CHAPTER 4. DISCUSSION
4.12. RECOMMENDATIONS
Recent studies have sought to determine if the cognitive or psychomotor impairments caused by opioids can be reversed using adjuvant psychopharmaceuticals. In particular, pilot studies of psychostimulant drugs such as caffeine and methylphenidate have shown a reversal of the impairing effects of opioids in patients who have just commenced opioid therapy (see Bruera et aL, 1987; Mercadante et a l, 2001; Yee and Berde, 1994). It should perhaps be investigated if breakthrough-morphine-induced impairment can similarly be reversed.
In addition combining a psychostimulant with an opioid may actually enhance the analgesic action of the opioid, and therefore the benefit may be two-fold (Dalai and Melzack, 1998). Of course the use of psychostimulants needs to be balanced against the potentially increased toxicity of an additional drug.
Psychological approaches may also be relevant to ameliorating the cognitive effects of opioids. The literature on cognitive rehabilitation of dementia patients may be
particularly relevant (Clare et al, 2003). For example, techniques drawn from experimental psychology have been applied in dementia patients to bypass the limitations imposed by impairments in episodic memory, like the ones found in the current study. For example, ‘spaced retrieval’ and ‘errorless learning’ have successfully been applied to cognitively impaired elderly patients (Clare and Woods, 2001). In addition, individually tailored compensatory strategies (such as the use of external memory aids) may be developed.
Furthermore, it has been found that a positive and supportive environment can offset the effects of ‘malignant social psychology’ which can exacerbate cognitive impairment and result in ‘excess disability’ (see Kitwood, 1996). NHS guidance for the care of patients in palliative care settings already recommends such supportive environments, thus reducing possible cognitive-‘excess disability’ through malignant social psychology influences (Commission for Health Improvement document, 2001).
4.13. SUMMARY
In summary, the present study with patients receiving palliative care used a crossover, placebo-controlled, double-blind design to determine the effects of breakthrough doses of morphine on cognitive functioning, mood and pain.
Anterograde impairments of episodic memory were induced by a breakthrough dose of morphine and were most pronounced when remembering occurred after a time delay. There were also retrograde impairments observed when patients given morphine recalled
a story they heard before morphine. Evidence for executive function deficit was obtained on the Reitan’s Trials task.
Although breakthrough-morphine produced significantly more self-rated pain-relief than placebo, patients could not distinguish between the two treatments. Finally, patients did not seem to respond to the reinforcing effects of morphine and neither were they susceptible to changes in mood ratings following their breakthrough dose.
These findings suggest that patients will experience a significant impairment in cognitive functioning following their intake of breakthrough morphine which could impinge on their everyday functioning.
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APPENDICES
APPENDIX 1. Research Ethics Approval Letter APPENDIX 2. Patient Information Form
APPENDIX 3. Consent Form
APPENDIX 4. MRS - Pre-Treatment APPENDIX 5. MRS - Post-Treatment
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