Primary care

Randomised crossover trial of transdermal fentanyl and sustained release oral morphine for treating chronic non-cancer pain

Laurie Allan, director, ^a Helen Hays, associate clinical professor, ^b Niels-Henrik Jensen, head of department, ^c Bernard Le Polain de Waroux, staff anaesthesiologist, ^d Michiel Bolt, anaesthesiologist, ^e Royden Donald, specialist anaesthetist, ^f Eija Kalso, head. ^g

^a Chronic Pain Services, Northwick Park and St Mark's NHS Trust, Harrow, Middlesex HA1 3UJ, ^b Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada T6G 2C8, ^c Multidisciplinary Pain Centre, Department of Anaesthesiology, Herlev University Hospital, DK-2730, Denmark, ^d Cliniques Universitaires St-Luc, 1200 Brussels, Belgium, ^e Alg Ziekenhuis Eemland De Lichtenberg, 3818 ES Amersfoort, Netherlands, ^f Strand Private Hospital, Cape Town 7139, South Africa, ^g Helsinki University Central Hospital Pain Clinic, 00290 Helsinki, Finland

Correspondence to: L Allan northwick.pain{at}bigfoot.com

Objectives: To compare patients' preference for transdermal fentanyl or sustained release oral morphine, their level of pain control, and their quality of life after treatment.
Design: Randomised, multicentre, international, open label, crossover trial.
Setting: 35 centres in Belgium, Canada, Denmark, Finland, the United Kingdom, the Netherlands, and South Africa.
Participants: 256 patients (aged 26-82 years) with chronic non-cancer pain who had been treated with opioids.
Main outcome measures: Patients' preference for transdermal fentanyl or sustained release oral morphine, pain control, quality of life, and safety assessments.
Results: Of 212 patients, 138 (65%) preferred transdermal fentanyl, whereas 59 (28%) preferred sustained release oral morphine and 15 (7%) expressed no preference. Better pain relief was the main reason for preference for fentanyl given by 35% of patients. More patients considered pain control as being "good" or "very good" with fentanyl than with morphine (35% v 23%, P=0.002). These results were reflected in both patients' and investigators' opinions on the global efficacy of transdermal fentanyl. Patients receiving fentanyl had on average higher quality of life scores than those receiving morphine. The incidence of adverse events was similar in both treatment groups; however, more patients experienced constipation with morphine than with fentanyl (48% v 29%, P<0.001). Overall, 41% of patients experienced mild or moderate cutaneous problems associated with wearing the transdermal fentanyl patch, and more patients withdrew because of adverse events during treatment with fentanyl than with morphine (10% v 5%). However, within the subgroup of patients naive to both fentanyl and morphine, similar numbers of patients withdrew owing to adverse effects (11% v 10%, respectively).
Conclusion: Transdermal fentanyl was preferred to sustained release oral morphine by patients with chronic non-cancer pain previously treated with opioids. The main reason for preference was better pain relief, achieved with less constipation and an enhanced quality of life.