Is there enough evidence to advocate opioid combinations? Does one and one make two or more?

Zylicz, Zbigniew; Mercadante, Sebastiano
June 2010
Advances in Palliative Medicine;2010, Vol. 9 Issue 2, p31
Academic Journal
Despite a more than tenfold increase in opioid consumption in the past decades, many cancer patients still suffer pain. The current understanding of this situation is poorly understood. It is still possible that in some countries pain is still undertreated, but it is also possible that we do not appreciate opioid induced toxicity and other phenomena an/or our opioid prescribing needs to be refreshed. At the moment the only evidence based tool to deal with opioid toxicity is switching to another opioid. Other methods are also described, but are far less well evidenced. However, the effects after switching are short-lived and sometimes a number of switches are needed. In this article we discuss the rationale behind and the possibility of combining different opioids with each other. Opioids are all different and opioid receptors are heterogenous. There are data to suggest that widening the activity spectrum of opioids may be the way forward in order to decrease adverse effects and maintain analgesia. At the moment there are only some data on the interaction of fentanyl and morphine, morphine and oxycodone, and buprenorphine and morphine. These data suggest that we should investigate these problems vigorously and, instead of switching from one opioid to another, we may, in future, adopt the concept of a semi-switch, where the dose of the first opioid is decreased and a second opioid is added.


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