***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract A total of 119 bone marrow transplant patients suffering from oral mucositis pain were enrolled in a r and omized , double‐blind , parallel‐group trial comparing the efficacy of patient‐controlled analgesia with morphine , hydromorphone and sufentanil . Patient ratings of pain and side‐effects on visual analog scales were gathered daily from the start of patient‐controlled analgesia ( PCA ) therapy until the discontinuation of opioid treatment either because of resolution of oral mucositis pain , intolerable side‐effects , inadequate pain control , or complications related to transplantation . Of the 119 enrolled subjects , 100 met the evaluable criteria of developing oral mucositis and remaining on the study for at least 2 days .  Multivariate analysis of the outcome measures indicated that the analgesia achieved in all three opioid groups was nearly equivalent , while measures of side‐effects , especially for the combination of sedation , sleep and mood disturbances , were statistically lower in the morphine group than in hydromorphone or sufentanil groups . Patients in the hydromorphone group exhibited the most variability in pain control . Event analysis also indicated significant differences in time to treatment failure between the three groups , with the morphine arm exhibiting clear superiority . The proportion of patients discontinued because of inadequate pain relief was much higher in the sufentanil group ( 7/36 ) as compared to the hydromorphone ( 0/34 ) or the morphine group ( 1/30 ) . The daily opioid consumption pattern showed a continual dose escalation during the first week of therapy for all groups , coincident with worsening mucositis . Morphine consumption reached a plateau by day 5 , whereas hydromorphone and sufentanil consumption continued to rise until days 7 and 9 , respectively . Sufentanil dose requirement increased by approximately 10‐fold compared to morphine and hydromorphone , whose requirements increased only 5‐fold , suggesting the possibility of development of acute pharmacological tolerance in some patients with this phenylpiperidine opioid . This study provides support for the recommendation that morphine is the opioid of first choice when patient‐controlled analgesia is employed for the treatment of severe oropharyngeal pain in bone marrow transplantation ( BMT ) patients Abstract This study investigated the analgesic effects of three intravenous bolus doses of hydromorphone ( 10 , 20 , 40 & mgr;g/kg ) on experimental pain measures in normal humans . Ten healthy male volunteers participated in four study sessions , one for each of the hydromorphone doses as well as a placebo ( saline ) . They received the four treatments in counterbalanced order under double‐blind conditions and with study days at least 1 week apart . During each session subjects underwent repeated electrical tooth pulp stimulation at intensities sufficient to elicit a rating of ‘ strong pain ’ before drug administration . Subjective pain reports ( PRs ) and dental evoked potential amplitude measures ( EPs ) served as analgesic effect indicators . We observed dose‐dependent analgesia as measured by both PR ( P=0.009 ) and EP ( P=0.017 ) . Area under the PR versus time curve as well as the EP versus time curve decreased in a log dose‐dependent fashion . Although the peak effect was poorly defined , the onset of analgesia was rapid , within 5 min , and maximum analgesic effect was seen between 10 and 20 min after maximum plasma hydromorphone concentration . However , within sessions we found a poor correspondence between hydromorphone plasma concentration and effect . Compared to pain report data from other human studies done in our laboratory , hydromorphone has a shorter time to peak effect compared to morphine , and overall , hydromorphone hydrochloride is approximately five times as potent as morphine sulfate on a milligram basis Goals of workThe purpose of this trial was to evaluate the effect of long-term treatment with either oral sustained-release hydromorphone ( HM ) or morphine ( M ) on nausea , emesis , and constipation . Material s and methods In a prospect i ve , open-labeled , controlled trial , 100 out patients with cancer pain and treatment with HM or M  were enrolled .  