In contrast to the use of opioids for the treatment of acute and chronic cancer pain, the administration of chronic opioid therapy for pain not due to malignancy remains controversial. We describe 100 patients who were chronically given opioids for treatment of nonmalignant pain. Most patients experienced neuropathic pain or back pain. We used sustained-release dihydrocodeine, buprenorphine, and sustained-release morphine. Pain reduction was measured with visual analogue scales (VAS), and the Karnofsky Performance Status Scale was used to assess the patient's function. Good pain relief was obtained in 51 patients and partial pain relief was reported by 28 patients. Only 21 patients had no beneficial effect from opioid therapy. There was a close correlation between the sum and the peak VAS values (r = 0.983; p less than 0.0001) and pain reduction was associated with an increase in performance (p less than 0.0001). The most common side effects were constipation and nausea. There were no cases of respiratory depression or addiction to opioids. Our results indicate that opioids can be effective in chronic nonmalignant pain, with side effects that are comparable to those that complicate the treatment of cancer pain.

Direct conversion from oral morphine to transdermal fentanyl with a ratio of oral morphine/transdermal fentanyl (100:1 mg) daily was examined in patients with cancer pain. Patients with a 'stable and low level of cancer pain' receiving a constant dosage of sustained release morphine during a pre-study phase of 6 days were included in the study. Initial fentanyl dosage was calculated by a conversion table. The transdermal system was changed every 72 h and the dosage was adjusted to the needs of the patients according to the VAS scores and the requirement of liquid morphine, which was allowed to achieve sufficient pain relief. Regression analysis at the end of the study revealed a mean morphine/transdermal fentanyl ratio of 70:1. Pain relief during treatment with transdermal fentanyl was identical to sustained release morphine. However, significantly more patients took supplemental medication with liquid morphine during transdermal fentanyl therapy. The number of patients suffering from pain attacks did not increase with transdermal fentanyl. Constipation and medication with laxatives decreased significantly during fentanyl therapy. Other side effects and vital signs were identical. Three patients suffered from a morphine withdrawal syndrome beginning within the first 24 h of transdermal fentanyl therapy. Cutaneous reactions to the patch were rare, mild and transient. Patients and physicians reported satisfaction with the transdermal therapy. 94.7% of the patients chose to continue the transdermal fentanyl therapy at the end of the study due to better performance in comparison to oral morphine. Due to these results an initial conversion from oral morphine to transdermal fentanyl with the ratio of 100:1 is safe and effective.

The aim of this survey was to determine the prescribing patterns of German physicians in the treatment of cancer pain. The computerized patient records of 330 practices, which treated a total number of 1,104,435 patients over a 3-year period, were analyzed. "Strong" opioids, widely accepted in the management of severe cancer pain, were prescribed to just 322 of 16,630 cancer patients (1.9%). Only 99 (0.6%) patients received more than three prescriptions during more than 3 weeks of treatment. Additionally, many prescriptions mandated inadequate time intervals for the dosing, and 12% of the prescriptions were given "as required." From these data, it can be concluded that the majority of cancer patients in Germany are not treated for pain at all, and that those patients who receive treatment are treated inadequately. Germany is still a developing country in terms of pain therapy. This situation is symptomatic of many countries and reflects the continuing prejudice against opioids.

The long-term therapy of 51 patients using transdermal fentanyl was evaluated. The transdermal therapy was performed for 158 days (range, 15-855 days). The need for increasing dosages of transdermal fentanyl was caused by the progression of the underlying cancer disease (mean initial dose, 69.5 micrograms fentanyl/hr; mean final dose, 167.7 micrograms fentanyl/hr). The transdermal system was changed every third day. Application intervals had to be shortened in 23.5% of the patients. Pain reduction was good throughout the study. Severe side effects did not occur. Constipation and the need for laxatives occurred less frequently than with previously administered oral morphine. Skin tolerance of the transdermal system was good. The treatment of cancer pain with transdermal fentanyl can be performed as a long-term therapy and result in good pain relief. Considering its specific pharmacokinetic properties, it is an alternative medication on step III of the World Health Organization's guidelines for cancer pain management.

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