OXFORD, UK-Epidural delivery of opioids effectively relieves pain
in patients with advanced cancer who are intolerant of or insensitive
to high-dose oral morphine, but improvement in quality of life
may be more difficult to achieve, Christopher Glynn, MB, said
at a workshop on pain management in palliative care, held at the
For patients with a terminal disease, quality of life might better
be termed quality of dying, he said, and for these patients, according
to his study results, pain relief alone may not lead to reported
improvements in quality of life.
"This finding came as quite a shock," Dr. Glynn said.
"We thought that having relieved the pain in these patients,
we would have an effect on their quality of life."
Dr. Glynn and his colleagues in the Pain Relief Unit, Churchill
Hospital, Oxford, audited the records of 52 cancer patients who
had received epidural morphine at home. "All but one died
at home with continuous epidural systems in place," he said.
The researchers found few complications with the system. Among
all cancer patients sent home with an epidural (probably 50 to
75 a year), "we've had only one infection," he said.
"Reinsertion has not been a problem. We've offered to put
in an implantable system when catheters fall out, and no patient
has required this. They like the simplicity of the system, and
its simplicity is its beauty."
In this series, the median starting morphine dose was 10 mg/day
and the finishing dose was 30 mg/day, with most patients requiring
no more than two or three dose revisions. "Some patients
required as much as 200 mg/day, but by and large, daily doses
were below 100 mg," Dr. Glynn said. He added that, at these
dosages, side effects have not been a problem.
Patients also received bupivicaine at a median dose of 42 mg/day.
"Patients have the ability with the syringe driver to boost
the bupivicaine dose for incident, or movement-related, pain,
to enable them to mobilize," he said. Clonidine was added
to the regimen for patients with neuropathic pain.