in Patients with Persisting Exacerbation of Cancer Pain

BACKGROUND

Patients with cancer pain with initially adequate analgesia under oral sustained-release opioid medication may suffer from persisting pain exacerbations. Sometimes even fast help is needed and then optimally performed by intravenous application (IVA) of immediate-release (IR) opioids. This IVA, however, may only be performed by physicians in Germany.

OBJECTIVE

We wanted to find out if subcutaneous application of IR-opioids might be an adequate alternative to IVA in persisting pain exacerbations of patients with cancer pain because this could be performed by the nursing staff in Germany as well.

DESIGN

An open randomized controlled trial was used to compare intravenous versus subcutaneous morphine titration in persisting pain exacerbations in patients with cancer pain.

SETTING/SUBJECTS

Thirty-nine patients with cancer (21 intravenously, 18 subcutaneously) of the pain management department of the university hospital of Cologne, Germany were included into the study.

MEASUREMENTS

Calculated from preexisting analgesic medication boli of morphine were given every 5 minutes (intravenously) or 30 minutes (subcutaneously) up to adequate analgesia or intolerable side effects. Pain intensity, nausea, sedation, and some vital parameters were documented before the start, after each application and at the end of titration.

RESULTS

Thirty-five patients were pretreated with oral opioids, 4 patients with nonopioid analgesics. Six patients stopped titration because of intolerable side effects (sedation, vomiting). Thirty patients (77%) reported at least sufficient pain reduction, 3 patients were free of pain (intravenously). Mean pain intensity decreased on a visual analogue scale (VAS, 0-100) from 83 to 32 (intravenously) and from 68 to 42 (subcutaneously). Morphine doses ranged from 4 mg to 32 mg (intravenously; mean, 18.5 +/- 9.2 mg) and from 10 mg to 200 mg (subcutaneously mean, 57.9 +/- 59.6 mg). Mean time up to adequate analgesia was 53 (intravenously) 77 min (subcutaneously), respectively. There was no change in vital parameters but an increase of sedation in both groups. The adaptation of the continuous analgesic medication resulted in a stable and lasting pain relief after 4 days in both groups.

CONCLUSIONS

Intravenous and subcutaneous-morphine titration are adequate to antagonize persisting pain exacerbations in cancer pain patients quickly and to adapt the continuous opioid analgesic medication.

A validation study of the WHO analgesic ladder: a two-step vs three-step strategy

GOALS OF WORK

The aims of the present study were to verify whether an innovative therapeutic strategy for the treatment of mild-moderate chronic cancer pain, passing directly from step I to step III of the WHO analgesic ladder, is more effective than the traditional three-step strategy and to evaluate the tolerability and therapeutic index in both strategies.

METHODS

Patients aged 18 years or older with multiple viscera or bone metastases or with locally advanced disease were randomized. Pain intensity was assessed using a 0-10 numerical rating scale based on four questions selected from the validated Italian version of the Brief Pain Inventory. Treatment-specific variables and other symptoms were recorded at baseline up to a maximum follow-up of 90 days per patient.

RESULTS

Fifty-four patients were randomized onto the study, and pain intensity was assessed over a period of 2,649 days. The innovative treatment presented a statistically significant advantage over the traditional strategy in terms of the percentage of days with worst pain > or =5 (22.8 vs 28.6%, p < 0.001) and > or =7 (8.6 vs 11.2%, p = 0.023). Grades 3 and 4 anorexia and constipation were more frequently reported in the innovative strategy arm, although prophylactic laxative therapy was used less in this setting.

CONCLUSIONS

Our preliminary data would seem to suggest that a direct move to the third step of the WHO analgesic ladder is feasible and could reduce some pain scores but also requires careful management of side effects.

