LETTER
Morphine for Dyspnea in Patients with Cancer
Steven H. Krasnow, MD;
Robert G. Wadleigh, MD; and
Martin H. Cohen, MD
15 April 1994 | Volume 120 Issue 8 | Pages 692-693
TO THE EDITOR:
We agree with Bruera and colleagues [1] that morphine alleviates dyspnea in patients with advanced cancer but are concerned about some of their findings and the study design. They detected no respiratory depression by pulse oximetry; however, most patients in our prospective trial of continuous-infusion morphine for dyspnea [2] showed progressive increases in PCO2 and decreases in blood pH during serial arterial blood gas determinations. Bruera and colleagues' patients scored a mean of 30 on a 100-point dyspnea scale, suggesting only moderate dyspnea, whereas most of our patients were severely dyspneic. Milder dyspnea probably implies less pulmonary compromise and more resistance to the respiratory suppressive effects of morphine. A direct-dose comparison between the studies is difficult because Bruera and colleagues chose an arbitrary morphine dose (50% greater than the dose required for pain), whereas we titrated the doses to control dyspnea.
In Bruera and colleagues' study, pain was assessed only at baseline. The placebo-recipients probably experienced increased pain during the observation period, and the increased anxiety and discomfort may have affected their dyspnea scale.
The use of the subcutaneous route of morphine, which necessitated repeated injections, may also have increased discomfort and anxiety. Patients who cannot receive oral nutrition or medications, including narcotics, usually require intravenous access for hydration. Continuous intravenous morphine, as used in our study, is as safe and effective as intermittent injections and may be more convenient for both patients and staff [3, 4].
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Author and Article Information
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Veterans Affairs Medical Center; Washington, DC 20422
Albert Einstein Medical Center; Philadelphia, PA 19141
1. Bruera E, MacEachern T, Ripamonti C, Hanson J. Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med. 1993; 119:906-7.
2. Cohen MH, Anderson AJ, Krasnow SH, Spagnolo SV, Citron ML, Payne M, et al. Continuous intravenous infusion of morphine for severe dyspnea. South Med J. 1991; 230:229-34.
3. Briggs GG, Berman ML, Lange S, Riker J, Rettenmaier M, DiSaia P. Morphine: continuous intravenous infusion versus intramuscular injections for postoperative pain relief. Gynecol Oncol. 1985; 22:288-93.
4. Portenoy RK, Moulin DE, Rogers A, Inturrisi CE, Foley KM. I.v. infusion of opioids for cancer pain: clinical review and guidelines for use. Cancer Treat Rep. 1986; 70:575-81.
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