heroin and Pain--Intractable

We describe two patients in whom diamorphine was administered into the intraventricular space via an Ommaya reservoir, producing excellent pain relief. The use of this technique for long term administration of analgesia is reviewed.

Topics: Adolescent; Catheters, Indwelling; Female; Heroin; Humans; Injections, Intraventricular; Male; Middle Aged; Neoplasms; Pain, Intractable

Topics: Administration, Oral; Clinical Trials as Topic; Heroin; Humans; Morphine; Neoplasms; Pain, Intractable

Topics: Chemistry, Pharmaceutical; Chlorpromazine; Clinical Trials as Topic; Cocaine; Drug Combinations; Drug Evaluation; Female; Heroin; Humans; London; Male; Morphine; Neoplasms; Pain, Intractable; Palliative Care

Intraspinal analgesia can be helpful in some patients with intractable pain. Over 15 years palliative care professionals evolved their spinals policy through a repeated series of evaluations, discussions and literature reviews. One hundred intraspinal lines were then reviewed. Notable changes in policy were the switch from epidurals to intrathecals, and the insertion of lines during working hours rather than as emergencies. Our efficacy, and frequency of adverse effects, is equal or better to published studies. Key issues in reducing adverse effects were the improved care of the spinal line exit site, a change from bolus administration to continuous infusions, and modifying line insertion techniques. Current policy is to use continuous infusions of diamorphine and bupivacaine in a 1:5 ratio through externalized intrathecal lines. The lines are effective in approximately two thirds of patients and can be kept in place for up to 18 months. The policy continues to be updated and common documentation is now in place.

Topics: Adult; Aged; Aged, 80 and over; Analgesia; Analgesia, Epidural; Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Drug Administration Schedule; Drug Combinations; Heroin; Humans; Injections, Spinal; Middle Aged; Neoplasms; Pain, Intractable; Palliative Care

We report a case in which the signs of a malignant meningitis could have been confused with complications of an in-dwelling epidural catheter which was being used for analgesia. This confusion could have had disastrous implications for the patient's pain relief. We also discuss some of the issues and problems surrounding the use of in-dwelling epidurals in terminal care patients.

Topics: Analgesia, Epidural; Catheters, Indwelling; Diagnosis, Differential; Diagnostic Errors; Fatal Outcome; Heroin; Humans; Male; Meningitis; Middle Aged; Narcotics; Pain, Intractable; Palliative Care

A study was undertaken in 1988 to examine various aspects of administering diamorphine subcutaneously by syringe driver at the time when its use had recently been introduced into the community. The results of this study and of a comparative study undertaken in 1994 are reported. It was found that in both studies the syringe driver was used mainly for patients who were unable to take oral medication or who were vomiting. However, in the first study, subcutaneous diamorphine was used in 31% of patients with no absorption problems, to improve pain control in those whose pain was poorly controlled on oral medication. In the second study, the syringe driver was used in only 8% of patients for this purpose. In both studies the use of the driver was continued until death in 37 of the 39 patients (95%) in each group. The syringe driver was used for longer than 14 days in most patients (56%) in the first study and the dose of diamorphine was increased in 54% of patients. In the second study, the driver was used mainly in the last week of life (69%) and the dose was more stable, remaining unchanged in 69% of patients. The incidence of site complications (5%) was the same in both groups, but other problems occurred with the use of the driver in the first group.

Topics: Adult; Aged; Aged, 80 and over; Female; Heroin; Hospices; Humans; Injections, Subcutaneous; Male; Middle Aged; Narcotics; Pain, Intractable; Syringes

Topics: Drug and Narcotic Control; Heroin; Humans; Internationality; Pain; Pain, Intractable; Pharmacists; Risk Assessment; Social Responsibility; United States

Topics: Euthanasia; Heroin; Home Care Services; Humans; Pain, Intractable; Terminal Care

Topics: Euthanasia; Heroin; Humans; Morphine; Pain, Intractable

We report the cases of 5 patients who developed severe local toxicity during the subcutaneous administration of morphine sulphate and hydromorphone hydrochloride. All patients required site changes more frequently than once every 24 h due to redness, swelling, or pain while receiving morphine or hydromorphone. All patients showed prolongation in the duration of sites of infusion once an equianalgesic dose of diamorphine hydrochloride (heroin) was started. No change in pain control or systemic toxicity was detected with diamorphine. These findings suggest that diamorphine could be a useful alternative for patients who develop severe toxicity to subcutaneous morphine or hydromorphone.