Functional identification of a BAC clone from 16q24 carrying a senescence gene SEN16 for breast cancer cells

We have identified an 85 kb BAC clone, 346J21, that carries a cell senescence gene (SEN16), previously mapped to 16q24.3. Transfer and retention of 346J21 in breast cancer cell lines leads to growth arrest after 8-10 cell doublings, accompanied by the appearance of characteristic senescent cell morphology and senescence-associated acid beta-galactosidase activity. Loss of transferred BAC results in reversion to the immortal growth phenotype of the parental cancer cell lines. BAC 346J21 restores senescence in the human breast cancer cell lines, MCF.7 and MDA-MB468, and the rat mammary tumor cell line LA7, but not in the human glioblastoma cell line T98G. We postulate that inactivation of both copies of SEN16 is required for the immortalization of breast epithelial cells at an early stage of tumorigenesis. Positional mapping of 346J21 shows that SEN16 is distinct from other candidate tumor suppressor genes reported at 16q24.

La titration intraveineuse de morphine

OBJECTIVES

To describe principles of intravenous (i.v.) morphine titration. To analyse current knowledge based on the experimental and clinical studies. To describe clinical implications in the operating room, postanaesthesia care unit (PACU), prehospital care, emergency and intensive care units (ICU), and cancerology. To provide recommendations for clinical practice.

DATA SOURCES

Search in the Medline database without limitation, using the following keywords: morphine titration.

STUDY SELECTION

All types of articles were selected including prospective randomised (or not randomised) studies in adults and children, practice guidelines, reviews, editorials and case reports.

DATA SYNTHESIS

Intravenous (i.v.) morphine titration is a pharmacological method which involves morphine boluses administration until pain relief, allowing a limitation in morphine side effects which are mainly dose dependent. I.v. morphine titration is widely used in prehospital care, emergency unit, PACU, ICU, and cancerology, in young and elderly patients. In the PACU, when the VAS (visual analogue scale) increases to more than 30 mm, i.v. morphine titration every five minutes with an unlimited number of 2 or 3 mg boluses provides an efficient analgesic regimen in adults. Titration is performed until pain relief (VAS < or =30), sedation that is the most frequent side effect during i.v. morphine titration (Ramsay score >1), severe side effects (like respiratory depression).

CONCLUSION

Because of important pharmacological variability in morphine need, iv morphine titration is a simple method which allows a rapid and efficient pain relief notably in the postoperative care.

Opioid Dose Titration for Severe Cancer Pain: A Systematic Evidence-Based Review

Dosing strategies to achieve rapid analgesia in patients with severe or crescendo cancer pain are important. A systematic review of research trials for treatment of severe or crescendo cancer pain was conducted; nine studies were identified. Eight trials were prospective; two were randomized between different dosing strategies. Dosing frequency predicted onset to analgesia regardless of baseline opioid dose. None of the trials were associated with evidence of respiratory depression. The studies all suffered significant methodological problems limiting broad conclusions. Until better data exist, opioid dose titration for severe/crescendo pain will be guided by expert opinion and experience.

Hallmarks of senescence in carcinogenesis and cancer therapy

Cellular senescence is a signal transduction program leading to irreversible cell cycle arrest. This growth arrest can be triggered by many different mechanisms including recognition by cellular sensors of DNA double-strand breaks leading to the activation of cell cycle checkpoint responses and recruitment of DNA repair foci. Senescence is initiated by the shortening of telomeres (replicative senescence) or by other endogenous and exogenous acute and chronic stress signals (STASIS: stress or aberrant signaling-induced senescence). The process of carcinogenesis involves a series of changes that allow tumor cells to bypass the senescence program. Nevertheless, tumor cells retain the capacity to undergo senescence. Treatment of tumor cells with many conventional anticancer therapies activates DNA damage signaling pathways, which induce apoptosis in some cells and senescence in others. Overexpression of tumor suppressors or inhibition of oncogenes can also induce rapid senescence in tumor cells. Senescent cells, while not dividing, remain metabolically active and produce many secreted factors, some of which stimulate and others inhibit the growth of tumors. The emerging knowledge about the pathways that lead to senescence and determine the pattern of gene expression in senescent cells may lead to more effective treatments for cancer.

