Robert Twycross

Morphine and alternative opioids in cancer pain: the EAPC recommendations.

An expert working group of the European Association for Palliative Care has revised and updated its guidelines on the use of morphine in the management of cancer pain. The revised recommendations presented here give guidance on the use of morphine and the alternative strong opioid analgesics which have been introduced in many parts of the world in recent years. Practical strategies for dealing with difficult situations are described presenting a consensus view where supporting evidence is lacking. The strength of the evidence on which each recommendation is based is indicated.

Pain in far-advanced cancer

Abstract Hundred patients with far‐advanced cancer and pain were interviewed within a few days of admission to a special care unit. Eighty had more than one pain; 34 had four or more. A total of 303 anatomically distinct pains were recorded. Ninety‐one patients had pain caused by the cancer itself. Twelve had treatment‐related pain; and 19 had pain related to chronic disease or debility (‘associated pain’). Thirty‐nine patients had one or more pains unrelated to cancer or treatment; the most common of these was myofascial pain. In 41 patients only was all the pain caused directly by the cancer. Bone involvement and nerve compression were the most common forms of cancer‐related pain; soft tissue and visceral pains also occurred frequently. Fifty‐seven patients had pain for more than 4 months.

Midazolam for intractable hiccup

We describe two terminally ill cancer patients severely distressed by intractable hiccup. Commonly recommended treatments were ineffective. Intravenous midazolam 5-10 mg rapidly relieved the hiccup. Maintenance treatment comprised midazolam 40-120 mg/24 hr by continuous subcutaneous infusion.

Pain and analgesics

The problem of pain and its treatment is reviewed, particularly in relation to advanced cancer and other chronic conditions in which persistent pain demands relief. The nature of pain, its assessment and treatment options are discussed briefly, as is the use of different types of analgesics to raise the patients pain threshold. The importance of regular reassessment of the patient and his needs, and the settling of realistic analgesic treatment objectives, such as an initial target of a pain-free full nights sleep, is stressed.

Euthanasia: going Dutch?

My experience in 25 years as a hospice doctor have reinforced my belief that when everything is taken into account--physical, psychological, social and spiritual--euthanasia is not the answer. This belief is enhanced by what I see happening in the Netherlands. However, lest it be thought that I have become hardened and indifferent to suffering let me add that, although firmly opposed to euthanasia, I consider that: (i) a doctor who has never been tempted to kill a patient probably has had limited clinical experience or is not able to empathize with those who suffer (ii) a doctor who leaves a patient to suffer intolerably is morally more reprehensible than the doctor who performs euthanasia A doctor has twin obligations to preserve life and to relieve suffering. Preserving life is increasingly meaningless when a terminally ill patient is close to death, and the emphasis on relieving suffering becomes paramount. Even here, however, the doctor is obliged to achieve his objective with minimum risk to the patients life. This means that treatment to relieve pain and suffering which coincidentally might bring forward the moment of death by a few hours or days is acceptable (the principle of double effect), but administering a drug such as potassium or curare, with the primary intention of causing death, is not.

Evaluation of the palatability of Oramorph- a proprietary preparation of oral morphine sulphate:

The palatability of Oramorph, a proprietary preparation of morphine sulphate (Boehringer Ingelheim), was compared with an aqueous solution produced by the hospital pharmacy. Thirty patients receiving regular oral morphine sulphate for either pain relief or dyspnoea entered a double-blind, randomized, comparator- controlled crossover trial. Taste preference and other factors were evaluated using Visual Analogue Scales (VAS). Eighteen patients preferred the taste of Oramorph and 12 the hospital formulation. The mean preference in Oramorphs favour, however, did not reach statistical significance (p = 0.3). When each patients scores were examined separately, 17 expressed a preference, the magnitude of which was of clinical importance, (score of > 30mm on the VAS). Eleven of these were for Oramorph and six for aqueous morphine. When the pleasantness of taste for each solution was assessed independently, a similar result was obtained, with 20 patients rating Oramorph as having a more pleasant taste than aqueous morphine. Ten patients found the reverse to be true. The majority, 22 patients, found Oramorph to be less bitter than aqueous morphine. There was no difference between the smell and texture of the two solutions.

Diagnosis and management of pain in patients with cancer. Pain and headache series, vol. 10: R. Kanner, Karger, Basel, 1988, ix + 104 pp., 1 fig., 3 tab., Price £31.40, ISBN 3-805-54690-4

This book is Vol. 10 of a series entitled Pain and Headache. It is written for the practicising physician, meaning presumably the non-specialist. It is a slender volume which, in the age of massive multi-author tomes, makes a refreshing change. There is also a remarkable dearth of figures and tables. The opening chapter discusses causes of pain in cancer. I found this curiously unbalanced although full of interest. For example, visceral pain is hardly mentioned, and there are no discrete sections on deafferentation and sympathetic maintained pains. A synoptic table would have helped provide a coherent focus. A number of comments about treatment are clearly out of place here. The next 3 chapters deal with analgesic and adjuvant medication. For a book issued by an international publishing house, it is strange that acetaminophen is not identified by its alternative generic name, paracetamol. It is also a pity that it is not clearly stated that non-acetylated salicylates have no effect on platelet function and bleeding time. Published data, which demonstrate that dextropropoxyphene has definite analgesic properties and is only marginally less potent than codeine, are not mentioned. The section on morphine is disappointing. A short sentence to emphasize that pain is the physiological antagonist to the central depressant effects of morphine would have been welcome. The one-sided discussion of the oral to parenteral potency ratio for morphine ignores ‘grass-roots’ practice even in the author’s own country. To recommend a 1: 6 ratio as the basis for converting from oral to parenteral routes is irresponsible given the accumulated clinical experience which points strongly to a ratio of 1 : 2 or 1 : 3. Further, there is no discussion about the analgesic properties of morphine-6glucuronide. Generally, the chapter on narcotic analgesics is not well structured. The chapter on surgical neuroablative procedures concentrates appropriately on spinothalamic tractotomy (cordotomy) and hypophysectomy. The absence of a discussion of coeliac axis plexus block at this point is surprising. Given the importance of psychosocial aspects of care in everyday clinical practice, the chapter on psychological issues is disappointingly short. Thus, given the target audience is the non-specialist physician, I feel the book is of limited value.