Mobility , pain , and gastrointestinal symptoms were assessed by the ECOG performance status , selected items of the EORTC question naire and Numerical Rating Scales ( NRS ) . Data were analyzed using descriptive and confirmatory statistics ( paired t-test , chi square test , Poisson regression).Main results Demographic and medical data were comparable in both treatment groups . Taking into account different conversion factors , opioid doses ( M 94.4 mg/d vs. HM 137.6 [ HM/M = 1:5 ] , p = 0.05 and HM 206.4 [ HM/M = 1:7.5 ] , p = 0.0002 , respectively ) were higher under hydromorphone and NRS of pain ( M 2.3 vs. HM 3.6 , p = 0.0002 ) lower under morphine .  Nausea and emesis did not attenuate in 33 % of patients . NRS of nausea ( M 2.5 vs. HM 1.5 ; p = 0.01 ) , incidences of emesis ( M 0.7/d vs. HM 0.1/d , p = 0.0001 ) , the consumption of antiemetics ( M 26 vs. HM 14 , p = 0.01 ) , and the number of constipated patients ( M 8 vs. HM 2 , p = 0.04 ) were higher in the morphine group . An extended use of substances for symptom control revealed constipating effects ( M 31 vs. HM 13 , p = 0.0003 ) and was associated with a higher incidence of constipation in the morphine group . Conclusions Symptom control in out patients with cancer pain may be complicated by a symptom controlling medication . Particularly , antiemetics revealed potentially constipating effects . Despite lower opioid doses , morphine provided a better pain control but produced more side effects . Comparing hydromorphone with morphine , it remains unclear if fewer incidences of constipation and nausea in the hydromorphone group were related to pharmacodynamic effects or to a less effective pain control with significantly higher NRS for pain . However , the conversion factor of oral hydromorphone and morphine needs to be question ed To compare the safety and efficacy of subcutaneous and intravenous infusion of opioid analgesics , a r and omised , double-blind , crossover trial was carried out in in patients . 15 patients with severe cancer pain received two 48 h infusions of hydromorphone -- one subcutaneously and one intravenously in r and omly allocated order . The study was made double-blind by the use of two infusion pumps throughout ; during the active subcutaneous infusion the intravenous pump delivered saline and vice versa . Serial measurements of pain intensity , pain relief , mood , and sedation by means of visual analogue scales showed no clinical ly or statistically significant difference between the two infusion routes . Side-effects were slight , and the mean number of morphine injections for breakthrough pain did not differ significantly between the routes ( 4.8 [ SD 4.5 ] for intravenous vs 5.3 [ 5.6 ] for subcutaneous ) . Plasma hydromorphone concentrations measured at 24 h and 48 h of infusion showed stable steady-state pharmacokinetics ; the mean bioavailability from subcutaneous infusion was 78 % of that with intravenous infusion . Because of the simplicity , technical advantages , and cost-effectiveness of continuous subcutaneous opioid infusion into the chest wall or trunk , intravenous opioid infusion for the management of severe cancer pain should be ab and oned Background Long-acting opioid formulations are advocated for maintaining pain control in chronic cancer pain .  OROS ® hydromorphone is a sustained-release formulation of hydromorphone that requires dosing once daily to maintain therapeutic concentrations . The objective of this study was to demonstrate the clinical equivalence of immediate-release and sustained-release formulations of hydromorphone and morphine for chronic cancer pain . Methods 200 patients with cancer pain ( requiring ≤ 540 mg/d of oral morphine ) participated in this double-blind , parallel-group trial . Patients were r and omized to receive hydromorphone or morphine ( immediate-release for 2–9 days , sustained-release for 10–15 days ) . Efficacy was assessed with the Brief Pain Inventory ( BPI ) , investigator and patient global evaluations , Eastern Cooperative Oncology Group performance status , and the Mini-Mental State Examination . The primary endpoint was the ' worst pain in the past 24 hours ' item of the BPI , in both the immediate-release and sustained-release study phases , with treatments deemed equivalent if the 95 % confidence intervals ( CI ) of the between-group differences at endpoint were between -1.5 and 1.5 . No equivalence limits were defined for secondary endpoints . Results Least-squares mean differences ( 95 % CI ) between groups were 0.2 ( -0.4 , 0.9 ) in the immediate-release phase and -0.8 ( -1.6 , -0.01 ) in the sustained-release phase ( intent-to-treat population ) , indicating that the immediate-release formulations met the pre-specified equivalence criteria , but that the lower limit of the 95 % CI ( -1.6 ) was outside