Senescing oral dysplasias are not immortalized by ectopic expression of hTERT alone without other molecular changes, such as loss of INK4A and/or retinoic acid receptor-β: but p53 mutations are not necessarily required

Our previous work showed that acquisition of immortality at the dysplasia stage of oral cancer progression was consistently associated with four changes: loss of retinoic acid receptor (RAR)-beta and p16INK4A expression, p53 mutations and activation of telomerase. One atypical dysplasia (D17) that underwent delayed senescence after an extended lifespan showed loss of RAR-beta and p16INK4A/p14ARF expression, but retained functional wild-type p53 and telomerase was not activated. We now demonstrate that retroviral delivery of hTERT results in telomere lengthening and immortalization of D17 without loss of functional wild-type p53 activity. In contrast, the expression of hTERT in two other typical mortal dyplasia cultures (that retain RAR-beta and p16INK4A expression) does not extend their lifespan, even though telomeres are lengthened.

Intravenous fentanyl for cancer pain: a "fast titration" protocol for the emergency room

Patients with cancer sometimes are admitted to the emergency room due to severe pain. Despite the fact that morphine's hydrophilicity can delay its peak effects after intravenous administration up to 30 minutes, it is still the most commonly used opioid during cancer pain emergencies. Fentanyl is a synthetic, lipophilic opioid, more potent than morphine, and achieves peak effects after intravenous administration in 5 minutes. According to our observations, intravenous fentanyl could be safely used in the emergency room to treat patients who need fast titration of an opioid to control their pain. In our study, fentanyl was employed in a four-step protocol to treat patients admitted to our palliative care emergency room due to severe pain, regardless of the previous use of morphine at home. Titration with intravenous fentanyl was successfully employed in 18/18 (100%) of patients, with an average time for pain control at about 11 minutes, and without relevant adverse effects. We conclude that intravenous fentanyl could be safely used for severe cancer pain when rapid titration is being considered.

Intravenous morphine for rapid control of severe cancer pain

This randomized controlled trial compared intravenous route with oral route for initial dose titration of morphine in 62 patients with end-stage cancer and severe pain. Patients in the intravenous group received 1.5 mg intravenous bolus doses of morphine every ten minutes till pain relief was total or until they became drowsy. After that they got oral morphine at a dose equal to the total initial intravenous requirement four-hourly. Patients in the oral group got oral morphine 5 mg doses (if opioid-naïve) or 10 mg (if already on weak opioid) four-hourly. Patients in both groups had the option to receive rescue doses of their regular oral dose as and when needed, if necessary hourly. Twenty-seven of 31 in the intravenous group had either total or satisfactory pain relief by the end of one hour, whereas only eight of 31 in the oral group had a similar result. After 24 hours and later both groups had similar results. There was no immediate serious side effect in any of the patients. The late side effects were similar in the two groups. In the intravenous group, the ratio of initial intravenous dose requirement to the subsequent regular single oral dose after two days centred around 1:1 (range 1:0.5-1:3.3). This study found the intravenous method to be safe, effective and superior to the traditional method in providing immediate relief to severe cancer pain.

Rapid titration with intravenous morphine for severe cancer pain and immediate oral conversion

BACKGROUND

Cancer pain emergencies presenting with severe excruciating pain require a rapid application of powerful analgesic strategies. The aim of the current study was to evaluate a method of rapid titration with intravenous morphine to achieve relief of cancer pain of severe intensity.

METHODS

Forty-nine consecutive patients admitted to a Pain Relief and Palliative Care Unit for severe and prolonged pain were enrolled in the study. Pain was evaluated on a numeric scale of 0-10 (0 indicated no pain and 10 indicated excruciating pain). After the initial assessment (T0), an intravenous line was inserted and boluses of morphine (2 mg every 2 minutes) were given until the initial signs of significant analgesia were detected or severe adverse effects occurred (T1). A continuous reassessment was warranted and the effective total dose administrated intravenously was assumed to last approximately 4 hours and was calculated for 24 hours. The dose immediately was converted to oral morphine (a 1:3 ratio for low doses and a 1:2 ratio for high doses).

RESULTS

Data from 45 patients was analyzed. A significant decrease in pain intensity was achieved in a mean of 9.7 minutes (95% confidence interval [95% CI], 7.4-12.1 minutes), using a mean dose of intravenous morphine of 8.5 mg (95% CI, 6.5-10.5 mg). The doses administered rapidly were converted to oral morphine and pain control was maintained until the patient's discharge, which occurred in a mean of 4.6 days (95% CI, 4.1-5.2 days). The incidence of adverse effects was minimal.

CONCLUSIONS

The results of the current study demonstrate that cancer pain emergencies can be treated rapidly in the majority of cancer patients with an acceptable level of adverse effects. Intravenous administration of morphine requires initial close supervision and continuity of medical and nursing care.

Regulation of apoptosis by p53 in UV-irradiated human epidermis, psoriatic plaques and senescent keratinocytes

The carcinogenic effects of sunlight in human epidermis may be thwarted by either: transient growth arrest and repair of DNA photodamage in keratinocytes (KCs); elimination of KCs with damaged DNA via apoptosis; or by stimulating a senescence switch whereby KCs become irreversibly growth arrested. Using normal human skin organ cultures and living epidermal equivalents, we demonstrate that in the proliferative basal layer, removal of KCs via apoptosis had a rapid onset (beginning within 2 h) following UV-light exposure generating progressively greater numbers of KCs with thymine dimers as the dose of UV-light was increased; involved induction of Apaf-1, activation of caspase-3, and was dependent on p53 activation as addition of a p53 chemical inhibitor blocked the apoptotic response. Suprabasal layer KCs underwent apoptosis at much later time points (>8 h). KCs in the basal layer repaired DNA damage more rapidly than KCs in suprabasal layers. Steady state levels of p53 increased in irradiated cells, and the increase was accompanied by phosphorylation of serine 9 and serine 15, but not serine 6 residues. By contrast, cultured KCs undergoing spontaneous replicative senescence were resistant to UV-induced apoptosis. Senescent KCs constitutively contained low levels of p53, which were neither increased nor phosphorylated or acetylated after UV-exposure and possessed minimal DNA binding activity, indicative of functional inactivation. Furthermore, treatment of senescent KCs with DNA damaging agent adriamycin did not result in activation of latent p53 or apoptosis. When KCs within psoriatic plaques were examined, they resembled senescent KCs in that they expressed p53, which was not phosphorylated or acetylated. Thus, UV-light induces DNA damage in human epidermal KCs triggering p53 activation, and subsequent apoptosis involving distinct cell layers and kinetics. However, the lack of p53 activation as seen in senescent KCs and psoriatic plaques, is associated with a relative resistance of KCs to UV-induced apoptosis. In conclusion, the sensitivity and resistance of KCs to apoptosis depends not only on the location within various layers of epidermis and levels of p53, but may also involve p53 activation via post-translational modifications.

Telomeres, aging and cancer: in search of a happy ending

Telomeres are distinctive structures, composed of a repetitive DNA sequence and associated proteins, that cap the ends of linear chromosomes. Telomeres are essential for maintaining the integrity and stability of eukaryotic genomes. In addition, under some circumstances, telomeres can influence cellular gene expression. In mammals, the length, structure, and function of telomeres have been proposed to contribute to cellular and organismal phenotypes associated with cancer and aging. Here, we discuss what is known about the basis for the links between telomeres, aging and cancer, and some of the known and proposed consequences of telomere dysfunction and maintenance for mammalian cells and organisms.

