Opiate titration in patients with moderate/severe cancer pain

Background and Goal of Study: The management of moderate/severe cancer pain with opiates implies an essential stage of initial titration.(1) Literature provides no univocal guidelines for such stage; the use of immediate release morphine sulphate, administered every 4 hours with the double dose at night (2) is awkward because of management, pharmacokinetic and patients' compliance limitations. Aim of this study was to verify the effectiveness and applicability of a titration approach based on the administration of a combination of sustained release (SR) opiate and an immediate release (IR) opiate as rescue dose. Materials and Methods: In this observational and retrospective study (hospital ethic committee notified) were included 98 consecutive inpatients with moderate/severe cancer pain (NRS>4), followed by the hospital pain management service in 2008-2009. Opiate titration in these patients consisted of the administration of oxycodone SR (OS-SR ≥ 5mg) twice a day and morphine IR (MS-IR, 30% daily dose of OS-SR) administered as 'rescue dose', maximum four times daily. Measures: socio-demographic characteristics, initial OS-SR dose, initial MS-IR dose, initial and post-treatment pain scores, (NRSs, under static and NRSd, dynamic- conditions), number of rescue doses administered in the 24h, variations of OS-SR dose and side effects. Results and Discussion: Titration approach was satisfactory in most patients: statistically significant and rapid decrease of pain were shown after 24h. In particular, pain intensity decreased from a median of NRSs=5 and NRSd=7 to NRSs=2 and NRSd=4, with scarce presence of side effects, along with high patient and caregiver satisfaction. In the following days OS-SR dose was hence stabilized. Conclusion(s): The proposed titration approach can be considered as a valid alternative to that suggested in the literature; it guarantees: efficient and rapid pain control, improvement of the patients' quality of life and involvement in the therapy process, less opiates side effects, major patient and care giver compliance with the prescribed therapy, and rational use of opiates. References: 1. Mercadante S. Opioid titration in cancer pain: a critical review. Eur.J.Pain 2007;11:823-30 2.Twycross R.G. Control of pain. J R Coll Physicians Lond 1984;18,1:32-3