Despite a more than tenfold increase in opioid consumption in the past decades, many cancer patients still
suffer pain. The current understanding of this situation is poorly understood. It is still possible that in some
countries pain is still undertreated, but it is also possible that we do not appreciate opioid induced toxicity
and other phenomena an/or our opioid prescribing needs to be refreshed. At the moment the only evidence
based tool to deal with opioid toxicity is switching to another opioid. Other methods are also described, but
are far less well evidenced. However, the effects after switching are short-lived and sometimes a number
of switches are needed. In this article we discuss the rationale behind and the possibility of combining different
opioids with each other. Opioids are all different and opioid receptors are heterogenous. There are
data to suggest that widening the activity spectrum of opioids may be the way forward in order to decrease
adverse effects and maintain analgesia. At the moment there are only some data on the interaction of
fentanyl and morphine, morphine and oxycodone, and buprenorphine and morphine. These data suggest
that we should investigate these problems vigorously and, instead of switching from one opioid to another,
we may, in future, adopt the concept of a semi-switch, where the dose of the first opioid is decreased and
a second opioid is added.
Adv. Pall. Med. 2010; 9, 2: 31–38Despite a more than tenfold increase in opioid consumption in the past decades, many cancer patients still
suffer pain. The current understanding of this situation is poorly understood. It is still possible that in some
countries pain is still undertreated, but it is also possible that we do not appreciate opioid induced toxicity
and other phenomena an/or our opioid prescribing needs to be refreshed. At the moment the only evidence
based tool to deal with opioid toxicity is switching to another opioid. Other methods are also described, but
are far less well evidenced. However, the effects after switching are short-lived and sometimes a number
of switches are needed. In this article we discuss the rationale behind and the possibility of combining different
opioids with each other. Opioids are all different and opioid receptors are heterogenous. There are
data to suggest that widening the activity spectrum of opioids may be the way forward in order to decrease
adverse effects and maintain analgesia. At the moment there are only some data on the interaction of
fentanyl and morphine, morphine and oxycodone, and buprenorphine and morphine. These data suggest
that we should investigate these problems vigorously and, instead of switching from one opioid to another,
we may, in future, adopt the concept of a semi-switch, where the dose of the first opioid is decreased and
a second opioid is added.
Adv. Pall. Med. 2010; 9, 2: 31–3
