Cancer
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The results of nine US multicenter, sequential crossover, dose titration studies of controlled-release oral morphine (MS Contin 30 mg tablets [MSC], Purdue Frederick, Norwalk, CT) are reviewed in Part I. The studies demonstrated the prolonged analgesic efficacy of the preparation in the treatment of patients with moderate to severe cancer-related pain. Approximately 93% of the patients achieved satisfactory to excellent analgesia on a 12-hour regimen when appropriate dose titration was allowed. ⋯ The results showed that MSC 15-mg, 30-mg, 60-mg, and 100-mg dosage strengths are bioequivalent and dose proportional, and, therefore, therapeutically interchangeable. It was concluded that with routine assessment of the patient and adherence to the principles of analgesic dosing, MSC can be successfully used to control cancer-related pain. Furthermore, the availability of various MSC tablet strengths can be expected to facilitate the analgesic management of a patient population with widely differing opioid requirements.
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Randomized Controlled Trial Comparative Study Clinical Trial
Pharmacokinetics and clinical efficacy of oral morphine solution and controlled-release morphine tablets in cancer patients.
Twenty-three adult patients with chronic pain due to cancer completed a double-blind, randomized, two-phase crossover trial comparing plasma morphine concentrations and analgesic efficacy of oral morphine sulfate solution (MSS) and controlled-release morphine sulfate tablets (MS Contin [MSC], Purdue Frederick, Inc., Toronto, Ontario, Canada). MS Contin was given every 12 hours to all patients except those whose daily morphine dose could not be equally divided into two 12-hour doses with the tablet strengths available. MSS was given every 4 hours. ⋯ There were no significant differences between MSC and MSS in pain scores or side effects. Under the conditions of this study there was no clinically significant difference in bioavailability between MSC and oral MSS. When given on a 12-hourly basis in individually titrated doses, the MSC provided therapeutic plasma morphine concentrations throughout the dosing interval.
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This review focuses on available anesthetic techniques for cancer patients, the indications, and appropriate agents for these potent tools in a stepwise approach to cancer pain. Anesthetic procedures are desirable when they will not compromise bodily functions important to the patient, and when tumor-directed therapy and noninvasive or less-invasive, low-risk approaches (primarily pharmacologic tailoring of analgesic drugs) fail to control pain. Nondestructive techniques include the epidural/intrathecal use of opioids via an implanted catheter, and local anesthetic blocks of nerves and sympathetic ganglia. ⋯ Destructive anesthetic procedures comprise injections of neurolytic agents (most commonly phenol or alcohol), and insertion of freezing probes, into nerves and ganglia. The types of nerve blocks performed, their complications, and success rates, and limitations of commonly used neurolytic agents as well as their proper applications, are described. The importance of proper patient selection and knowledge of the pathophysiology of the pain being treated is stressed, as is the appropriate timing of anesthetic procedures in the course of the disease.
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Randomized Controlled Trial Comparative Study Clinical Trial
Analgesic response to single and multiple doses of controlled-release morphine tablets and morphine oral solution in cancer patients.
Immediate-release oral morphine, given every four hours in individually titrated doses, is effective in the control of severe cancer pain. To evaluate the analgesic efficacy of a controlled-release morphine sulfate preparation, MS Contin tablets (MSC, Purdue Frederick, Toronto, Ontario, Canada), after a single dose and under steady-state conditions, the authors compared MSC administered every 12 hours with morphine oral solution (MOS) administered every 4 hours in 17 adult cancer patients with chronic severe pain. In the single-dose evaluation, in which the patients were randomly assigned to receive MSC or MOS, there were no significant differences in analgesic efficacy or requirement for supplemental morphine between the two treatments. ⋯ There was no significant difference between MSC and MOS in overall pain scores or in pain scores analyzed by time of day and day of therapy. In conclusion, that an individualized twice-daily regimen of MSC is as effective as 4-hourly MOS for the control of chronic severe cancer pain. The twice-daily regimen has several advantages: it allows an uninterrupted night's sleep, it is substantially more convenient, and it can be expected to reduce both medication errors and noncompliance.
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Patients with pain syndromes resulting from recurrent or metastatic cancer should be evaluated carefully to determine the cause of their pain and the need for appropriate antitumor treatment. Currently, opioid analgesics are the mainstay of pain control, but side effects limit their use in some patients. When pharmacologic pain control is inadequate or associated with intolerable side effects, neurosurgery should be considered. ⋯ Although the place of neurostimulatory procedures in controlling cancer pain is not well established, they are attractive because of their nondestructive nature and potential usefulness in the treatment of bilateral pain syndromes. Specific antitumor surgical procedures should be considered in patients with certain spinal and plexopathy syndromes, because such intervention offers the prospect of both pain relief and tumor control. In this article, the neurosurgical procedures used in the management of cancer pain are reviewed.