This Page Intentionally Left Blank - Int Medical

Mucositis and stomatitis 255
discussed here. For CTAM that does develop, pain can be severe and opioids
are the therapeutic mainstay. In fact, CTAM pain often necessitates IV
morphine and even hospitalization and institution of a PCA regimen. 1
Cochrane review found that the opioid PCA regimen, while providing no
better overall pain relief than standard-regimen IV opioids, was associated
with lower medication dosages per hour and a shorter pain duration. 2 It is
likely that in many hospitals, ED utilization of PCA will be limited by a variety
of factors (e.g. relatively short duration of ED stay, physician and nursing
familiarity with PCA, availability of PCA pumps). However, for those settings
with access to (and expertise in) PCA use, the earlier institution of this
analgesia modality is desirable.
Methodologically rigorous comparisons of morphine, hydromorphone,
and sufentanil PCA for mucositis find each of the therapies generally efficacious,
but morphine exhibits advantages in safety and side effects. 1
Hydromorphone is the next most desirable opioid for PCA-administered
mucositis pain; sufentanil’s disadvantage (as demonstrated in adults) is a
greater susceptibility to tolerance. 1,3,4 As is the case in other conditions in
which PCA may be useful in the ED, initial pain reduction should be achieved
with IV bolus opioid therapy before instituting a PCA regimen.
While the IV route is preferred for severe pain, other methods of opioid
delivery have been studied for CTAM. Transdermal fentanyl in doses of up to
50 μg/h is ineffective for CTAM. 5 Results have been better with the oral
topical route for opioids. Morphine mouthwash is demonstrated safe and
effective in multiple trials. 6–8 Oral rinsing with 15 mL morphine (2:1000)
reduces patients’ pain scores by an average of 80%; pain relief occurs within
30 min and lasts nearly 4 h. 8 Serum levels of morphine after the mouth rinse
are negligible, and neither systemic drug effects nor toxicity are seen in extant
studies. 7
Besides morphine, other topical approaches for CTAM have been tried, but
they tend to fall short of the opioids in safety, efficacy, or both. The NSAIDs
may have some promise, and doxepin may have utility in refractory cases,
but trials of other approaches have been disappointing.
The NSAIDs that have been investigated for topical application in CTAM
include various preparations of indomethacin and benzydamine. More