***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: OBJECTIVE We prospect ively investigated the efficacy of opioid rotation from oral morphine to oral oxycodone in cancer patients who had difficulty in continuing oral morphine treatment because of inadequate analgesia and /or intolerable side effects . METHODS Twenty-seven patients were enrolled and 25 were evaluated . The rate of patients who achieved adequate pain control , which provided an indication of treatment success , was evaluated as primary endpoint . The acceptability and pharmacokinetics of oxycodone were evaluated in addition to the assessment of analgesic efficacy and safety during the study period . RESULTS In spite of intense pain , the morphine daily dose could not be increased in most patients before the study because of intolerable side effects . However , switching to oral oxycodone allowed approximately 1.7-fold increase as morphine equivalent dose . Consequently , 84.0 % ( 21/25 ) of patients achieved adequate pain control . By the end of the study , all patients except one had tolerated the morphine-induced intolerable side effects ( i.e. nausea , vomiting , constipation , drowsiness ) . Common side effects ( > 10 % ) that occurred during the study were typically known for strong opioid analgesics , and most were mild to moderate in severity . A significant negative correlation between creatinine clearance ( CCr ) value and the trough concentrations of the morphine metabolites was observed . On the other h and , no significant correlation was found between CCr value and the pharmacokinetic parameters of oxycodone or its metabolites . CONCLUSIONS For patients who had difficulty in continuing oral morphine treatment , regardless of renal function , opioid rotation to oral oxycodone may be an effective approach to alleviate intolerable side effects and pain Opioid switching is often used to improve the opioid response in cancer patients experiencing poor analgesia or adverse effects . However , no data are available on plasmatic changes of opioids and their metabolites during these phases , and whether there exists a relationship with the clinical events . In a prospect i ve study of 10 consecutive cancer patients on oral morphine but with uncontrolled pain ( greater > 4 on a numerical scale of 0 to 10 ) and /or moderate to severe opioid adverse effects ( on a level of 2 and 3 of a verbal scale ) and not responsive to adjuvant medications , switching to oral methadone was performed using a fixed ratio of 5:1 , leaving extra-doses of 1/5 of the daily dose of methadone calculated as needed . Blood sample s were obtained at the same hour for four days , before the switching , and then on day 1 , 2 , and 3 . The intensity of pain and the adverse effects were assessed daily to calculate the switching score before and after switching . Completed blood sample s were obtained in 9 patients . One patient was separately considered , because of his renal impairment . Significant improvements in pain intensity as well as adverse effects within an average period of 1–2 days were observed . Morphine , morphine-6-glucuronide , and morphine-3-glucuronide were progressively cleared from plasma to almost disappear within three days . Methadone rapidly achieved a stable concentration in 1–2 days . The doses of methadone were changed , but not significantly , and tended to decrease in the following days , according to the clinical situation . The results of this study confirm the need to stop rapidly morphine , and to use a priming dose of methadone , rather than using progressive decrements and increments of morphine and methadone , respectively , during opioid switching . This method allows for a rapid clearance of morphine and its metabolites are rapidly cleared , except in patients with renal failure .  Opioid plasma changes substantially overlap the clinical changes observed in these patients , in terms of benefit between analgesia and adverse effects OBJECTIVE This prospect i ve study documents the use of methadone as part of an opioid rotation strategy in patients with uncontrolled pain and severe delirium admitted for terminal care to a tertiary cancer palliative care hospital . METHODS We review ed the treatment of 20 patients with severe pain and delirium at the end of life who 's delirium did not improve 24 h or longer after starting a neuroleptic medication .  