Neuropsychological and pharmacokinetic assessment of hospice inpatients receiving morphine

Pharmacokinetic and neuroimmune pharmacogenetic impacts on slow-release morphine cancer pain control and adverse effects

The aim was to determine if opioid neuroimmunopharmacology pathway gene polymorphisms alter serum morphine, morphine-3-glucuronide and morphine-6-glucuronide concentration-response relationships in 506 cancer patients receiving controlled-release oral morphine. Morphine-3-glucuronide concentrations (standardised to 11 h post-dose) were higher in patients without pain control (median (interquartile range) 1.2 (0.7-2.3) versus 1.0 (0.5-1.9) μM, P = 0.006), whereas morphine concentrations were higher in patients with cognitive dysfunction (40 (20-81) versus 29 (14-60) nM, P = 0.02). TLR2 rs3804100 variant carriers had reduced odds (adjusted odds ratio (95% confidence interval) 0.42 (0.22-0.82), P = 0.01) of opioid adverse events. IL2 rs2069762 G/G (0.20 (0.06-0.52)), BDNF rs6265 A/A (0.15 (0.02-0.63)) and IL6R rs8192284 carrier (0.55 (0.34-0.90)) genotypes had decreased, and IL6 rs10499563 C/C increased (3.3 (1.2-9.3)), odds of sickness response (P ≤ 0.02). The study has limitations in heterogeneity in doses, sampling times and diagnoses but still suggests that pharmacokinetics and immune genetics co-contribute to morphine pain control and adverse effects in cancer patients.

Revision of Pharmacological Treatment Recommendations for Cancer Pain: Clinical Guidelines from the Japanese Society of Palliative Medicine

Background: Pain is one of the most common symptoms in cancer patients. The Japanese Society for Palliative Medicine (JSPM) first published its clinical guidelines for the management of cancer pain in 2010. Since then, more research on cancer pain management has been reported, and new drugs have become available in Japan. Thus, the JSPM has now revised the clinical guidelines using a validated methodology. Methods: This guideline was developed through a systematic review, discussion, and the Delphi method, following a formal guideline development process. Results: Thirty-five recommendations were created: 19 for the pharmacological management of cancer pain, 6 for the management of opioid-induced adverse effects, and 10 for pharmacological treatment procedures. Due to the lack of evidence that directly addressed our clinical questions, most of the recommendations had to be based on consensus among committee members and other guidelines. Discussion: It is critical to continue to build high-quality evidence in cancer pain management, and revise these guidelines accordingly.

Opioid Use in the Nondialysis Chronic Kidney Disease Population

Although pain is a common and burdensome condition in patients with chronic kidney disease (CKD), little is known about the use and safety of opioids in this patient population. Recommendations regarding opioid use in patients with CKD are based on pharmacokinetic data, extrapolation from non-CKD studies, and from clinical experience. Given the potential increased risk for opioid-related adverse events in patients with reduced kidney function, health care providers may be hesitant to prescribe opioids, resulting in inadequate pain control. This review summarizes current studies of opioid use in patients with CKD, highlights special considerations, and proposes an opioid prescribing strategy for this unique patient population. Specifically, oral hydromorphone, transdermal fentanyl, and buprenorphine should be considered as the first-line opioids for patients with CKD if opioid management is indicated. A stepwise approach such as the Screen-Quantify-Use opioids-Adjust-Reassess-Engage prescribing strategy proposed here is critical to ensure optimal pain control while minimizing the side effects and adverse events of opioids. The effects of opioids on clinically relevant outcomes in the CKD population remains to be explored in future studies.