the boundary ( -1.5 ) for the sustained-release formulations . BPI ' pain now PM ' was significantly lower with OROS ® hydromorphone compared with controlled-release morphine ( least-squares mean difference [ 95 % CI ] , -0.77 [ -1.49 , -0.05 ] ; p = 0.0372 ) . Scores for other secondary efficacy variables were similar between the two sustained-release treatments . At endpoint , > 70 % of investigators and patients rated both treatments as good to excellent . The safety profiles of hydromorphone and morphine were similar and typical of opioid analgesics . Conclusion Equivalence was demonstrated for immediate-release formulations of hydromorphone and morphine , but not for the sustained-release formulations of OROS ® hydromorphone and controlled-release morphine . The direction of the mean difference between the treatments ( -0.8 ) and the out-of-range lower limit of the 95 % CI ( -1.6 ) were in favor of OROS ® hydromorphone . Trial registration Clinical Trials.gov : PURPOSE To evaluate the safety and efficacy of a new slow-release preparation of hydromorphone ( SRH ) in the treatment of cancer pain . PATIENTS AND METHODS Ninety-five adult patients from three Canadian Palliative Care Centers with no evidence of mental impairment received treatment for cancer pain with an oral opioid analgesic .  After informed consent was obtained , patients underwent titration to a stable dose of immediate-release hydromorphone ( IRH ) for 48 hours , and were then r and omized to receive IRH or SRH for 5 days in a double-blind basis . During day 6 , a crossover took place , and patients received the alternate drug for 5 days . Pain intensity was assessed using a visual analog scale ( VAS ) and ordinal scale ( OS ) . Side effects were assessed using VAS . Patients and investigators made a blinded global rating of efficacy a blinded final choice between SRH and IRH . RESULTS In 75 assessable patients , pain intensity of the VAS and OS were ( mean + /- SD ) 27 + /- 21 and 1.3 + /- 0.6 on IRH , versus 29 + /- 21 ( P = .13 ) and 1.3 + /- 0.6 ( P = .19 ) on SRH , respectively . The total number of extra doses of opioids , global rating , and final blinded choice by both patients and investigators were not significantly different between IRH and SRH . Differences in side effects were not significant . CONCLUSION Our findings suggest that SRH is as safe and effective as IRH in the treatment of cancer pain The use of oxycodone to treat  chronic cancer pain has been hampered by its short elimination half‐life , which necessitates administration every 4 hours . This study compared the clinical efficacy and safety of a novel oxycodone formulation with that of hydromorphone in the treatment of cancer pain INTRODUCTION The purpose of this trial was to evaluate the effect of long-term treatment with oral sustained-release hydromorphone , transdermal fentanyl , and transdermal buprenorphine on nausea , emesis and constipation . PATIENTS AND METHODS R and omly selected out patients with cancer pain receiving one of the study medications were enrolled in a prospect i ve , open-labeled , controlled trial ( n=174 ) .  Mobility , pain , and gastrointestinal symptoms were assessed directly and per selected item on the ECOG ( Eastern Cancer Oncology Group ) , EORTC ( European Organisation for Research and Treatment of Cancer ) question naires , NRS ( Numerical Rating Scales ) , and analyzed statistically . RESULTS Demographic and medical data were comparable in all groups . Only 15 % of patients suffered from constipation . 59 % took the prescribed laxatives . The incidence of stool free periods > 72 h was significantly higher with transdermal opioids ( transdermal fentanyl : 22 % ; transdermal buprenorphine : 21 % ; oral hydromorphone : 2 % ; p=0.003 ) . 21 % of patients revealed nausea and emesis . The mean NRS for nausea ( transdermal fentanyl:1.3 ; transdermal buprenorphine : 1.2 ; oral hydromorphone : 1.5 ; p=0.6 ) , the consumption of antiemetics  ( transdermal fentanyl : 42 % ; transdermal buprenorphine : 33 
    Output:
    
The RCTs comparing hydromorphone with morphine and oxycodone showed similar analgesic results , while the comparison of side effects showed minor differences , not consistent across studies .
In conclusion there is evidence to support the efficacy and tolerability of hydromorphone for moderate to severe  cancer  pain as an alternative to morphine and oxycodone , while there is no evidence to demonstrate its superiority or inferiority in comparison with morphine as the first choice opioid for the same indication