Opioid for cancer pain

Mercadante S, Fulfaro F. Alternatives to oral opioids for cancer pain. Oncology. 1999 13 215-229. 

Mystakidou K, Befon S, Tsilika E, Dardoufas K, Georgaki S, Vlahos L. Use of TTS fentanyl as a single opioid for cancer pain relief a safety and efficacy clinical trial in patients naive to mild or strong opioids. Oncology 2002 62(1) 9-16. 

Morphine is still very widely used for analgesia. Indeed, it has been recommended by the World Health Organization as the standard opioid for cancer pain [6], since it is widely available and inexpensive. In the W.H.O. pain ladder, first published in 1986, the first step in pain management is described as adjuvant medications. The second step is weak opioids, such as codeine, while the third step is high-potency opioids such as morphine. 

The World Health Organization guidelines for cancer pain recommend opioid treatment of moderate-to-severe cancer pain using oral medication whenever possible [6]. An extensive systematic review of opioids for cancer pain did not find clear evidence of superiority or inferiority of morphine over other opioids for cancer pain, and it remains a very commonly used treatment for cancer pain [38]. The variety of routes for morphine, including oral, rectal, intramuscular, intravenous, subcutaneous, and intrathecal, make it a highly versatile medication. 

McNicol ED, Strassels S, Goudas L, Lau J, Carr DB. NSAIDS or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database SystRev 2005 2 CD005180. 

In a comparison of oral sustained-release morphine (mean 94 mg/day) and hydromor-phone (138 or 206 mg/day) with regard to nausea, vomiting, and constipation, in patients receiving opioids for cancer pain, morphine provided better pain relief at lower doses (after accounting for dose conversion) but was associated with more nausea, constipation, and higher consumption of antiemetic and gastroprotective drugs [104 ]. 

Mercadante S Opioid rotation for cancer pain Rationale and clinical aspects. Cancer 1999 86 1856. [PMID 10547561] Mercadante S, Arcuri E Opioids and renal function. J Pain 2004 5 2. [PMID 14975374]... 

Under controlled conditions, transdermal fentanyl is a useful option for direct conversion from mild to strong opioids in cancer patients. In addition, 25 pg/hour daily incremental steps of transdermal fentanyl can be made by palliative care specialists, if it is required for cancer pain management (59). 

Vielvoye-Kerkmeer AP, Mattern C, Uitendaal MP. Transdermal fentanyl in opioid-naive cancer pain patients an open trial using transdermal fentanyl for the treatment of chronic cancer pain in opioid-naive patients and a group using codeine. J Pain Symptom Manage 2000 19(3) 185-92. 

Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, Mercadante S, Meynadier J, Poulain P, Ripamonti C, Radbruch L, Casas JR, Sawe J, Twycross RG, Ventafridda V Expert Working Group of the Research Network of the European Association for Palliative Care. Morphine and alternative opioids in cancer pain the EAPC recommendations. Br J Cancer 2001 84(5) 587-93. 

Bressler, L.R. Geraci, M.C. Feinberg, W.J. Pharmacists attitudes and dispensing patterns for opioids in cancer pain management. J. Pain Symptom Manage. 1995, 3 (2), 5-20. 

Zeppetella G (2008) Opioids for cancer breakthrough pain a pilot study reporting patient assessment of time to meaningful pain relief. J Pain Symptom Manage 35(5) 563-567... 

The World Health Organization s (WHO) three-step analgesic ladder for cancer pain control recommends using acetaminophen alone for mild pain (step 1) and in combination with opioids for moderate pain (step 2). 

Portenoy RK, Taylor D, Messins J, and Tremmel L (2006) A randomized, placebo-controlled study of fentanyl buccal tablet for breakthrough pain in opioid-treated patients with cancer. Clin. J. Pain 22 805-811. 

Daily limit Once a successful dose has been found, instruct patients to limit consumption to 4 units/day or less. If consumption increases to more than 4 units/day, reevaluate the dose of the long-acting opioid for persistent cancer pain. 

Potent opioids act through opioid receptors in the central nervous system where they inhibit the transport of pain impulses. They are mostly used for treatment of malignant cancer pain and for post-operative pain. Severe, long-term non-malignant pain, e.g. in ischaemic leg ulcers, sometimes necessitates the use of opioids. The risk of treatment discontinuation due to adverse reactions is high. 

Yee, J.D. and Berde, C.B. (1994) Dextroamphetamine ot methyl-phenidate as adjuvants to opioid analgesia for adolescents with cancer. / Pain Symptom Manage 9 122-125. 

Conversely, the perceived dangerous side-effects and fears of addiction and tolerance associated with potent opioid analgesics (e.g. morphine) has led to restrictions and controversy regarding their use. Clinical studies, however, have demonstrated that these risks are low and potent opioid analgesics today are more widely accepted for treating severe cancer pain, but experts are still calling for broader use of opioids in non-malignant chronic pain. 

Local legislation limits the availability and choice of opioids in many countries, but there can also be a reluctance to prescribe opioids for non-cancer pain due to the assumption that susceptible individuals may become addicted to these potent drugs through abuse. However, if opioids are prescribed on an individual basis with adequate support and education for the patients as well as their familes or carers, a great deal of unnecessary chronic pain and suffering can be prevented. But today there are still several unresolved clinical issues surrounding opioid use for which there is no data to construct a suitable policy. 

Opioids are used for the treatment of moderate to severe or very severe pain of acute or chronic type (Stein, 1999). Nearly all forms of pain are sensitive to opioid treatment and in contrast to traditional opinions even neuropathic pain is reasonably sensitive to higher doses of opioids. This was clearly shown in well-controlled clinical studies (Watson, 2000). The most important use of opioids in acute pain treatment is postoperative pain, whereas treatment of cancer pain, often accompanied by a neuropathic pain component, is the classical domain of chronic opioid treatment. 

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