Opioid Management in Older Adults with Chronic Kidney Disease: A Review

Chronic pain, a common comorbidity of chronic kidney disease, is consistently under-recognized and difficult to treat in older adults with nondialysis chronic kidney disease. Given the decreased kidney function associated with aging and chronic kidney disease, these patients are at increased risk for drug accumulation and adverse events. Emerging research has demonstrated the efficacy of opioids in chronic kidney disease patients, but research specifically focusing on older, nondialysis chronic kidney disease patients is scarce. The primary objective of this review is to determine which oral and transdermal opioids are the safest for older, nondialysis chronic kidney disease patients. We discuss the limited existing evidence on opioid prescription in older, nondialysis chronic kidney disease patients and provide recommendations for the management of oral and transdermal opioids in this patient population. Specifically, transdermal buprenorphine, transdermal fentanyl, and oral hydromorphone are the most tolerable opioids in these patients; hydrocodone, oxycodone, and methadone are useful but require careful monitoring; and tramadol, codeine, morphine, and meperidine should be avoided due to risk of accumulation and adverse events. Because older adults with nondialysis chronic kidney disease are at increased risk for adverse events, vigilant monitoring of opioid prescription is critical. Lastly, collaboration among an interprofessional clinical team can ensure safe prescription of opioids in older adults with nondialysis chronic kidney disease.

Serum and urine concentrations of morphine and morphine metabolites in patients with advanced cancer receiving continuous intravenous morphine: an observational study

BACKGROUND

The feasibility and clinical implication of drug monitoring of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) need further investigation. This study aimed to determine what predicts serum concentrations of morphine in cancer patients receiving continuously intravenous morphine, the relationships between serum concentration of morphine/its metabolites and urinary concentrations, and the relation between morphine concentrations and with clinical outcomes.

METHODS

We collected serum and urine samples from 24 patients with advanced cancer undergoing continuously intravenous morphine therapy. Serum samples were obtained at day one. Spot urine samples were collected once daily on three consecutive days. Pain and adverse drug events were assessed using the Korean version of MD Anderson Symptom Inventory.

RESULTS

A total of 96 samples (72 urine and 24 serum samples) were collected. Median dose of morphine was 82.0 mg/24 h. In a multivariate analysis, total daily morphine dose was the most significant predictors of both serum and urine concentration of morphine. Morphine, M6G, and M3G in serum and urine were statistical significantly correlated (correlation coefficient = 0.81, 0.44, 0.56; p values < 0.01, 0.03, 0.01, respectively).

CONCLUSION

Spot urine concentrations of morphine and its metabolites were highly correlated to those of serum. Total dose of daily morphine was related to both serum and urine concentration of morphine and its metabolites.

WITHDRAWN: Opioid switching to improve pain relief and drug tolerability

The original authors were unable to complete an update of this review. A new protocol is in preparation with a new author team, who have revised the title. Publication of the new protocol is expected in 2014 with the title 'Opioid switching for cancer pain in adults'.

At November 2015, the new author team are no longer available to complete the replacement protocol. Please contact the PaPaS CRG for more information.

The editorial group responsible for this previously published document have withdrawn it from publication.

Undetected cognitive impairment and decision-making capacity in patients receiving hospice care

OBJECTIVE

: Cognitive dysfunction is common in patients with advanced, life-threatening illness and can be attributed to a variety of factors (e.g., advanced age, opiate medication). Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end-of-life approaches and patients face multiple choices regarding treatment, family, and estate planning. This study examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically apparent cognitive impairment (e.g., delirium, unresponsiveness).

DESIGN

: A total of 110 participants receiving hospice services completed a 1-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews.

RESULTS

: In general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairment. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43-2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity.

CONCLUSION

: Despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. Assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision making may lead to effective interventions to improve decision making and honor the wishes of patients and families.

A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project

BACKGROUND

Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative's opioid guidelines project.

OBJECTIVE

The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines.

SEARCH STRATEGY

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals.

SELECTION CRITERIA

Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded.

DATA COLLECTION AND ANALYSIS

This is a narrative systematic review and no meta-analysis was performed. The Grading of RECOMMENDATIONS Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines.

MAIN RESULTS

Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil.

CONCLUSIONS

All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids.

RECOMMENDATIONS

RECOMMENDATIONS regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.

