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Heroin vs Morphine for Cancer Pain?

Heroin vs Morphine for Cancer Pain? Abstract • Narcotic analgesics are the mainstay of pain control in patients with cancer. A controversy has been raging in the United States and Canada as to the legalization of heroin. We have reviewed the literature in order to determine the relative efficacy of heroin and morphine in cancer pain. We applied the following methodologic criteria: (1) Was the assignment of patients to the different opiates randomized? (2) Were all clinically relevant outcomes reported? (3) Were the patients recognizable? (4) Were both clinical and statistical significance considered? (5) Was the opiate regimen feasible in routine clinical practice? (6) Were all patients who entered the study accounted for at its conclusion? Two trials satisfied our first standard. The first, a double-blind cross-over trial, failed to meet standard 4 (the negative conclusion may represent a type 2 error) and only 21% of patients completed both treatment periods. The second study, which compared intramuscular heroin and morphine among patients with postoperative pain, failed to meet standards 3 (patients not described in sufficient detail and only tangentially related to chronic cancer pain) and 4 (type 2 error). Thus the relative efficacy of heroin and morphine in the relief of chronic cancer pain remains unknown. Randomized trials that meet all six methodologic standards must therefore be carried out for this controversy to be resolved. (Arch Intern Med 1986;146:353-356) References 1. Brandt EN Jr: Compassionate pain relief: Is heroin the answer? N Engl J Med 1984;311:530-532.Crossref 2. Mondzac AM: In defense of the reintroduction of heroin into American medical practice and H.R. 5290: The Compassionate Pain Relief Act (HR 5290). N Engl J Med 1984;311:532-535.Crossref 3. McGrath J: Newfoundland MP (PC-St John's East). Session 33, bill 213. First reading, Dec 3,1984; second reading, Dec 20,1984. 4. Cancer Pain: Report of the Advisory Committee on the Management of Severe Chronic Pain in Cancer Patients . Ottawa, Minister of Supply and Services, 1984. 5. Department of Clinical Epidemiology and Biostatistics: Clinical Epidemiology Rounds: How to read clinical journals: V. To distinguish useful from useless or even harmful therapy. Can Med Assoc J 1981;124:1156-1162. 6. Smith GE, Beecher HK: Subjective effects of heroin and morphine in normal subjects. J Pharmacol Exp Ther 1962;136:47-52. 7. Smith GE, Semke CW, Beecher HK: Objective evidence of mental effects of heroin, morphine and placebo in normal subjects. J Pharmacol Exp Ther 1962:136:53-58. 8. Reichle CW, Smith GM, Grauenstein JS, et al: Comparative analgesic potency of heroin and morphine in post-operative patients. J Pharmacol Exp Ther 1962;136:43-46. 9. Scott ME, Orr R: Effects of diamorphine, methadone, morphine and pentazocine in patients with suspected acute myocardial infarction. Lancet 1969;1:1065-1067.Crossref 10. Twycross RG: Choice of a strong analgesic in terminal cancer: Diamorphine or morphine? Pain 1977;3:93-104.Crossref 11. Inturrisi CE, Max MB, Foley KM, et al: The pharmacokinetics of heroin in patients with chronic pain. N Engl J Med 1984;310:1213-1217.Crossref 12. Twycross RG: The equipotent dose ratio of diamorphine and morphine administered by mouth. Br J Pharmacol 1972;46:554-555. 13. Inturrisi CE, Schultz M, Shin S, et al: Evidence from opiate binding studies that heroin acts through its metabolites. Life Sci 1983;33( (suppl 2) ): 773-776.Crossref 14. Sackett DL, Gent M: Controversy in counting and attributing events in clinical trials. N Engl J Med 1979;301:1410-1412.Crossref 15. Kaiko RF, Wallerstein SL, Rogers AG, et al: Analgesic and mood effects of heroin and morphine in cancer patients with postoperative pain. N Engl J Med 1981;304:1501-1505.Crossref 16. Kaiko RF, Wallerstein SL, Rogers AG, et al: Relative Analgesic Potency of Intramuscular Heroin and Morphine in Cancer Patients With Postoperative Pain and Chronic Pain due to Cancer . National Institute on Drug Abuse Research Monograph Series. Dept of Health, Education, and Welfare, 1981, vol 34, pp 213-219. 17. Beaver WT, Schein PS, Hext MA: A comparison of the analgesic effect of intramuscular heroin and morphine in patients with cancer pain, abstracted. Proc Am Soc Clin Oncol 1981;22:420. 18. Health and Public Policy Committee, American College of Physicians: Drug therapy for severe chronic pain in terminal illness. Ann Intern Med 1983;99:870-873.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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Publisher
American Medical Association
Copyright
Copyright © 1986 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1986.00360140183027
Publisher site
See Article on Publisher Site

