Non-cardiogenic pulmonary edema after narcotic treatment for cancer pain.

During recent years, better awareness of the problem of cancer pain has resulted in the use of increased doses of narcotics. We report the cases of 3 patients who presented non-cardiogenic pulmonary edema while receiving large doses of narcotics for cancer pain. In all cases, pulmonary edema occurred after patients required large increases in the dose of narcotic over a short period of time for rapidly progressing pain. Although pulmonary edema has been described after overdose of narcotics, it had not been previously reported during the course of treatment for cancer pain. Its mechanism appears to be increased capillary permeability because of immunoglobulin and complement deposition of the lung, or due to neurogenic increase in permeability by the effect of narcotics on the brain-stem. We conclude that narcotic-induced pulmonary edema should be suspected in patients who require massive increases in the dose of narcotics. The use of adjuvant pharmacologic and non-pharmacologic analgesic treatments in order to minimize the need for dose increase, as well as the prevention of precipitating factors such as over hydration, corticosteroids or excessive oxygen therapy, should be contemplated in this population.

Circadian distribution of extra doses of narcotic analgesics in patients with cancer pain: a preliminary report.

In this open study we reviewed the circadian distribution of extra doses of narcotic analgesics in 61 bed-ridden patients with cancer pain. The information was collected prospectively and retrospectively in 34 and 27 cases, respectively. All patients were receiving parenteral narcotics using the Edmonton Injector, and none had incidental pain or cognitive impairment. A total of 1322 extra doses of narcotics (each dose = 10% of the daily dose) were administered during 610 patient days (average of 2.17 +/- 1.6 doses/patient/day). The mean daily number of extra doses during each interval was as follows: 02.00-06.00 h (0.24 +/- 0.27), 06.00-10.00 h (0.26 +/- 0.31), 10.00-14.00 h (0.43 +/- 0.44), 14.00-18.00 h (0.44 +/- 0.41), 18.00-22.00 h (0.40 +/- 0.36), and 22.00-02.00 h (0.40 +/- 0.36) (02.00-06.00 h and 06.00-10.00 h vs. 10.00-02.00 h: P less than 0.01). Forty-five of 61 patients (76%) received most of their extra doses of narcotics between 10.00 and 22.00 h. The data suggest that our patients require a larger number of extra doses during day time. Our design cannot establish the reason for this circadian variation.

Neuropsychological effects of methylphenidate in patients receiving a continuous infusion of narcotics for cancer pain.

Twenty consecutive patients with cancer pain receiving a continuous subcutaneous infusion of narcotics were admitted to a double-blind, crossover trial designed to assess the effects of methylphenidate on neuropsychological functions. After a baseline assessment, patients were randomized to receive methylphenidate orally at 08.00 h for 2 consecutive days or placebo. During day 3, a crossover took place and patients received the alternate treatment for 2 more days. At the end of the trial, both patients and investigators were asked to choose blindly the most effective treatment. Cognitive tests (finger tapping, FT 10 and 30 sec; arithmetics, A; reverse memory of digits, RM; and visual memory, VM) were performed in all patients before and 45 min after their morning dose of narcotics for 2 consecutive days. Mean percentual change in FT 10 sec, FT 30 sec, A, RM, and VM after the narcotic dose were 89 +/- 12%, 98 +/- 15%, 108 +/- 17%, 101 +/- 17%, and 97 +/- 21% in the placebo group versus 119 +/- 16 (P less than 0.001), 130 +/- 19 (P less than 0.001), 78 +/- 21 (P less than 0.001), 125 +/- 28 (P less than 0.01), and 128 +/- 26 (P less than 0.001) in the methylphenidate group, respectively. After completion of the trial, methylphenidate was chosen blindly by the patient and investigator in 13 and 14 cases, placebo in 3 and 2 cases, a "no choice" in 3 and 3 cases, respectively (P less than 0.01). Our results suggest that methylphenidate is capable of improving cognitive function in patients receiving high doses of opiates subcutaneously. More research is necessary in order to determine the duration of cognitive improvement after each dose of methylphenidate as well as the best type and dose of amphetamine.