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Opioid titration with sustained-release oxycodone and immediate-release morphine for moderate/severe cancer pain: A pilot assessment of the CoDem protocol

Boaz Gedaliahu Samolsky Dekel, MD, PhD, MA, Marco Tomasi, MD, Alessio Vasarri, MD, Alberto Gori, MD, Marco Adversi, MD, Anna Castagnoli, MD, GianFranco Di Nino, MD, Rita Maria Melotti, MD

Abstract


Objectives: Opioid titration is the first challenging stage for rapid control of moderate/severe cancer pain. Evidence shows that sustained-release formulations may be used for opioid titration. We set a pilot assessment of the efficacy and tolerability of our in-house protocol (continuous and on demand opioids [CoDem]) of the association of sustained-release oxycodone and immediate-release morphine as rescue dose for opioid titration/rotation in opioid-naïve (NAOP, n = 13), tolerant to weak (WOP, n = 20), or strong opioids (STOP, n = 44) in-patients with moderate/severe cancer pain.

Methods: Observational and retrospective analysis of cancer in-patients treated for 7 days with the CoDem protocol.

Outcome measures: Pain intensity (patients self-reported pain with numerical rating scale [NRS] under static [NRSs] and dynamic [NRSd] conditions), amount of drug consumption, opioid adverse effects, and patient satisfaction.

Efficacy endpoints: In more than 50 percent of the patients and in <72 hours, steady NRSs and NRSd score reduction of at least two points, NRSs 3 and NRSd 4; and mean daily morphine consumption < mean of one rescue dose and t1:t6 ratio of mean oxycodone daily dose < 1:2.

Results: Endpoints were reached within 24 hours both within the sample and subgroups. Only NAOP patients reached NRSd 4 endpoint within 48 hours. Against moderate and transient adverse effects, most patients (84.4 percent) found pain treatment to be good or excellent.

Conclusions: The CoDem protocol was shown to be effective and reasonably tolerated for titration for moderate/severe cancer pain relief in both opioid-naïve or opioid-tolerant cancer in-patients. This pilot assessment warrants prospective and comparative studies with larger samples for more generalized results.


Keywords


opioid titration, opioid naïve, opioid tolerant, cancer pain, oxycodone, morphine, sustained release

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References


Hanks GW, Conno F, Cherny N, et al.: Morphine and alternative opioids in cancer pain: The EAPC recommendations. Br J Cancer. 2001; 84(5): 587-593.

Bekkering GE, Soares-Weiser K, Reid K, et al.: Can morphine still be considered to be the standard for treating chronic pain? A systematic review including pair-wise and network meta-analyses. Curr Med Res Opin. 2011; 27(7): 1477-1491.

Mercadante S: Opioid titration in cancer pain: A critical review. Eur J Pain. 2007; 11(8): 823-830.

Caraceni A, Hanks G, Kaasa S, et al.: Use of opioid analgesics in the treatment of cancer pain: Evidence-based recommendations from the EAPC. Lancet Oncol. 2012; 13(2): e58-e68.

Ashby M, Fleming B, Wood M, et al.: Plasma morphine and glucuronide (M3G and M6G) concentrations in hospice inpatients. J Pain Symptom Manage. 1997; 14(3): 157-167.

Dale O, Piribauer M, Kaasa S, et al.: A double-blind, randomized, crossover comparison between single-dose and double-dose immediate-release oral morphine at bedtime in cancer patients. J Pain Symptom Manage. 2009; 37(1): 68-76.

Ferrel BA: Pain management by elderly persons. In Payne R, Pall RB, Stratton Hill C (eds.): Assessment and Treatment of Cancer Pain. Seattle: IASP Press, 1998: 53-66.

Houde RW, Wallenstein SL, Beaver WT: Clinical measurement of pain. In de Stevens G (ed.): Analgetics. New York: Academic Press, 1965: 75-121.

Klepstad P, Kaasa S, Borchgrevink PC: Start of oral morphine to cancer patients: Effective serum morphine concentrations and contribution from morphine-6-glucuronide to the analgesia produced by morphine. Eur J Clin Pharmacol. 2000; 55(10): 713-719.

Todd J, Rees E, Gwilliam B, et al.: An assessment of the efficacy and tolerability of a ‘double dose’ of normal-release morphine sulphate at bedtime. Palliat Med. 2002; 16(6): 507-512.

Davies A, Sitte T, Elsner F, et al.: Consistency of efficacy, patient acceptability, and nasal tolerability of fentanyl pectin nasal spray compared with immediate-release morphine sulfate in breakthrough cancer pain. J Pain Symptom Manage. 2011; 41(2): 358-366.

Miaskowski C, Dodd MJ, West C, et al.: Lack of adherence with the analgesic regimen: A significant barrier to effective cancer pain management. J Clin Oncol. 2001; 19(23): 4275-4279.

Wiffen PJ, McQuay HJ: Oral morphine for cancer pain. Cochrane Database Syst Rev. 2007; (4): CD003868.

Kalso E: Oxycodone. J Pain Symptom Manage. 2005; 29(5 suppl): S47-S56.

Koizumi W, Toma H, Watanabe K, et al.: Efficacy and tolerability of cancer pain management with controlled-release oxycodone tablets in opioid-naive cancer pain patients, starting with 5 mg tablets. Jpn J Clin Oncol. 2004; 34(10): 608-614.

Jacobsen R, Liubarskiene Z, Moldrup C, et al.: Barriers to cancer pain management: A review of empirical research. Medicina (Kaunas). 2009; 45(6): 427-433.

Citron ML, Kaplan R, Parris WC, et al.: Long-term administration of controlled-release oxycodone tablets for the treatment of cancer pain. Cancer Invest. 1998; 16(8): 562-571.

Lauretti GR, Oliveira GM, Pereira NL: Comparison of sustained-release morphine with sustained-release oxycodone in

advanced cancer patients. Br J Cancer. 2003; 89(11): 2027-2030.

Biancofiore G: Oxycodone controlled release in cancer pain management. Ther Clin Risk Manag. 2006; 2(3): 229-234.

Riley J, Ross JR, Rutter D, et al.: No pain relief from morphine? Individual variation in sensitivity to morphine and the need to switch to an alternative opioid in cancer patients. Support Care Cancer. 2006; 14(1): 56-64.

Wittnik H, Carr DB (eds.): Pain Management: Evidence, Outcomes and Quality of Life. A Sourcebook. Amsterdam: Elsevier, 2005.

Brennan F, Carr DB, Cousins M: Pain management: A fundamental human right. Anesth Analg. 2007; 105(1): 205-221.

Brennan F: Palliative care as an international human right. J Pain Symptom Manage. 2007; 33(5): 494-499.

Vondrackova D, Leyendecker P, Meissner W, et al.: Analgesic efficacy and safety of oxycodone in combination with naloxone as prolonged release tablets in patients with moderate to severe chronic pain. J Pain. 2008; 9(12): 1144-1154.




DOI: https://doi.org/10.5055/jom.2014.0189

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