Pain and pain treatments in European palliative care units. Palliat Med. In a review, the authors suggest that the WHO protocol does not use evidence-based recommendations. The WHO analgesic lad- der for cancer pain control, twenty years of use. How much pain relief does one get from using it? Some authors criticize the restriction of potent opioids for the third step. Use of strong opioids in advanced cancer pain: a randomized trial. J Pain Symptom Manage.
Better pain control and patient satisfaction could be obtained with the use of potent opioids as first medication. Because of these controversies, further studies are needed. The aim of this study was to determine whether the use of morphine in the first step of the WHO ladder can improve the outcome. Patients with difficulty in maintaining clinical follow-up, cognitive impairment and previous treatment with opioids were excluded.
The study was registered at clinicaltrials. The patients were divided into two groups with the use of envelopes containing the number of the patient and the group to which he she belonged.
Patients were included in the sequence by allotment in the visit. G2 patients received morphine 10 mg every four hours. Whenever indicated, adjuvant drugs were associated to the treatment. According to pain intensity, G1 patients switched drug in obedience to the analgesic ladder and G2 patients had adjusted the dose of the analgesic drug.
The need for palliative cancer therapy, such as radiotherapy, chemotherapy or hormone therapy, was indicated by the oncologist. Pain intensity every two weeks by using the visual analogue scale VAS , quality of life every four weeks through the brief questionnaire of quality of life of the WHO, 15 Evaluating correlation and interrater reliability for four performance scales in the Pallia- tive Care Setting.
Adverse effects were recorded. Follow-up was done for three months or until the death of the patient. To calculate the sample size, BioEstat 2. The mean and standard deviation of another similar study were used as reference. For the statistical analysis, GraphPad Prism program was used. The Student t test to compare age, weight and height; chi-square test for patient satisfaction, need for complementation and adverse effects; and Mann-Whitney test for pain intensity, quality of life and physical function were used.
The sequence of this study is shown in the diagram Fig. By reason of death, only 24 patients from G1 and 29 from G2 completed the study. The groups were similar with respect to demographics sex, age, weight and height Table 1. The most common locations of tumors were in the head and neck G1: 22, G2: 26 , with the same region for pain G1: 21, G2: The most frequent type of pain was somatic G1: 27, G2: There was no difference in pain intensity Table 2 or quality of life Table 3.
There was no difference in physical capacity on the first G1: 0. In this study, there was a reduction in pain intensity in the two groups, which suggests that the techniques are effective. In another study, patients receiving potent opioids had better pain control and greater satisfaction than the conventional group, but with more adverse effects.
It is possible that the combination of paracetamol and morphine resulted in better analgesic effect. In other studies, the combination of potent opioids and non-opioids resulted in better control of pain. However, in one study half the patients previously treated with the combination of paracetamol with a potent opioid also obtained pain control without paracetamol; a substantial number of patients discontinued the use of this agent, because of the inconvenience of swallowing so many medications, and still maintained control of pain.
Oral cancer pain. Oral Oncol. Analgesic effect of paraceta- mol on cancer related pain in concurrent strong opioid therapy. A prospective clinical study. Acta Oncol. Morphine taken by mouth has been used since the s for controlling cancer pain. In the World Health Organization recommended taking an oral solution of morphine every four hours. Morphine is now available in a number of different formats that release the morphine over various periods of time.
Morphine immediate release is rapidly absorbed, and would usually be taken every four hours. Modified release tablets are available that release morphine more slowly, so that they can be taken only twice a day or even only once a day.
In this updated review we set out to estimate how well morphine worked, how many people had side effects, and how severe those side effects were — for example, whether they were so severe that participants stopped taking their oral morphine. We found 62 studies with participants. The studies were often small, compared many different preparations, and used different study designs.
This made it difficult to work out whether any one tablet or preparation of oral morphine was better than any other. There did not seem to be much difference between them. More than 9 in 10 participants had pain that went from moderate or severe before taking morphine to pain that was no worse than mild when taking morphine.
More than 6 in 10 participants were very satisfied with the morphine treatment, or considered the result to be very good or excellent. Only about 1 person in 20 stopped taking morphine because of side effects. Morphine is associated with some unwanted effects, mainly constipation, and nausea and vomiting. At one level these are good results. On another level, the quality of studies is generally poor and we could wish for more consistency in study design, and especially in study reporting, which should include the outcome of pain reduced to tolerable levels — no worse than mild pain — so that people with cancer are not bothered by pain.
The conclusions have not changed for this update. The effectiveness of oral morphine has stood the test of time, but the randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than participants and did not provide appropriate data for meta-analysis. The review demonstrates the wide dose range of morphine used in studies, and that a small percentage of participants are unable to tolerate oral morphine.
The review also shows the wide range of study designs, and inconsistency in cross-over designs. You might find that over time you need larger doses of pain medicine. This may be because the pain has increased or you have developed a drug tolerance. Many people do not develop a tolerance to opioids. But if you do develop drug tolerance, usually small increases in the dose or a change in the kind of medicine will help relieve the pain.
Not everyone has side effects from opioids. The most common side effects are usually sleepiness, constipation, nausea, and vomiting. Some people might also have dizziness, itching, mental effects such as nightmares, confusion, and hallucinations , slow or shallow breathing, or trouble urinating. Many side effects from opioid pain medicine can be prevented.
Some of the mild ones such as nausea, itching, or drowsiness, often go away without treatment after a few days, as your body adjusts to the medicine. When you first start taking them, opioids might make you sleepy, but this usually goes away after a few days. You also will get less sleepy as your body gets used to the medicine. Sometimes it may be unsafe for you to drive a car, or even to walk up and down stairs alone. Opioids cause constipation in most people, but it can often be prevented or controlled.
Opioids slow the movement of stool through the intestinal tract, which allows more time for water to be absorbed by the body. The stool then becomes hard. For more detailed information on what you can do, see Constipation.
Nausea and vomiting caused by opioids will usually go away after a few days of taking the medicine. For suggestions on handling this side effect, see Nausea and vomiting.
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