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Topical Morphine in the Treatment of Painful Ulcers
304
Letters
Ignazio Cutaia, MD Irene Parrino, MD Archimede Center, Palermo, Italy
Vol. 30 No. 4 October 2005
Topical Morphine in the Treatment of Painful Ulcers
Alessandra Casuccio, MD Univeristy of Palermo, Palermo, Italy doi:10.1016/j.jpainsymman.2005.08.010
References 1. National Institutes of Health NIDDK/DKUHD: Excerpts from the United States renal data system 2001. Annual data report. Am J Kidney Dis 2001; 38(Suppl 3). 2. Poppel DM, Cohen LM, Germain MJ. The renal palliative care initiative. J Palliat Med 2003;6: 321--326. 3. Merskey H. Classification of chronic pain: description of chronic pain syndromes and definitions of pain terms. Pain 1986;(Suppl 3):S1--S225. 4. Weisbord SD, Fried L, Arnold RM, et al. Development of a symptom assessment instrument for chronic hemodialysis patients: the dialysis symptom index. J Pain Symptom Manage 2004;27:226--240. 5. Serlin RC, Mendoza TR, Nakamura Y, Edwards K, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995;61:277--284. 6. Mercadante S, Arcuri E. Opioids and renal function. J Pain 2004;5:2--19. 7. Jensen MP, McFarland CA. Increasing the reliability and validity of pain intensity measurement in chronic pain patients. Pain 1993;55:195--203.
To the Editor: In a previous issue of the journal, Zeppetella et al. published data regarding the use of topical morphine in the treatment of painful ulcers, confirming the results of a pilot study. Topical morphine seems to be safe and efficacious in the treatment of ulcer-related pain.1,2 At the Medical Oncology Department of the University of L’Aquila, five patients with malignant or benign painful ulcers were observed recently. All were affected by metastatic cancer and were receiving opioids; none was receiving disease-oriented therapies. On admission, all patients reported pain localized to ulcers, which was no longer controlled by systemic treatment; pain scores were O 5 on a numerical rating scale (NRS). Morphine was topically applied to ulcers three times daily (morphine sulfate injection 10 mg in 8 g Intrasite gelÒ, Smith & Nephew, Agrate Brianza, Italy). The morphine dose was the same in all patients, regardless of the ulcer size and the scheduled systemic treatment. Ulcers were washed before treatment with a ringer lactate and metronidazole solution. Systemic treatment was not modified. Pain was assessed daily by the patients using the NRS; nurses reported local and/or systemic adverse effects related to treatment in nursing charts. Patients were observed in the hospital for seven days. Characteristics of patients and pain scores are reported in Table 1. All patients responded
Table 1 Patient Characteristics and NRS Scores Patient Sex Age Primary cancer Scheduled analgesia Ulcer etiology Site NRS baseline NRS Day 1 NRS Day 2 NRS Day 3 NRS Day 4 NRS Day 5 NRS Day 6 NRS Day 7
1 Female 76 Breast Tramadol 100 mg 12 hourly Malignant Sternum 6 3 1 1 0 0 0 0
2 Female 82 Cervix TTS Fentanyl 100 mg/h 60 hourly Pressure Right foot 8 5 2 1 1 1 1 1
3 Male 56 Colon Morphine 30 mg 12 hourly Malignant Sternum 7 1 1 2 1 1 1 1
4 Female 64 Cervix TTS Fentanyl 100 mg/h 72 hourly Pressure Sacrum 9 4 3 3 1 1 1 1
5 Female 71 Vulva Morphine 30 mg SC infusion 24 hourly Malignant Vulva 9 5 2 1 2 2 1 2
Vol. 30 No. 4 October 2005
Letters
305
to treatment promptly (NRS # 5 after 24 hours of treatment) and analgesia was maintained during the hospital stay. Nurses and/or patients did not report local and/or systemic adverse effects. Our data, although related to a small series of patients without a control group, seem to confirm Zeppetella et al.’s results, suggesting a possible role for local opioids in the treatment of painful ulcers. We would like to emphasize that a satisfactory level of analgesia was obtained without escalation of systemic doses of opioids and without adverse effects. As suggested by Zeppetella et al., larger studies are required to confirm these promising observations.
or music. They are less common than unformed acoustic hallucinations such as tinnitus.2 As stated in the letter, musical hallucinations are usually melodies that are repetitions of well-known music from former times, in particular, religious songs, folk songs, or pop songs known from the radio and heard during childhood or adolescence.2 Disorders that have been associated with musical hallucinations are hypacusis (acquired hearing loss), structural brain lesions, psychiatric disorders, and pharmacologic agents (see Table 1). Structural lesions associated with musical hallucinations include cerebral atrophy, brainstem lesions, and temporal lobe disease.
