Strategies to Manage the Adverse Effects of Oral Morphine: An Evidence-Based Report

Abstract

Successful pain management with opioids requires that adequate analgesia be achieved without excessive adverse effects. By these criteria, a substantial minority of patients treated with oral morphine (10% to 30%) do not have a successful outcome because of (1) excessive adverse effects, (2) inadequate analgesia, or (3) a combination of both excessive adverse effects along with inadequate analgesia. The management of excessive adverse effects remains a major clinical challenge. Multiple approaches have been described to address this problem. The clinical challenge of selecting the best option is enhanced by the lack of definitive, evidence-based comparative data. Indeed, this aspect of opioid therapeutics has become a focus of substantial controversy. This study presents evidence-based recommendations for clinical-practice formulated by an Expert Working Group of the European Association of Palliative Care (EAPC) Research NETWORK: These recommendations highlight the need for careful evaluation to distinguish between morphine adverse effects from comorbidity, dehydration, or drug interactions, and initial consideration of dose reduction (possibly by the addition of a co analgesic). If side effects persist, the clinician should consider options of symptomatic management of the adverse effect, opioid rotation, or switching route of systemic administration. The approaches are described and guidelines are provided to aid in selecting between therapeutic options.

HIFU for Palliative Treatment of Pancreatic Cancer

“…Pain is often reported by patients with advanced disease, and palliative treatment methods are commonly employed and include opioid therapy and celiac plexus neurolysis (4). However, opioids may produce a range of side-effects from dysphoria to respiratory depression, and celiac plexus neurolysis provides limited benefit in pain relief, in addition to being an invasive procedure (5,6).…”

Differences in the Prevalence and Severity of Side Effects Based on Type of Analgesic Prescription in Patients with Chronic Cancer Pain

“…A number of systematic reviews have evaluated the prevalence of analgesic side effects associated with the treatment of cancer (1,4) and chronic noncancer (5)(6)(7)(8)(9) pain. Most prevalence rates were derived from adverse event data reported as a part of studies of new analgesics.…”

“…Cherny et al (1) identified six side effects that adversely impact oncology patients use of opioid medications, namely: nausea/vomiting, constipation, sedation, cognitive failure, myoclonus, and pruritis. McNicol et al (4) conducted a systematic review of 67 studies on the management of side effects associated with opioids.…”

“…These side effects limit the titration of analgesics to achieve optimal pain control and decrease the patient's quality of life (1,2). Side effects commonly associated with chronic administration of various classes of analgesic medications include gastrointestinal (e.g., nausea, vomiting, indigestion, constipation), central nervous system (e.g., drowsiness, difficulty concentrating, hallucinations/nightmares, lightheadedness, poor coordination, lack of energy), and autonomic nervous system (e.g., urinary retention, xerostomia) effects.…”

Switching from oxycodone to methadone in advanced cancer patients

“…Opioid substitution has been found to produce an improvement in the opioid response [3]. Given the increasing use of oxycodone, even at high doses, it is likely that some patients may not respond and require an opioid switching.…”