Over-expression of insulin-like growth factor binding protein-related protein-1(IGFBP-rP1/mac25) in the M12 prostate cancer cell line alters tumor growth by a delay in G1 and cyclin A associated apoptosis

In the present study, we examined the effects of over-expression of the potential tumor suppressor gene IGFBP-rP1/mac25 on cell-cycle kinetics in prostate cancer cells. The majority of the high expressing IGFBP-rP1/mac25 cell population was located in the G1 and sub-G0/G1 peaks; synchronizing cells in G2/M with nocodazole demonstrated the high expressing IGFBP-rP1/mac25 clones were delayed in the G1 phase of the cell cycle. Unscheduled expression of cyclin A in the sub-G0/G1 peak occurred in the IGFBP-rP1/mac25 clones. Immunoblots showed decreased cyclin D1 and p21 and increased cyclin E, p16, and p27 in the high expressing IGFBP-rP1/mac25 clones compared to the control cells. Cyclin D1/cdk-4,6 and cyclin E/cdk-2 kinase activities decreased but cyclin A/cdk-2 kinase activity increased for the high expressing IGFBP-rP1/mac25 clones compared to control cells. A pRb immunoprecipitation demonstrated more binding of E2F-1 to pRb in the high expressing IGFBP-rP1/mac25 clones than in control cells. Finally, cell senescence, as assessed by senescence-associated beta-galactosidase, demonstrated significantly more staining in the IGFBP-rP1/mac25 cells than control cells. These results suggest that IGFBP-rP1/mac25 alters the cell cycle kinetics of the M12 prostate cell line by delaying the cells in the G1 phase of the cell cycle. In addition, the appearance of cyclin A in the sub-G0/G1 phase of the cell cycle and the increased kinase activity of cyclin A/cdk-2 in the IGFBP-rP1/mac25 clones suggests that cyclin A is associated with the apoptotic cells.

Role of cyclin-dependent kinase inhibitors in the growth arrest at senescence in human prostate epithelial and uroepithelial cells

Cellular senescence has been proposed to be an in vitro and in vivo block that cells must overcome in order to immortalize and become tumorigenic. To characterize these pathways, we focused on changes in the cyclin-dependent kinase inhibitors and their binding partners that underlie the cell cycle arrest at senescence. As a model, we utilized normal human prostate epithelial cell (HPEC) and human uroepithelial cell (HUC) cultures. After 30-40 population doublings cells became growth-arrested in G0/1 with a threefold decrease in Cdk2-associated activity, a point defined as pre-senescence. Temporally following this growth arrest, the cells develop a senescence morphology and express senescence-associated beta-galactosidase (SA-beta-gal). Levels of p16(INK4a) and p57(KIP2) rise in HUCs during progressive passages, whereas only p16 increases in HPEC cultures. The induced expression of p57, similar to p16, produces a senescent-like phenotype. pRB, cyclin D, p19(INK4d) and p27(KIP1) decrease in both cell types. We find that p53, p21(CIP1) and p15(INK4b) are transiently elevated in HPECs and HUCs at the pre-senescent growth arrest, then return to low proliferating levels at terminal senescence. Analysis of p53, p21(CIP1), p15(INK4b), p16(INK4a), and p57(KIP2) reveals altered expression in immortalized, non-tumorigenic HPV16 E6 and E7 prostate lines and in tumorigenic prostate cancer cells. These results indicate: (i) the existence of a subset of growth inhibiting genes elevated at the onset of the senescence, (ii) a distinct class of genes involved in the maintenance of senescence, and (iii) the frequent inactivation of these pathways during immortalization.

Medical use, misuse, and diversion of opioids in India

In less-developed countries, opioids such as morphine are often not available for pain relief because of excessive regulations imposed to prevent their misuse and diversion. We describe the effect that these draconian measures have had on the availability of drugs for medical use in Kerala, India, and present results of a study, which we did to ascertain whether or not the misuse and diversion of opioids is as prevalent as the government reaction would suggest. We followed 1723 patients in Calicut, India, who were being treated for pain with oral morphine on an outpatient home-care basis. Over 2 years, we did not identify any instances of misuse or diversion. These results suggest that, in the context of India as a less-developed country, oral morphine can be dispensed safely to patients for use at home. We recommend that palliative care programmes talk to concerned governmental authorities, to make them aware of the medical need for opioids, and communicate with local news media to increase awareness of palliative care and the use of these analgesics. Our project has overcome regulatory barriers that had interrupted availability of morphine and its use in pain relief in India.