REPLY
Morphine for Dyspnea in Patients with Cancer
Eduardo Bruera, MD, and
Robin L. Fainsinger, MBChB
15 April 1994 | Volume 120 Issue 8 | Pages 692-693
IN RESPONSE:
We read with interest the letter by Krasnow and colleagues. Differences in results of pulse oximetry [1] and end-tidal CO2 [2] after an increase of 50% in the analgesic dose of morphine may be due to differences in patient population or, more likely, to the mode of administration of morphine (intermittent injection compared with continuous infusion). Although some patients present with continuous dyspnea, most experience wide diurnal variations in the intensity of their dyspnea. The use of continuous opiates presents the same problems as that observed in the management of incident pain [3]: excessive dose when the symptom intensity is low and insufficient dose when it is high.
Krasnow and colleagues expressed concern about the possibility of increasing pain in the placebo group. In previous studies, we found that patients with good pain control show no significant increase in pain for approximately 60 minutes after the scheduled opioid dose [2] or after a dose of placebo [4]. For this reason, our assessments took place at 30, 45, and 60 minutes only.
Finally, they state that patients who cannot receive medications and hydration orally usually require intravenous access for hydration. However, the overwhelming majority of our patients received parenteral medications and hydration only subcutaneously [5]. Using this route, patients have much greater mobility (hydratin can be completed as a 2-hour bolus or overnight), their limbs are free, subcutaneous needles remain in place approximately 1 week, the overall cost is lower, and home management becomes easier. Nonetheless, more studies are needed to define the best mode of administration of opioids for dyspnea in patients with cancer.
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Author and Article Information
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University of Alberta; Edmonton, Alberta T5K OL4; Canada
1. Bruera E, MacEachern T, Ripamonti C, Hanson J. Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med. 1993; 119:906-7.
2. Bruera E, Macmillan K, Pither J, MacDonald RN. The effects of morphine on the dyspnea of terminal cancer patients. Journal of Pain and Symptom Management. 1990; 5:341-4.
3. Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain. 1990; 41:273-81.
4. Bruera E, Ripamonti C, Brennels C, Macmillan K, Hanson J. A randomized double-blind crossover trial of intravenous lidocaine in the treatment of neuropathic cancer pain. Journal of Pain and Symptom Management. 1992; 7:138-40.
5. Fainsinger RL, MacEachern T, Miller MJ, Bruera E, Spachynski K, Kuehn N, et al. The use of hypodermoclysis (HDC) for rehydration in terminally ill cancer patients. Journal of Pain and Symptom Management. 1994; (In press).
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