Unrecognised cognitive impairment in hospice patients: a pilot study

The presence of cognitive impairment in patients who are receiving hospice care can affect numerous practical, ethical and legal aspects of their healthcare. A number of factors can contribute to cognitive impairment in these patients. Prevalence rates of cognitive impairment vary widely, but it remains under-recognised and under-treated. The aims of this pilot study were to evaluate the presence and nature of cognitive deficits in patients receiving inpatient hospice care who did not have a known current or past diagnosis of a cognitive disorder or any obvious cognitive impairments. A convenience sample of 30 patients receiving inpatient hospice care underwent bedside cognitive testing. A comprehensive battery of tests was used, including the Mini-Mental State Examination (MMSE) and standardised neuropsychological tests of pre-morbid intellectual functioning, immediate and delayed recall, digit span forward and backward, verbal reasoning and letter and category fluency. On average, subjects were impaired on the MMSE and on tests of learning, verbal reasoning and letter and category fluency. Furthermore, 12 of the 30 subjects met DSM-IV cognitive impairment criteria for dementia based on impaired performance in memory and at least one other cognitive domain on testing. The results of this pilot study suggest that a sizable proportion of patients receiving inpatient hospice care have undetected but clinically significant cognitive impairments. Assessing for and helping patients, families and caregivers deal with cognitive impairment might benefit patients' quality of life, relationships and overall care at the end of life. Future research in this population is needed to evaluate the causes and time course of cognitive impairment over time, as well as any relationship between cognitive impairment and decision-making capacity.

The effect of opioids on driving and psychomotor performance in patients with chronic pain

OBJECTIVES

This study compared the psychomotor performance and driving ability of patients with chronic pain managed with stable regimens of opioid analgesics with that of normal healthy volunteers. The hypothesis was that patients with chronic pain on stable opioid analgesic regimens operate their automobiles safely with proficiency equal to normal volunteer controls.

METHODS

Patients were evaluated for errors while driving their own automobile through a predetermined route in the community, including variable residential and highway conditions, and for speed and accuracy on repeated trials through a 5-station obstacle course that evaluated forward and reverse driving, turning, and parallel parking. Patients also completed the Test of Variables of Attention and the Digit Symbol Substitution Test.

RESULTS

No significant differences were observed among groups in driving performance in the community and on the obstacle course or on the Test of Variables of Attention. Results on dependent measures within the opioid group generally were not correlated with morphine equivalent daily opioid doses, which averaged 118 mg (median 40 mg).

CONCLUSIONS

Many patients with chronic pain, even if treated with potent analgesics such as morphine and hydromorphone, show comparable driving ability as normals.

The cognitive effects of opioids

Successful opioid therapy often depends on achieving a balance between analgesic effectiveness and side effects. The risk of opioid-induced cognitive impairment often hinders clinicians and patients from initiating or optimizing opioid therapy. Despite subjective experiences of mental dullness and sedation, objective tests of cognitive functioning do not always demonstrate marked changes following opioid administration. To guide clinical practice, as well as patient and family teaching, pain management nurses should be familiar with literature regarding this topic. The purpose of this article is to review the empiric literature on opioids and cognitive functioning, including the relationships among pain, cognition, delirium, and opioids. In general, research reflects minimal to no significant impairments in cognitive functioning. If impairment does occur, it is most often associated with parenteral opioids administered to opioid-naive individuals. Some evidence suggests that opioids may actually enhance cognitive function and decrease delirium in some patient populations. This article describes this research and explores the clinical implications of the research in this area.

Opioid switching to improve pain relief and drug tolerability

BACKGROUND

Patients with cancer, and increasingly chronic non-cancer pain frequently require strong opioids for pain relief. Morphine is the first-line strong opioid of choice for these patients. While most achieve adequate analgesia with morphine, a significant minority either suffer intolerable side-effects, inadequate pain relief, or both. For these patients switching to an alternative opioid is becoming established clinical practice. However, the evidence for the effectiveness of opioid switching does not appear to be established.

OBJECTIVES

The aim of this review was to investigate the usefulness of opioid switching for patients with pain.

SEARCH STRATEGY

Randomised trials that assessed opioid rotation, switching, or substitution in adults or children with acute or chronic pain were sought through electronic databases and by handsearching relevant journals. Date of the most recent search: January 2003.