Giampiero Porzio, MD Federica Aielli, MD Lucilla Verna, MD Katia Cannita, MD Supportive Care Task Force Medical Oncology Department University of L’Aquila L’Aquila, Italy
Table 1 Conditions Associated with Musical Hallucinations
Paolo Marchetti, MD Corrado Ficorella, MD Medical Oncology Department University of L’Aquila L’Aquila, Italy doi:10.1016/j.jpainsymman.2005.08.011
References 1. Zeppetella G, Paul J, Ribeiro MDC. Analgesic efficacy of morphine applied topically to painful ulcers. J Pain Symptom Manage 2003;25:555--558. 2. Zeppetella G, Ribeiro MDC. Morphine in Intrasite gel applied topically to painful ulcers. J Pain Symptom Manage 2005;29:118--119.
Musical Hallucinations and Opioids: A Word of Caution To the Editor: In response to the letter by Davies and Quinn,1 I would like to address several points regarding musical hallucinations in general, and then look at the possible causes of musical hallucinations as they relate to opioid use. Musical hallucinations are characterized as complex auditory hallucinations. Complex hallucinations involve the spoken word, voices,
Hypacusis Psychiatric Disorders Depression Schizophrenia Obsessive-compulsive disorders Structural Brain Lesions Cerebral atrophy Temporal lobe lesions Epilepsy Brainstem lesions Brain tumors Cerebral vascular accident/multi-infarct dementia Drugs Ketamine Ranitidine Prazosin Bromocriptine Propranolol Opioids Tricyclic antidepressants Salicylate Pentoxifylline Voriconazole Ethyl Alcohol Benzodiazepines Corticosteroids Clomipramine Amphetamines Quinine Carbamazepine Marijuana Paracetamol Phenytoin Bisphosphonates Clinical Scenarios General anesthesia Drug withdrawal Systemic Illnesses Lyme disease Listeriosis
Letters
Ignazio Cutaia, MD Irene Parrino, MD Archimede Center, Palermo, Italy
Vol. 30 No. 4 October 2005
Topical Morphine in the Treatment of Painful Ulcers
Alessandra Casuccio, MD Univeristy of Palermo, Palermo, Italy doi:10.1016/j.jpainsymman.2005.08.010
References 1. National Institutes of Health NIDDK/DKUHD: Excerpts from the United States renal data system 2001. Annual data report. Am J Kidney Dis 2001; 38(Suppl 3). 2. Poppel DM, Cohen LM, Germain MJ. The renal palliative care initiative. J Palliat Med 2003;6: 321--326. 3. Merskey H. Classification of chronic pain: description of chronic pain syndromes and definitions of pain terms. Pain 1986;(Suppl 3):S1--S225. 4. Weisbord SD, Fried L, Arnold RM, et al. Development of a symptom assessment instrument for chronic hemodialysis patients: the dialysis symptom index. J Pain Symptom Manage 2004;27:226--240. 5. Serlin RC, Mendoza TR, Nakamura Y, Edwards K, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995;61:277--284. 6. Mercadante S, Arcuri E. Opioids and renal function. J Pain 2004;5:2--19. 7. Jensen MP, McFarland CA. Increasing the reliability and validity of pain intensity measurement in chronic pain patients. Pain 1993;55:195--203.
To the Editor: In a previous issue of the journal, Zeppetella et al. published data regarding the use of topical morphine in the treatment of painful ulcers, confirming the results of a pilot study. Topical morphine seems to be safe and efficacious in the treatment of ulcer-related pain.1,2 At the Medical Oncology Department of the University of L’Aquila, five patients with malignant or benign painful ulcers were observed recently. All were affected by metastatic cancer and were receiving opioids; none was receiving disease-oriented therapies. On admission, all patients reported pain localized to ulcers, which was no longer controlled by systemic treatment; pain scores were O 5 on a numerical rating scale (NRS). Morphine was topically applied to ulcers three times daily (morphine sulfate injection 10 mg in 8 g Intrasite gelÒ, Smith & Nephew, Agrate Brianza, Italy). The morphine dose was the same in all patients, regardless of the ulcer size and the scheduled systemic treatment. Ulcers were washed before treatment with a ringer lactate and metronidazole solution. Systemic treatment was not modified. Pain was assessed daily by the patients using the NRS; nurses reported local and/or systemic adverse effects related to treatment in nursing charts. Patients were observed in the hospital for seven days. Characteristics of patients and pain scores are reported in Table 1. All patients responded
Table 1 Patient Characteristics and NRS Scores Patient Sex Age Primary cancer Scheduled analgesia Ulcer etiology Site NRS baseline NRS Day 1 NRS Day 2 NRS Day 3 NRS Day 4 NRS Day 5 NRS Day 6 NRS Day 7
1 Female 76 Breast Tramadol 100 mg 12 hourly Malignant Sternum 6 3 1 1 0 0 0 0
2 Female 82 Cervix TTS Fentanyl 100 mg/h 60 hourly Pressure Right foot 8 5 2 1 1 1 1 1
3 Male 56 Colon Morphine 30 mg 12 hourly Malignant Sternum 7 1 1 2 1 1 1 1
4 Female 64 Cervix TTS Fentanyl 100 mg/h 72 hourly Pressure Sacrum 9 4 3 3 1 1 1 1
5 Female 71 Vulva Morphine 30 mg SC infusion 24 hourly Malignant Vulva 9 5 2 1 2 2 1 2
Vol. 30 No. 4 October 2005
Letters
305
to treatment promptly (NRS # 5 after 24 hours of treatment) and analgesia was maintained during the hospital stay. Nurses and/or patients did not report local and/or systemic adverse effects. Our data, although related to a small series of patients without a control group, seem to confirm Zeppetella et al.’s results, suggesting a possible role for local opioids in the treatment of painful ulcers. We would like to emphasize that a satisfactory level of analgesia was obtained without escalation of systemic doses of opioids and without adverse effects. As suggested by Zeppetella et al., larger studies are required to confirm these promising observations.
or music. They are less common than unformed acoustic hallucinations such as tinnitus.2 As stated in the letter, musical hallucinations are usually melodies that are repetitions of well-known music from former times, in particular, religious songs, folk songs, or pop songs known from the radio and heard during childhood or adolescence.2 Disorders that have been associated with musical hallucinations are hypacusis (acquired hearing loss), structural brain lesions, psychiatric disorders, and pharmacologic agents (see Table 1). Structural lesions associated with musical hallucinations include cerebral atrophy, brainstem lesions, and temporal lobe disease.
Giampiero Porzio, MD Federica Aielli, MD Lucilla Verna, MD Katia Cannita, MD Supportive Care Task Force Medical Oncology Department University of L’Aquila L’Aquila, Italy
Table 1 Conditions Associated with Musical Hallucinations
Paolo Marchetti, MD Corrado Ficorella, MD Medical Oncology Department University of L’Aquila L’Aquila, Italy doi:10.1016/j.jpainsymman.2005.08.011
References 1. Zeppetella G, Paul J, Ribeiro MDC. Analgesic efficacy of morphine applied topically to painful ulcers. J Pain Symptom Manage 2003;25:555--558. 2. Zeppetella G, Ribeiro MDC. Morphine in Intrasite gel applied topically to painful ulcers. J Pain Symptom Manage 2005;29:118--119.
Musical Hallucinations and Opioids: A Word of Caution To the Editor: In response to the letter by Davies and Quinn,1 I would like to address several points regarding musical hallucinations in general, and then look at the possible causes of musical hallucinations as they relate to opioid use. Musical hallucinations are characterized as complex auditory hallucinations. Complex hallucinations involve the spoken word, voices,
Hypacusis Psychiatric Disorders Depression Schizophrenia Obsessive-compulsive disorders Structural Brain Lesions Cerebral atrophy Temporal lobe lesions Epilepsy Brainstem lesions Brain tumors Cerebral vascular accident/multi-infarct dementia Drugs Ketamine Ranitidine Prazosin Bromocriptine Propranolol Opioids Tricyclic antidepressants Salicylate Pentoxifylline Voriconazole Ethyl Alcohol Benzodiazepines Corticosteroids Clomipramine Amphetamines Quinine Carbamazepine Marijuana Paracetamol Phenytoin Bisphosphonates Clinical Scenarios General anesthesia Drug withdrawal Systemic Illnesses Lyme disease Listeriosis