Patient-controlled analgesic administration. A comparison of steady-state morphine infusions with bolus doses

Abstract

The authors have shown previously that bone marrow transplant (BMT) patients who self-administered bolus doses of morphine gained equal oral mucositis pain relief while using less drug compared with similar patients receiving morphine by staff-controlled continuous infusion. In a follow-up study they compared the efficacy and side effects of morphine in two groups of marrow transplant patients who controlled their own analgesic administration either by conventional bolus-dose, patient-controlled analgesia (PCA) or by adjusting the rate of continuous morphine infusion to increase or decrease their plasma morphine concentration. Patients controlling their morphine infusion rates (pharmacokinetically based patient-controlled analgesia [PKPCA] group) obtained more relief from oral mucositis pain than did patients using conventional PCA. Patients in the PKPCA group used more morphine than PCA patients and achieved superior pain relief without significant increases in side effects (e.g., nausea, mood changes, sedation). The authors conclude that PKPCA improves the management of prolonged, severe pain in marrow transplant patients and that this approach to patient-controlled analgesia may be useful in other types of persistent pain.

Postoperative morphine consumption in children with sickle‐cell disease

“…The results of clinical studies have been highly variable, with some studies reporting a lack of development of tolerance with chronic opioid dosing (19). However, tolerance to the analgesic effect of morphine has been demonstrated in postoperative patients with chronic opioid exposure (20), and studies in bone marrow transplant patients have reported a right shift of the dose response (21). Morphine is the most commonly used analgesic in sickle‐cell vaso‐occlusive crisis (22).…”

Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis

“…Guideline: The panel recommends patient‐controlled analgesia (PCA) with morphine as the treatment of choice for oral mucositis pain in patients undergoing HSCT ( level of evidence, I; grade of recommendation, A ). Control of mucositis‐induced pain is achieved by PCA with intravascular morphine sulfate 41–49. Level I evidence supports PCA for oral mucositis pain in patients who undergo HSCT, but there is little evidence to recommend its use in other patients and settings.…”

“…Pediatric populations also can use PCA efficiently. Initial studies of transdermal fentanyl have been published,44, 49 but further study is required to confirm its efficacy.…”

Topical Ketamine in the Treatment of Mucositis Pain

“…Systemic opiates are the cornerstone of treatment for severe mucositis pain, but the level of relief achieved at well‐tolerated doses is often suboptimal [4,5]. The use of anesthetic agents by swish and rinse has been an appealing strategy for adjunctive analgesia, though one for which the treatment results are often disappointing [12].…”

“…Systemic opiates, usually by the parenteral or transdermal route, are the standard of care for the pain of severe mucositis arising from chemotherapy and radiotherapy. Relief of rest pain is, however, often suboptimal at tolerated doses [4,5], and opiates are even less effective for the mechanical and chemical hyperalgesia that occurs with eating. Topical approaches have the potential advantage of local pain control with minimal systemic side effects and good patient acceptability [6].…”