RESULTS Ten male and 10 female patients , 47 to 77 years old , were rotated or " switched " to methadone due to uncontrolled pain in the setting of delirium , limiting further opioid dose escalation . At 2 weeks , a total of 10 patients had expired . Of the 10 patients who were alive 2 weeks after starting methadone , 7 patients were stable on an average of 1.1 mg/h methadone , 2 patients were restarted on morphine IV and one on Percocet . The calculated average equianalgesic dose of methadone was 9 % ( 2%-17 % ) of the previous morphine-equivalent dose . Of the 20 patients who were switched to methadone for what appeared to be terminal delirium , the pain control was significant in 15 , moderate in 3 , and unchanged in 2 patients . Average analgesia was good to excellent ( average Numeric Analog Scale rating [ NAS ] decreased from 8.2 to 2.5 ) . Sedation had decreased from 1.65 to 0.55 on a scale of 0 to 3 . Of the 20 patients , improvement of cognitive status was significant in 9 , moderate in 6 , partial in 2 , and none in 3 patients . The Memorial Delirium Assessment Scale ( MDAS ) showed improvement from an average of 23.6 prior to the switch to 10.6 3 days after . Decreased alertness on methadone was devoid of agitated features . SIGNIFICANCE OF RESULTS Our study suggests that methadone can be effective in the treatment of both refractory pain and what appears to be terminal delirium . Most patients in our group had at least a short-term improvement in mental status as well as significant and lasting improvement in analgesia Background Due to tolerance development and adverse side effects , chronic pain patients frequently need to be switched to alternative opioid therapy Objective To assess the efficacy and tolerability of an alternative transdermally applied ( TDS ) opioid in patients with chronic cancer pain receiving insufficient analgesia using their present treatment . Methods A total of 32 patients received alternative opioid therapy  , 16 were switched from buprenorphine to fentanyl and 16 were switched from fentanyl to buprenorphine . The dosage used was 50 % of that indicated in equipotency conversion tables . Pain relief was assessed at weekly intervals for the next 3 weeks Results Pain relief as assessed by VAS , PPI , and PRI significantly improved ( p < 0.0001 ) in all patients at all 3 follow up visits . After 3 weeks of treatment , the reduction in the mean VAS , PPI , and PRI scores in the fentanyl and buprenorphine groups was 68 , 77 , 74 , and 69 , 79 , and 62 % , respectively . Over the same time period the use of oral morphine as rescue medication was reduced from 27.5 ± 20.5 ( mean ± SD ) to 3.75 ± 8.06 , and 33.8 ± 18.9 to 3.75 ± 10.9 mg/day in the fentanyl and buprenorphine groups , respectively . There was no significant difference in either pain relief or rescue medication use between the two patient groups The number of patient with adverse events fell during the study . After the third week of the treatment the number of patients with constipation was reduced from 11 to 5 , and 10 to 4 patients in the fentanyl and buprenorphine groups , respectively . There was a similar reduction in the incidence of nausea and vomiting . No sedation was seen in any patient after one week of treatment . Conclusion Opioid switching at 50 % of the calculated equianalgesic dose produced a significant reduction in pain levels and rescue medication . The incidence of side effects decreased and no new side effects were noted . Further studies are required to provide individualized treatment for patients according to their different types of cancer The study objective was to determine whether switching patients from morphine to transdermal fentanyl  result ed in a reduction of morphine-associated side effects , and an improvement in cognitive function and patients ' well being while maintaining adequate pain and symptom control . Nineteen patients aged 42– 86 with terminal cancer , maintained on morphine for pain and distressed as a result of morphine toxicity , were given the dose of fentanyl corresponding to their current morphine dose .  Pain control was then maintained ( mostly fentanyl 50– 100 μg/h ) over the 14-day study period . Throughout the study , patients ' global assessment of well being ( primary efficacy variable ) was statistically significantly improved . Sleepiness and drowsiness were significantly less of a problem . There was a trend towards improvement in attention span/ concentration , and in the power and quality of concentration . Cognitive function tests also revealed a significant improvement in working ( short term ) and speed of memory although not in secondary ( long term ) memory . Patients did not experience hallucinations or delusions and there was no change in levels of anxiety or depression ( Hospital Anxiety Depression Scale ) . The incidence of dizziness was significantly reduced , and there was a nonsignificant decrease in number of patients who suffered myoclonus and in the severity of this condition over the 14 days . The investigator 's overall impression of treatment with transdermal fentanyl was ‘ fair ’ , which was not in agreement with the positive impression expressed by patients ( score 74 , range : 0 worst , 100 best ) . Further work is required to determine if the improvement in patients ' well being and cognitive function is achieved in larger study population Although recent studies suggest that opioid rotation could be an effective treatment strategy for morphine-induced delirium , there have been no prospect i ve studies to investigate the treatment effects of opioid rotation using fentanyl . The primary aim of this study was to clarify the efficacy of opioid rotation from morphine to fentanyl in symptom palliation of morphine-induced delirium . Twenty-one consecutive cancer patients with morphine-induced delirium underwent opioid rotation to fentanyl . Physicians recorded the symptom severity of delirium ( the Memorial Delirium Assessment Scale , MDAS ) , pain , and other symptoms ( categorical verbal scale from 0 : none to 3 : severe ) and the Schedule for Team Assessment Scale ( STAS ) ( from 0 : none to 4 : extreme ) ; and performance status at the time of study enrollment and three and seven days after . Of 21 patients recruited , one patient did not complete the study . In the remaining 20 patients , morphine was substituted with transdermal fentanyl in 9 patients and parenteral fentanyl in 11 patients . Total opioid dose increased from 64 mg oral morphine equivalent/day ( Day 0 ) to 98 mg/day ( Day 7 ) , and the median increase in total opioid dose was 42 % . Treatment success , defined as an MDAS score below 10 and pain score of 2 or less , was obtained in 13 patients on Day 3 and 18 patients on Day 7 . The mean MDAS score significantly decreased from 14 ( Day 0 ) to 6.4 and 3.6 ( Days 3 and 7 , respectively , P < 0.001 ) . Pain scores significantly decreased from 2.2 ( Day 0 ) to 1.3 and 1.1 on the categorical verbal scale ( Days 3 and 7 , respectively , P < 0.001 ) ; from 2.6 ( Day 0 ) to 1.6 and 1.3 on the STAS ( Days 3 and 7 , respectively , P < 0.001 ) . Symptom scores of dry mouth , nausea , and vomiting significantly decreased , and performance status significantly improved . Opioid rotation from morphine to fentanyl may be effective in alleviating delirium and pain in cancer patients with morphine-induced delirium Patients with cancer often are rotated from other opioids to methadone to improve the balance between analgesia and side effects . To the authors ' knowledge , no clear guidelines currently exist for the safe and effective rotation from transdermal fentanyl to methadone PURPOSE The aim of this study was to examine the clinical effects of switching from transdermal ( TTS ) fentanyl to methadone , or vice versa , in patients with a poor response to the previous opioid . PATIENTS AND METHODS A prospect i ve study was carried out on 31 patients who switched from TTS fentanyl to oral methadone , or vice versa , because of poor opioid response . A fixed conversion ratio of fentanyl to methadone of 1:20 was started and assisted by rescue doses of opioids , and then doses were changed according to clinical response . Pain and symptom intensity , expressed as distress score , were recorded before switching doses of the two opioids and after subsequent doses . The number of changes of the daily doses , time to achieve stabilization , and hospital stay were also recorded . RESULTS Eighteen patients were switched from TTS fentanyl to methadone , and seven patients were switched from methadone to TTS fentanyl . A significant decrease in pain and symptom intensity , expressed as symptom distress score , was found within 24 hours after switching took place in both directions . Unsuccessful switching occurred in six patients , who were subsequently treated with an alternative therapy . CONCLUSION A rapid switching using an initial fixed ratio of fentanyl to methadone of 1:20 is an effective method to improve the balance between analgesia and adverse effects in cancer patients with poor response to the previous opioid . No relationship between the final opioid dose and the dose of the previous opioid has been found & NA ; The successful use of methadone in cancer pain has been supported by numerous case reports and clinical studies . Methadone is usually used as a second or third line opioid medication . 
    Output:
    
Pain intensity was significantly reduced in the majority of studies .
Serious adverse effects were improved .