Topics: Adult; Aged; Colonic Neoplasms; Female; Heroin; Humans; Hydromorphone; Injections, Subcutaneous; Male; Middle Aged; Morphine; Neoplasm Metastasis; Ovarian Neoplasms; Pain, Intractable; Prostatic Neoplasms; Uterine Cervical Neoplasms

Topics: Canada; Foundations; Heroin; Humans; Legislation, Drug; Pain, Intractable; Palliative Care

Topics: Administration, Oral; Age Factors; Analgesics, Opioid; Blood Circulation; Drug Interactions; Half-Life; Heroin; Humans; Infusions, Parenteral; Injections; Injections, Intramuscular; Injections, Spinal; Intestines; Kinetics; Liver; Metabolic Clearance Rate; Morphine; Pain; Pain, Intractable; Respiration

Topics: Canada; Health Policy; Heroin; Humans; Pain, Intractable; Social Perception

Topics: Analgesics, Opioid; Chronic Disease; Cocaine; Fentanyl; Half-Life; Heroin; Humans; Injections, Intramuscular; Methadone; Morphine; Pain, Intractable; Pain, Postoperative

Topics: Aged; Heroin; Humans; Male; Pain, Intractable; Palliative Care

Topics: Arizona; Drug and Narcotic Control; Heroin; Humans; Neoplasms; Pain, Intractable

Topics: Heroin; Humans; Morphine; Neoplasms; Pain, Intractable

We measured blood concentrations of heroin and its active metabolites, 6-acetylmorphine and morphine, serially in 11 patients with chronic pain (9 of whom had cancer) after intravenous injection, intravenous infusion, intramuscular injection, and an oral dose of heroin hydrochloride. Parenteral heroin provided measureable blood levels of heroin, 6-acetylmorphine, and morphine. Blood levels of heroin and 6-acetylmorphine reached their maximal concentrations within minutes and were cleared rapidly. The mean half-life of heroin (+/- S.D.) after intravenous injection or infusion was only 3.0 +/- 1.3 minutes, and the mean clearance of heroin from the blood at apparent steady state was 30.8 +/- 2.1 ml per kilogram of body weight per minute. Morphine levels rose more gradually, and morphine was cleared much more slowly. Oral administration of heroin resulted in measurable blood levels of morphine but not of heroin or 6-acetylmorphine. The amount of circulating morphine provided by an oral dose of heroin was only 79 per cent of that available from an equal amount of morphine. We conclude that heroin is a pro-drug that serves to determine the distribution of its active metabolites. Parenteral heroin is rapidly converted to 6-acetylmorphine, which contributes to rapid pain relief. Oral heroin is converted to morphine and appears to be an inefficient means of providing morphine to the systemic circulation.

Topics: Administration, Oral; Adult; Aged; Biological Availability; Chronic Disease; Female; Half-Life; Heroin; Humans; Infusions, Parenteral; Injections, Intramuscular; Injections, Intravenous; Kinetics; Male; Middle Aged; Morphine; Morphine Derivatives; Pain; Pain, Intractable; Time Factors

Topics: Heroin; Humans; Legislation, Drug; Neoplasms; Pain, Intractable; Terminal Care; United States

Topics: Heroin; Humans; Legislation, Drug; National Institutes of Health (U.S.); Neoplasms; Pain, Intractable; Terminal Care; United Kingdom; United States; United States Food and Drug Administration; United States Public Health Service

Topics: Heroin; Humans; Legislation, Drug; Neoplasms; Pain, Intractable; Terminal Care; United States

Topics: Heroin; Humans; Neoplasms; Pain, Intractable

In cancer, the use of morphine is dictated by intensity of pain and not by brevity of prognosis. It is a reliable and safe drug when given in simple aqueous solution and is the strong analgesic of choice at most hospices. The oral-parenteral potency rate is 1:3. The effective analgesic dose varies from as little as 2.4 mg to more than 100 mg by mouth every 4 h, though most patients do not need more than 30 mg. Most patients require antiemetic and laxative medication concomitantly; many benefit by the concurrent use of aspirin, corticosteroid or other "coanalgesic". By mouth, morphine and diamorphine have similar actions and unwanted effects, though the latter is about 1.5 times more potent. When injections are necessary, diamorphine hydrochloride is used at all hospices in Britain. It is considerably more soluble than morphine sulphate which means that the volume injected need never be large. The main indication for parenteral administration, apart from the last few hours of life, is intractable vomiting despite the prescription of antiemetic. Most patients can be maintained on oral medication. Neither morphine nor diamorphine should be regarded as the panacea for severe cancer pain. To achieve maximum benefit they must be used within the context of "broad spectrum" pain control and comprehensive patient care and family support.

Topics: Heroin; Humans; Morphine; Pain, Intractable; Terminal Care

Topics: Chloroform; Cocaine; Drug Combinations; Ethanol; Heroin; Humans; Pain, Intractable

Topics: Cocaine; Female; Heroin; Humans; Middle Aged; Multiple Myeloma; Nursing, Team; Pain, Intractable

Topics: Cognition; Heroin; Humans; Morphine; Neoplasms; Pain, Intractable

Topics: Administration, Oral; Chronic Disease; Heroin; Humans; Injections, Intramuscular; Legislation, Drug; Morphine; Pain; Pain, Intractable; Research Design; United States; United States Food and Drug Administration

Topics: Chronic Disease; Heroin; Heroin Dependence; Humans; Pain; Pain, Intractable

Topics: Administration, Oral; Adolescent; Aged; Antipsychotic Agents; Female; Heroin; Hospitals, Special; Humans; Injections, Intravenous; London; Male; Middle Aged; Neoplasms; Pain, Intractable; Palliative Care; Phenothiazines; Terminal Care

Topics: Administration, Oral; Adult; Aged; Female; Heroin; Humans; Injections, Intravenous; Male; Middle Aged; Neoplasms; Pain, Intractable; Terminal Care