SELECTION CRITERIA

The search strategy retrieved no randomised controlled trials, and therefore no studies were available to enable a quantitative synthesis that would assess the effectiveness of the strategy of opioid switching.

DATA COLLECTION AND ANALYSIS

Given the lack of RCTs, the review examined all case reports, uncontrolled, and retrospective studies in an attempt to determine the current level of evidence.

MAIN RESULTS

Fifty-two reports were identified, comprising 23 case reports, 15 retrospective studies/audits and 14 prospective uncontrolled studies. The majority of the reports used morphine as first-line opioid and the most frequently used second-line opioid was methadone. All reports, apart from one, concluded that opioid switching is a useful clinical manoeuvre for improving pain control and/or reducing opioid-related side-effects.

REVIEWERS' CONCLUSIONS

For patients with inadequate pain relief and intolerable opioid-related toxicity/adverse effects, a switch to an alternative opioid may be the only option for symptomatic relief. However, the evidence to support the practice of opioid switching is largely anecdotal or based on observational and uncontrolled studies. Randomised trials, including 'N of 1' studies, where a patient acts as their own control, are needed: firstly, to establish the true effectiveness of this clinical practice; secondly, to determine which opioid should be used first-line or second-line; and thirdly, to standardise conversion ratios when switching from one opioid to another.

Routine drug monitoring of serum concentrations of morphine, morphine-3-glucuronide and morphine-6-glucuronide do not predict clinical observations in cancer patients

The clinical importance of routine drug monitoring of serum concentrations of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) during chronic morphine therapy is not established. We measured morphine, M6G and M3G serum concentrations in cancer pain patients receiving oral (n = 263, median dose 80 mg/24 hours) or subcutaneous (sc) (n = 35, median dose 110 mg/24 hours) morphine. Regression analyses were performed to investigate if serum concentrations of morphine, M3G and M6G predicted pain intensity (Brief Pain Inventory), health-related quality-of-life variables (EORTC QLQ-C30) and cognitive function (Mini-Mental Score). Serum concentrations were also compared in patients categorized as morphine 'treatment successes' and 'treatment failures'. We observed that serum concentrations of morphine, M6G or M3G did not predict pain intensity, cognitive function, nausea or tiredness. 'Treatment failures' caused by nausea, tiredness, cognitive failure or constipation did not have statistically significant different morphine, M6G and M3G serum concentrations than patients classified as 'treatment successes'. In conclusion, this study did not observe any concentration-effect relationships of morphine, M3G or M6G with pain intensity, nausea, constipation, tiredness or cognitive failure in blood samples obtained during routine clinical drug monitoring in cancer patients. This result suggests that therapeutic drug monitoring as a routine tool during chronic morphine treatment has limited value for clinical decision making.

Long term effects of oral sustained release morphine on neuropsychological performance in patients with chronic non-cancer pain

Morphine is increasingly used in patients with chronic non-cancer pain, but a major concern associated with chronic use relates to possible cognitive side-effects. The aim of this long-term prospective study was to evaluate the cognitive impact of oral sustained release morphine in patients with non-cancer pain. A battery of neuropsychological tests to explore attention, psychomotor speed and memory was administered. The effects of morphine on pain, quality of life, mood, subjective memory impairment and side-effects were also investigated. Evaluations were performed at baseline in patients free from opioids and then after 3, 6 and 12 months. Twenty-eight patients were included: 18 received oral sustained morphine (range 40-140 mg/day), ten patients stopped morphine prematurely because of side-effects or insufficient pain relief and were followed as a control group. There was no impairment of any neuropsychological variable over time in the morphine treated patients in comparison with the control group. Two measures of information processing speed - the Stroop interference score and the digit symbol test were improved at 6 and 12 months and there were significant correlations with the pain relief and improvement of mood. Self-reported memory impairment improved notably in responders to morphine. Morphine induced persisting effects on pain, and to a lesser extent on quality of life and mood. The visual analog scale score for side-effects increased at 12 months and essentially consisted of gastrointestinal disorders. This study demonstrates that 12 months treatment with oral morphine does not disrupt cognitive functioning in patients with chronic non-cancer pain and instead results in moderate improvement of some aspects of cognitive functioning, as a consequence of the pain relief and concomitant improvement of well-being and mood.