Abstract

Abstract • Narcotic analgesics are the mainstay of pain control in patients with cancer. A controversy has been raging in the United States and Canada as to the legalization of heroin. We have reviewed the literature in order to determine the relative efficacy of heroin and morphine in cancer pain. We applied the following methodologic criteria: (1) Was the assignment of patients to the different opiates randomized? (2) Were all clinically relevant outcomes reported? (3) Were the patients recognizable? (4) Were both clinical and statistical significance considered? (5) Was the opiate regimen feasible in routine clinical practice? (6) Were all patients who entered the study accounted for at its conclusion? Two trials satisfied our first standard. The first, a double-blind cross-over trial, failed to meet standard 4 (the negative conclusion may represent a type 2 error) and only 21% of patients completed both treatment periods. The second study, which compared intramuscular heroin and morphine among patients with postoperative pain, failed to meet standards 3 (patients not described in sufficient detail and only tangentially related to chronic cancer pain) and 4 (type 2 error). Thus the relative efficacy of heroin and morphine in the relief of chronic cancer pain remains unknown. Randomized trials that meet all six methodologic standards must therefore be carried out for this controversy to be resolved. (Arch Intern Med 1986;146:353-356) References 1. Brandt EN Jr: Compassionate pain relief: Is heroin the answer? N Engl J Med 1984;311:530-532.Crossref 2. Mondzac AM: In defense of the reintroduction of heroin into American medical practice and H.R. 5290: The Compassionate Pain Relief Act (HR 5290). N Engl J Med 1984;311:532-535.Crossref 3. McGrath J: Newfoundland MP (PC-St John's East). Session 33, bill 213. First reading, Dec 3,1984; second reading, Dec 20,1984. 4. Cancer Pain: Report of the Advisory Committee on the Management of Severe Chronic Pain in Cancer Patients . Ottawa, Minister of Supply and Services, 1984. 5. Department of Clinical Epidemiology and Biostatistics: Clinical Epidemiology Rounds: How to read clinical journals: V. To distinguish useful from useless or even harmful therapy. Can Med Assoc J 1981;124:1156-1162. 6. Smith GE, Beecher HK: Subjective effects of heroin and morphine in normal subjects. J Pharmacol Exp Ther 1962;136:47-52. 7. Smith GE, Semke CW, Beecher HK: Objective evidence of mental effects of heroin, morphine and placebo in normal subjects. J Pharmacol Exp Ther 1962:136:53-58. 8. Reichle CW, Smith GM, Grauenstein JS, et al: Comparative analgesic potency of heroin and morphine in post-operative patients. J Pharmacol Exp Ther 1962;136:43-46. 9. Scott ME, Orr R: Effects of diamorphine, methadone, morphine and pentazocine in patients with suspected acute myocardial infarction. Lancet 1969;1:1065-1067.Crossref 10. Twycross RG: Choice of a strong analgesic in terminal cancer: Diamorphine or morphine? Pain 1977;3:93-104.Crossref 11. Inturrisi CE, Max MB, Foley KM, et al: The pharmacokinetics of heroin in patients with chronic pain. N Engl J Med 1984;310:1213-1217.Crossref 12. Twycross RG: The equipotent dose ratio of diamorphine and morphine administered by mouth. Br J Pharmacol 1972;46:554-555. 13. Inturrisi CE, Schultz M, Shin S, et al: Evidence from opiate binding studies that heroin acts through its metabolites. Life Sci 1983;33( (suppl 2) ): 773-776.Crossref 14. Sackett DL, Gent M: Controversy in counting and attributing events in clinical trials. N Engl J Med 1979;301:1410-1412.Crossref 15. Kaiko RF, Wallerstein SL, Rogers AG, et al: Analgesic and mood effects of heroin and morphine in cancer patients with postoperative pain. N Engl J Med 1981;304:1501-1505.Crossref 16. Kaiko RF, Wallerstein SL, Rogers AG, et al: Relative Analgesic Potency of Intramuscular Heroin and Morphine in Cancer Patients With Postoperative Pain and Chronic Pain due to Cancer . National Institute on Drug Abuse Research Monograph Series. Dept of Health, Education, and Welfare, 1981, vol 34, pp 213-219. 17. Beaver WT, Schein PS, Hext MA: A comparison of the analgesic effect of intramuscular heroin and morphine in patients with cancer pain, abstracted. Proc Am Soc Clin Oncol 1981;22:420. 18. Health and Public Policy Committee, American College of Physicians: Drug therapy for severe chronic pain in terminal illness. Ann Intern Med 1983;99:870-873.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Feb 1, 1986

References