October 27, 2014
Introduction In hospice and palliative care, sub-lingual morphine is the choice treatment for cancer pain. Sub-lingual morphine is readily absorbed into the system, however transdermal opioids such as fentanyl have also been used as there seem to be more compliance with these opioids. One may wonder if it is actually increased compliance or is it on account of these transdermal opioids being able to remain in place for up to 72 hours which would prove more manageable for patients and their caregivers. Clinical Question The question of main focus in this article seeks to find any evidence that transdermal opioids are more effective in the management of pain in adult cancer patients than oral morphine.
This study also investigated the safety of transdermal opioids in cancer patients. Literature Search The literature search for this article was done through MEDLINE, EMBRACE, CINAHL and the Cochrane system reviews. The combined analysis included the results of the trials testing both buprenorphine and fentanyl which are transdermal.Separate analyses were also done on each transdermal medications. This review was done by two independent reviewers and included all appropriate randomized phase II and III trials. If there were any discrepancies a third reviewer was brought in to discuss the findings. I think this literature research was very wide but the information they found was lacking enough evidence to prove the efficacy of oral morphine over transdermal opioids. Much of the information gathered stated patients and caregivers preferences. They were not able to locate a study which mainly explored the efficacy of both. Analysis of Evidence The GRADE system was used to analyze the trial data was analyzed using a to determine the quality of the evidence and to determine it’s efficiency for clinical practice. The GRADE system consists of a three step analysis which uses the data obtained from the literature review. This data analyses the risks and benefits of the opioids in use. The strength of each opioid is then assessed to provide the final response. The risk benefit ratio of the opioids are assessed by both reviewers, as gathered from the literature review. From this assessment a recommendation was made as a guide to clinical practice. In clinical practice there have been several occasions where both oral morphine and transdermal opioids have been used in conjunction to relieve severe pain. The transdermal opioid is used as a long acting pain control and the oral morphine is the short acting. These two combinations work well for some patients while for others it is not needed. When deciding to administer these medications the type of pain and the severity of the pain need to be taken into consideration as all patients are different and experience pain differently. Systemic Review of Literature There were over four hundred that were initially retrieved for this review. After careful review only thirteen were found eligible for the final analysis. There were two papers reporting data of different meta- analyses which looked at the role transdermal opioids played in cancer pain. Another paper showed evidence of randomized control trials comparing transdermal fentanyl with sub-lingual morphine and how it affects cancer pain. There were other papers that compared morphine and methadone for pain control. These two papers were not used as the study was looking for transdermal opioids. Analysis of risk benefit ratio Several papers were noted to have a low level of evidence which were obtained from randomized meta- analyses were found to be the result of low