Are opioid-dependent/tolerant patients impaired in driving-related skills? A structured evidence-based review

Previous reviewers have concluded that opioids cause dose-related impairment in opioid-naive volunteers on psychomotor skills related to driving. Data relating to opioid-dependent/tolerant patients have not yet been reviewed. To determine what evidence, if any, exists for or against opioid-related driving skill impairment in opioid-dependent/tolerant patients, we performed a structured evidence-based review of all available studies addressing the issue of whether opioid-dependent/tolerant patients are impaired in driving-related skills. A computer and manual literature search for studies relating to opioid-dependent/tolerant patients and driving-related skills produced 48 relevant reports. These references were reviewed in detail, sorted, and placed into tabular form according to the following subject areas: (1) psychomotor abilities studies; (2) cognitive function studies; (3) effect of opioid dosing on psychomotor abilities studies; (4) motor vehicle driving violations and motor vehicle accident studies; and (5) driving impairment as measured in driving simulators and off/on road driving studies. For each topic area, each study was categorized for the type of study it represented according to guidelines developed by the Agency for Health Care Policy Research (AHCPR). The strength and consistency of the evidence in each subject area also then was categorized according to AHCPR guidelines and a quantitative method. This evidence-based review indicated the following: (1) There was moderate, generally consistent evidence for no impairment of psychomotor abilities of opioid-maintained patients; (2) There was inconclusive evidence on multiple studies for no impairment on cognitive function of opioid- maintained patients; (3) There was strong consistent evidence on multiple studies for no impairment of psychomotor abilities immediately after being given doses of opioids; (4) There was strong, consistent evidence for no greater incidence in motor vehicle violations/motor vehicle accidents versus comparable controls of opioid-maintained patients; and (5) There was consistent evidence for no impairment as measured in driving simulators off/on road driving of opioid-maintained patients. Based on the above results, it can be concluded that the majority of the reviewed studies appeared to indicate that opioids do not impair driving-related skills in opioid-dependent/tolerant patients. This evidence was consistent in four out of five research areas investigated, but inconclusive in one. As such, additional controlled studies are required. Until more data are available, however, physicians may wish to consider the approach to this problem recommended in this review.

The psychiatric management of end-of-life pain and associated psychiatric comorbidity

Involvement by psychiatrists in the care of patients who are terminally ill has been limited historically; however, psychiatrists increasingly are participating in the care of these people who are facing the most challenging times of their lives. Pain management is considered to be an area of subspecialization for psychiatrists beyond their traditional role of being psychopharmacologists and psychotherapists. Biologically focused psychiatrists are able to address neuropsychiatric disorders, including pain and depression in the medically ill, and actively improve the quality of life for dying patients and their family members. This article provides a review of the recent literature that has addressed the involvement of psychiatrists in end-of-life care. Beginning with an example of the scientific aspects of cancer-related treatment from a patient's perspective, and into the major treatment considerations, this article addresses pain, its recognition, and management challenges when the end of life approaches. The prompt recognition of frequently overlooked and underestimated concomitant depressions, delirium, dementia, and other mental disorders is important for mental health specialists. The importance of psychiatric care for patients who are terminally ill and the role of psychiatrists in the phase of care also are discussed.

Assessing decision-making capacity in the setting of palliative care research

This paper begins with a discussion of why concerns about decision-making capacity are warranted in palliative medicine research. Next, procedures for assessing decision-making capacity are discussed. It concludes with recommendations to guide the judicious use of these procedures in the design of palliative care research.

