Anneli Vainio

Morphine and oxycodone hydrochloride in the management of cancer pain

In a double‐blind crossover study, morphine and oxycodone hydrochloride were administered to 20 patients who were experiencing severe cancer pain. The peroral doses were determined on the basis of patient‐controlled intravenous titration. The assumed oral bioavailability ratios were 44% (group 1, first 10 patients) and 33% (group 2, last 10 patients) for morphine and 66% (group 1) and 50% (group 2) for oxycodone hydrochloride, respectively. However, the patients were able to readjust their oral dosings. Equal analgesia was achieved with both drugs, but the intravenous dose of oxycodone hydrochloride needed was 30% higher than that of morphine. The median calculated oral/intravenous ratios giving comparable analgesia were 0.31 for morphine and 0.70 for oxycodone hydrochloride. Morphine caused more nausea than oxycodone hydrochloride and hallucinations occurred only during morphine treatment. Otherwise, there were no major differences in the side effects between these two opioids.

Driving ability in cancer patients receiving long-term morphine analgesia

When given in single doses to healthy volunteers, opioid analgesics impair reaction time, muscle coordination, attention, and short-term memory sufficiently to affect driving and other skilled activities. Despite the increasing use of oral morphine daily, little is known about the effect of long-term opioid therapy on psychomotor performance. To examine the effects of continuous morphine medication, psychological and neurological tests originally designed for professional motor vehicle drivers were conducted in two groups of cancer patients who were similar apart from experience of pain. 24 were on continuous morphine (mean 209 mg oral morphine daily) for cancer pain; and 25 were pain-free without regular analgesics. Though the results were a little worse in the patients taking morphine, there were no significant differences between the groups in intelligence, vigilance, concentration, fluency of motor reactions, or division of attention. Of the neural function tests, reaction times (auditory, visual, associative), thermal discrimination, and body sway with eyes open were similar in the two groups; only balancing ability with closed eyes was worse in the morphine group. These results indicate that, in cancer patients receiving long-term morphine treatment with stable doses, morphine has only a slight and selective effect on functions related to driving.

Epidural and subcutaneous morphine in the management of cancer pain: a double-blind cross-over study

&NA; Ten patients who suffered from severe cancer‐related pain participated in a randomised, double‐blind and cross‐over study to compare the effectiveness and acceptability of epidural and subcutaneous administration of morphine. The patients titrated themselves pain‐free in 48 h using a patient controlled analgesia system. The median daily doses calculated from the consumption of the last 4‐h study period were 372 mg for subcutaneous and 106 mg for epidural administration. The two modes of morphine administration turned out to be comparable in terms of both effectiveness and acceptability. Both treatments provided better pain relief with less adverse effects compared with the prestudy oral morphine treatment.

Treatment of cancer pain in Norway. A questionnaire study

&NA; A questionnaire study was performed in order to clarify knowledge and practice of cancer pain treatment in Norway: a 10% random sample of Norwegian physicians received a questionnaire. Of 800 correctly addressed questionnaires, 549 were returned and 306 were analyzed after exclusion of those doctors who never treated cancer patients, Their knowledge of the principles and methods of cancer pain treatment were evaluated with 8 multiple‐choice and 13 open questions. Their ability to apply their knowledge in practice was evaluated by analyzing their suggested treatment of 3 illustrative case histories. The results show that only 25% of Norwegian physicians treating cancer patients appear to have knowledge of the principles of the World Health Organization analgesic ladder strategy. However, the majority (86%) of the physicians were prepared to prescribe strong opioid analgesics, but in the illustrative cases where strong opioids were appropriate, 44% prescribed too small doses and often preferred neuroleptic drugs instead of increasing the analgesic to a sufficiently large dose. Patients needing step two on the analgesic ladder, in Norway often (49%) are treated with a standard combination of paracetamol and codeine. However, when a strong opioid is required, 50% of Norwegian physicians forget to continue the paracetamol or NSAID component. Two hundred seventy‐four (97%) of the physicians said they experienced problems when treating cancer pain, ranging from inefficient pain relief (52%) to side effects of opioid analgesics (32%), most often sedation, in combination with nausea and constipation. Only 13% of the physicians had a correct understanding of opioid drug dependence. As many as 72% of Norwegian physicians thought their education in cancer pain treatment was insufficient.

Management of cancer pain in Denmark: a nationwide questionnaire survey.

&NA; A questionnaire survey was carried out with the aim of evaluating knowledge about and practice of cancer pain treatment in Denmark. A questionnaire was sent out to a 10% random sample of Danish physicians. Of these 1411 physicians, 1068 (76%) returned the questionnaires and after exclusion of those doctors who never treated cancer patients, 577 (54%) were analyzed. Their knowledge of the principles and pratice of cancer pain treatment was evaluated by means of 14 multiple‐choice and open questions. Their ability to apply their knowledge in practice was evaluated by analyzing their suggested treatment of 3 simulated patient cases. The results show that a vast majority (97%) of the physicians were prepared to use opioids conventionally administered for severe pain and that 39% reported the use of other treatment modalities (psychological treatment, antineoplastic therapy, transcutaneous nerve stimulation/acupuncture, etc.). Ninety‐seven percent of the physicians recognized difficulties in cancer pain treatment, the most frequent being side effects of drugs and inadequate pain relief. Seventy‐five percent considered that their knowledge about pain treatment was fair or better. The overall evaluation of the proposals for pain treatment of the patient cases was primarily based on drug therapy. Adequate doses, correct dose intervals and selection of drugs, routes of administration and other treatments were the requirements for satisfactory answers. It appears that the majority the physicians could treat both pain from bone metastasis (75%) and visceral pain (78%) satisfactorily, while very few suggested co‐analgesics for neuropatic pain conditions (20%). Older physicians performed less well than their younger colleagues. Basic pain treatment skills have been acquired by the Danish physicians but, in the future, emphasis should be placed on the treatment of neuropathic pain with co‐analgesics and the management of opioid side effects.

Pain Treatment and Terminal Care in Finnish Hospitals

In Finland, with a population of about 5 million, the number of patients dying of malignant diseases is 10,000 a year. Almost all of them (93%) die in hospitals, 2% in other institutions, and only 5% die at home. During the last few years, increasing attention has been paid to the quality of terminal care. New ideas about individual and comprehensive care have entered into the Finnish communal home care system, and the first hospice is under construction.