Strategies to manage the adverse effects of oral morphine: An evidence-based report

Successful pain management with opioids requires that adequate analgesia be achieved without excessive adverse effects. By these criteria, a substanti al minority of patients treated with oral morphine (10% to 30%) do not have a successful outcome because of (1) excessive adverse effects, (2) inadequ ate analgesia, or (3) a combination of both excessive adverse effects along with inadequate analgesia. The management of excessive adverse effects rem ains a major clinical challenge. Multiple approaches have been described to address this problem. The clinical challenge of selecting the best option is enhanced by the lack of definitive, evidence-based comparative data. Ind eed, this aspect of opioid therapeutics has become a focus of substantial c ontroversy. This study presents evidence-based recommendations for clinical -practice formulated by an Expert Working Group of the European Association of Palliative Care (EAPC) Research Network. These recommendations highligh t the need for careful evaluation to distinguish between morphine adverse e ffects from comorbidity, dehydration, or drug interactions, and initial con sideration of dose reduction (possibly by the addition of a co analgesic), If side effects persist, the clinician should consider options of symptomat ic management of the adverse effect, opioid rotation, or switching route of systemic administration, The approaches are described and guidelines are p rovided to aid in selecting between therapeutic options. J Clin Oncol 19:25 42-2554. (C) 2001 by American Society of Clinical Oncology.