High-dose tramadol in comparison to low-dose morphine for cancer pain relief

Cancer pain treatment following the World Health Organization guidelines is effective and feasible. However, the evidence supporting the use of opioid s for mild to moderate pain on the second step of the analgesic ladder is w idely discussed. The present evaluation compares the efficacy and safety of high doses of oral tramadol (greater than or equal to 300 mg/d) with low d oses of oral morphine (less than or equal to 60 mg/d). Patients were includ ed in this nonblinded and nonrandomized study if the combination of a nonop ioid analgesic and up to 250 mg/d of oral tramadol was inadequate. 810 pati ents received oral tramadol for a total of 23,497 days, and 848 patients re ceived oral morphine for a total of 24,695 days. The average dose of tramad ol was 428 +/- 101 mg/d (range 300-600 mg/d); the average dose of morphine was 42 +/- 13 mg/d (range 10-60 mg/d). Additional nonopioid analgesics were given on more than 95% of days. Antiemetics, laxatives, neuroleptics, and steroids were prescribed significantly more frequently in the morphine grou p; the use of other adjuvants was similar in both groups. The mean pain intensity on a 0-100 numerical rating scale (NRS) was 27 +/- 21 (95% CI 26-29) in the tramadol and 26 +/- 20 (95% CI 24-27) in the morph ine group (NS). The analgesic efficacy was good in 74% and 78%, satisfactor y in 10% and 7%, and inadequate in 16% and 15% of patients receiving tramad ol and morphine, respectively (NS). Constipation, neuropsychological sympto ms, and pruritus were observed significantly more frequently with low-dose morphine; other symptoms had similar frequencies in both groups. These data suggest that tramadol can be used for the treatment of cancer pain, when n onopioids alone are not effective. High doses of tramadol are effective and safe. (C) U.S. Cancer Pain Relief Committee, 1999.