Effects of intermediate- and long-term use of opioids on cognition in patients with chronic pain

The authors review research on the intermediate- and long-term effects of taking opioid medication on cognitive functioning in patients with chronic cancer and noncancer pain. Opioids seem to be more likely to worsen cognitive performance during the first few days of use and during the first few hours after a given dose, particularly on timed performance in psychomotor tasks. Results have been inconsistent regarding what decrements in cognitive performance are observed when patients with chronic pain who have been using opioids for more than three days are compared with healthy volunteers. Relatively few differences have been found when cognitive performance in these patients is compared with their performance before taking opioids, or with the performance of a comparable pain population not taking opioids. Major unresolved questions remain regarding such important issues as effects of different types of opioids, dose effects, interactions with other medications, and subject variables.

The panorama of opioid-related cognitive dysfunction in patients with cancer: a critical literature appraisal

BACKGROUND

Opioids have an essential role in the management of pain in cancer patients, particularly those with advanced disease. Cognitive dysfunction is a recognized complication of opioid use. However, misconceptions and controversy surround the nature and prevalence of its occurrence. A projected increase in the aging cancer population highlights the need for a better understanding of this phenomenon.

METHODS

A critical appraisal of the literature evidence in relation to the pattern, pathophysiology, assessment, impact, and management of cognitive dysfunction due to opioid use in cancer pain management is given.

RESULTS

Studies in cancer patients with less advanced disease reveal subtle evidence of cognitive impairment, largely related to initial dosing or dose increases. In advanced cancer, opioid-induced cognitive dysfunction usually occurs in the form of delirium, a multifactorial syndrome. The presence of both cognitive impairment and delirium frequently is misdiagnosed or missed. Potential risk factors include neuropathic and incidental pain, opioid tolerance, somatization of psychologic distress, and a history of drug or alcohol abuse. Elevation of opioid metabolites with renal impairment may contribute to cognitive dysfunction. Recognition of opioid-related cognitive dysfunction is improved by objective screening. Successful management requires either dose reduction or a change of opioid, in addition to addressing other reversible precipitants such as dehydration or volume depletion.

CONCLUSIONS

Opioid-related cognitive dysfunction tends to be subtle in the earlier stages of cancer, whereas delirium, a more florid form with behavioral disturbance is likely to be present in the advanced cancer population. In patients with advanced disease, an optimal management approach requires careful clinical assessment, identification of risk factors, objective monitoring of cognition, maintenance of adequate hydration, and either dose reduction or switching to a different opioid.

Increased plasma morphine metabolites in terminally ill cancer patients with delirium: an intra-individual comparison

Delirium often causes severe distress for terminally ill cancer patients, and treatment of underlying pathologies is important to achieve symptom alleviation. Although accumulation of morphine metabolites may play an important role in development of delirium, empirical findings are conflicting due to a large inter-individual variation in morphine-related concentrations. To explore intra-individual changes of morphine metabolite concentrations before and after occurrence of terminal delirium, a prospective observational study was performed on terminally ill cancer patients. Among 131 consecutive hospice inpatients, 16 samples from 8 patients who received two blood samplings before and after development of delirium were analyzed. Delirium developed a median of 5 days before death, and clinical causes were attributed to multi-organ failure. Plasma concentrations of morphine-6-glucuronide (M-6-G) and morphine-3-glucuronide (M-3-G) significantly increased after development of delirium within the same patient. Mean normalized concentrations of M-6-G and M-3-G elevated from 1.24 +/- 1.06 to 2.94 +/- 3.52 ng/mL/mg (P = 0.016), and from 7.46 +/- 4.75 to 15.4 +/- 13.2 ng/mL/mg (P = 0.016), respectively. Normalized morphine concentration increased with a marginal statistical significance from 0.54 +/- 0.27 to 0.83 +/- 0.22 ng/mL/mg (P = 0.055). In conclusion, plasma concentrations of M-6-G and M-3-G were significantly higher after development of terminal delirium than before. It is suggested that accumulations of morphine metabolites can contribute to development of delirium in cancer patients whose death is impending.

Symptom control in hospice--state of the art

There are a myriad of physical symptoms which can complicate the care of patients with advanced disease. Without knowledge of and attention to these distressing symptoms, the rest of the work of the interdisciplinary hospice team is greatly hampered. In this article, we review the management of ten prevalent symptoms in hospice care and to identify areas of clinical investigation underway and point of future areas ripe for investigation.