Sodium picosulfate in opioid-induced constipation: results of an open-label, prospective, dose-ranging study.

Identification of a safe and effective dose of the laxative sodium picosulfate was investigated in a single-centre, open-label study of 23 patients (age 40-81 years) receiving > or =60 mg/day morphine sulphate and experiencing constipation. A starting dose of 5, 10 or 15 mg sodium picosulfate (1 mg/mL solution) was administered, based on the patient's clinical status at entry and recent requirements for laxatives. Dose titration was permitted (+/-2.5 or 5 mg increments), to a maximum daily dose of 60 mg. Bowel movements, concomitant medication and need for suppositories or enemas were recorded in daily diaries. Sixteen patients withdrew before the end of the planned 14-day treatment period because of deterioration of the underlying condition. Sodium picosulfate was well-tolerated. Serious adverse events were all related to the underlying condition. A satisfactory response (normal stool consistency, not requiring enemas, suppositories or manual evacuation, no significant adverse event) was achieved in 15/20 evaluable patients. The median daily dose to achieve this was 15 mg (range: 5-30 mg) and the median time to first bowel movement after dosing was 11.75 hours (range: 6-22.5 hours). There was no clear relationship between the opioid dose and the optimum dose of sodium picosulfate, confirming that individual dose titration is necessary.

The challenge of palliative care.

Palliative care is patient-centered, rather than disease-focused; accepts the inevitability of death while simultaneously is life-affirming; addresses psychological, social, and spiritual concerns as well as physical ones; and is best delivered by a multiprofessional team working in partnership with patients and their families. Palliative care stresses the importance of "appropriate treatment" and the need for doctors not to prescribe a lingering death. Even though there is no chance of cure, there is much scope for psychosocial and spiritual healing, and often some scope for physical rehabilitation. Palliative care is emotionally demanding for professional carers, and strategies for personal support are necessary. The World Health Organization has played a major part in the ongoing campaign to improve cancer pain management and to make medicinal morphine more widely available. A systematic approach to pain and symptom management is essential, and there is need for specific training for all health professionals. In most countries, for palliative care to take root, there is need for a charismatic "champion". However, for palliative care to flourish, there is need for a governmental commitment to its development. Charisma continues to be necessary to prevent palliative care being strangled by an over-rigid bureaucracy, but incorporation into existing health delivery systems is necessary to prevent it being stillborn through lack of resources.

Palliative care: an international necessity.

Palliative care is the care of patients whose disease is incurable and whose life expectancy is limited to weeks or months. This commentary describes the development of modern palliative care, some of the elements and underlying philosophical constructs of such care, and calls for expansion and improvement in end of life care throughout the world.

Pain in far-advanced cancer.

Hundred patients with far-advanced cancer and pain were interviewed within a few days of admission to a special care unit. Eighty had more than one pain; 34 had four or more. A total of 303 anatomically distinct pains were recorded. Ninety-one patients had pain caused by the cancer itself. Twelve had treatment-related pain; and 19 had pain related to chronic disease or debility ('associated pain'). Thirty-nine patients had one or more pains unrelated to cancer or treatment; the most common of these was myofascial pain. In 41 patients only was all the pain caused directly by the cancer. Bone involvement and nerve compression were the most common forms of cancer-related pain; soft tissue and visceral pains also occurred frequently. Fifty-seven patients had pain for more than 4 months.

Choice of strong analgesic in terminal cancer: diamorphine or morphine?

A controlled trial of diamorphine (diacetylmorphine, heroin) and morphine is reported in which the two drugs were administered regularly by mouth in individually determined effective analgesic doses. Elixirs contained cocaine hydrochloride 10 mg/dose; other drugs were prescribed when indicated clinically. 699 patients entered the trial and, of these, 146 crossed from diamorphine to morphine, or vice versa, after about two weeks using an oral potency ratio of 1.5/1 determined in a pilot trial. Additional medication and survival were closely similar in both treatment groups. In the female crossover patients, no difference was noted in relation either to pain or the other symptoms evaluated. On the other hand, male crossover patients experienced more pain, and were more depressed, while receiving diamorphine. In these, the potency ratio of diamorphine to morphine appeared to be less than 1.5/1. If this is allowed for, then the difference in mood is probably not significant. Compared with male patients, fewer females required a dose of 10 mg or more, but more were prescribed an anxiolytic. The ability to do without a 2 a.m. dose appeared to be related more to the size of the dose than to gender or treatment. It is concluded that, provided allowance is made for the difference in potency, morphine is a satisfactory substitute for orally administered diamorphine. However, when injections are necessary, the greater solubility of its hydrochloride gives diamorphine an important practical advantage over morphine, especially when large doses are required.