February 2002

Dear Readers: Here's the Article for this Month:

Name of article:

Strategies to manage the adverse effects of oral morphine: an evidence-based report

Author(s):  Cherny N, Ripamonti C, Pereira J, Davis C, Fallon M, McQuay H, Mercadante S, Pasternak G, and Ventafridda V for the Expert Working Group of the European Associan of Palliative Care Network

Reference: J Clinical Oncology 2001; 19: 2542-2554

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 (possible 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.

Why I chose this article as the Article of the Month?

Oral morphine is conventionally considered to be the drug of choice in treating moderate to severe cancer-related pain. What is to be done when oral morphine fails because of adverse effects ? This paper is the result of an international working group who worked together with the aim to review all the available data on the adverse effects of oral morphine, to discuss the evidence on the different possible therapeutical strategies, to manage them and then to propose practical recommendations for clinicians. Moreover guidelines for switching the opioids are supplied together with an up-dated dose conversion table of opioid analgesics.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC