UI - 000169

AU - Moulin DE

AU - Johnson NG

AU - Murray-Parsons N

AU - Geoghegan MF

AU - Goodwin VA

AU - Chester MA

TI - Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use [see

comments]

AB - OBJECTIVE: To provide guidelines for the institution and maintenance of a continuous subcutaneous

narcotic infusion program for cancer patients with chronic pain through an analysis of the narcotic

requirements and treatment outcomes of patients who underwent such therapy and a comparison of the costs

of two commonly used infusion systems. DESIGN: Retrospective study. SETTING: Tertiary care facilities

and patients' homes. PATIENTS: Of 481 patients seen in consultation for cancer pain between July 1987

and April 1990, 60 (12%) met the eligibility criteria (i.e., standard medical management had failed, and they

had adequate supervision at home). INTERVENTION: Continuous subcutaneous infusion with

hydromorphone hydrochloride or morphine started on an inpatient basis and continued at home whenever

possible. OUTCOME MEASURES: Patient selectivity, narcotic dosing requirements, discharge rate, patient

preference for analgesic regimen, side effects, complications and cost-effectiveness. RESULTS: The mean

initial maintenance infusion dose after dose titration was almost three times higher than the dose required

before infusion (hydromorphone or equivalent 6.2 v. 2.1 mg/h). Eighteen patients died, and the remaining 42

were discharged home for a mean of 94.4 (standard deviation 128.3) days (extremes 12 and 741 days). The

mean maximum infusion rate was 24.1 mg/h (extremes 0.5 and 180 mg/h). All but one of the patients

preferred the infusion system to their previous oral analgesic regimen. Despite major dose escalations nausea

and vomiting were well controlled in all cases. Twelve patients (20%) experienced serious systemic toxic

effects or complications; six became encephalopathic, which necessitated dose reduction, five had a

subcutaneous infection necessitating antibiotic treatment, and one had respiratory depression. The

programmable

computerized infusion pump was found to be more cost-effective than the disposable infusion device after a

break-even point of 8 months. CONCLUSIONS: Continuous subcutaneous infusion of opioid drugs with the

use of a portable programmable pump is safe and effective in selected patients who have failed to respond to

standard medical treatment of their cancer pain. Dose titration may require rapid dose escalation, but this is

usually well tolerated. For most communities embarking on such a program a programmable infusion system

will be more cost-effective than a disposable system

SO - Canadian Medical Association Journal 1992;146:891-89