Opioid titration with sustained-release oxycodone and immediate-release morphine for moderate/severe cancer pain: a pilot assessment of the CoDem protocol

J Opioid Manag. 2014 Jan-Feb;10(1):29-38. doi: 10.5055/jom.2014.0189.


Objectives: Opioid titration is the first challenging stage for rapid control of moderate/severe cancer pain. Evidence shows that sustained-release formulations may be used for opioid titration. We set a pilot assessment of the efficacy and tolerability of our in-house protocol (continuous and on demand opioids [CoDem]) of the association of sustained-release oxycodone and immediate-release morphine as rescue dose for opioid titration/rotation in opioid-naïve (NAOP, n = 13), tolerant to weak (WOP, n = 20), or strong opioids (STOP, n = 44) in-patients with moderate/severe cancer pain.

Methods: Observational and retrospective analysis of cancer in-patients treated for ≥7 days with the CoDem protocol.

Outcome measures: Pain intensity (patients self-reported pain with numerical rating scale [NRS] under static [NRSs] and dynamic [NRSd] conditions), amount of drug consumption, opioid adverse effects, and patient satisfaction.

Efficacy endpoints: In more than 50 percent of the patients and in <72 hours, steady NRSs and NRSd score reduction of at least two points, NRSs ≤ 3 and NRSd ≤4; and mean daily morphine consumption < mean of one rescue dose and t1:t6 ratio of mean oxycodone daily dose < 1:2.

Results: Endpoints were reached within 24 hours both within the sample and subgroups. Only NAOP patients reached NRSd ≤ 4 endpoint within 48 hours. Against moderate and transient adverse effects, most patients (84.4 percent) found pain treatment to be good or excellent.

Conclusions: The CoDem protocol was shown to be effective and reasonably tolerated for titration for moderate/severe cancer pain relief in both opioid-naïve or opioid-tolerant cancer in-patients. This pilot assessment warrants prospective and comparative studies with larger samples for more generalized results.

MeSH terms

  • Adult
  • Aged
  • Analgesics, Opioid / administration & dosage*
  • Chemistry, Pharmaceutical
  • Delayed-Action Preparations
  • Female
  • Humans
  • Male
  • Middle Aged
  • Morphine / administration & dosage*
  • Morphine / adverse effects
  • Neoplasms / physiopathology*
  • Oxycodone / administration & dosage*
  • Oxycodone / adverse effects
  • Pain, Intractable / drug therapy*
  • Pilot Projects
  • Retrospective Studies


  • Analgesics, Opioid
  • Delayed-Action Preparations
  • Morphine
  • Oxycodone