Is oral morphine still the first choice opioid for moderate to severe cancer pain? A systematic review within the European Palliative Care Research Collaborative guidelines project

Abstract

The aim of this systematic review was to evaluate the evidence that oral morphine can be recommended as the first choice opioid in the treatment of moderate to severe cancer pain in updating the European Association for Palliative Care opioid recommendations. A systematic literature review was performed to update the 2007 Cochrane review 'Oral morphine for cancer pain'. The literature search was conducted on MedLine, EMBASE and Cochrane Central Register of Controlled Trials databases. The search strategy, limited in time (from 1 July 2006 to 31 October 2009), was aimed to be as extensive as possible using both text words and MeSH/EMTREE terms; a hand search of the reference lists of identified papers was also performed. Randomized clinical trials, containing data on efficacy and/or side effects of morphine, were identified. Among the papers retrieved from the cited databases and the Cochrane review, 17 eligible studies, for a total of 2053 patients, and a meta-analysis were selected. These studies do not add significant information to the previous Cochrane review confirming the limitation of efficacy and tolerability data on opioid-naïve and non-selected populations of cancer patients treated with morphine and suggesting that oral morphine, oxycodone and hydromorphone have similar efficacy and toxicity in this patient population.

Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs

“…A review of oral step III analgesic therapy including 62 trials in a total of 4241 patients showed that a mean pain score of about 3/10 was obtained in slightly less than one-third of the trials (18/62, 29%) [29]. A recent systematic review showed limited efficacy of opioids for relieving cancer pain, with substantial toxicity [32]. Furthermore, recent opioids such as oxycodone (Oxycontin ® , Oxynorm ® ) or hydromorphone (Sophidone ® ) were not more effective than morphine [32].…”

“…A recent systematic review showed limited efficacy of opioids for relieving cancer pain, with substantial toxicity [32]. Furthermore, recent opioids such as oxycodone (Oxycontin ® , Oxynorm ® ) or hydromorphone (Sophidone ® ) were not more effective than morphine [32]. Similarly, although several recommendations indicate that preference should be given to sustained-release forms, the six randomized trials that compared sustained-release to immediate-release opioids found no difference [33] in efficacy or adverse events, particularly addiction, both in noncancer pain and in cancer pain [34].…”

A Morphine Manifesto

“…In the light of the available scientific evidence that immediate-release oral morphine is both safe and effective as first-line treatment for severe pain (4,5);…”

Novel Treatment Strategies for Cocaine and Opioid Abuse

“…Its short half-life allows frequent changes in dosing according to the individual needs. The low cost of morphine solution and immediate-release formulations and its potential availability are the major reasons for it to be recommended as a first-line opioid in the WHO Cancer Pain Relief Guidelines [15]. However, its narrow therapeutic index and severe side effects limit its therapeutic use.…”