Vol. 19 No. 5 May 2000 Letters 327

opioids are prescribed under severely restrictedreimbursement.

Donna Zhukovsky, MDDeclan Walsh, MDMarie Doona, MDThe Cleveland ClinicCleveland, Ohio, USA

PII S0885-3924(00)00135-4

References

1. Houde R. The use and misuse of narcotics in thetreatment of chronic pain. In: Bonica JJ, ed. Ad-vances in Neurology. New York: Raven Press, 1974;4:527–538.

2. Kaiko R, Lacouture P, Hopf K, et al. Analgesic on-set and potency of oral controlled-release (CR) oxy-codone and CR morphine [abstract]. Clin Pharma-col Ther 1996;59:130.

3. Kaiko RF. The use of controlled release opioids.In: Parris WCV, ed. Cancer pain management: prin-ciples and practice. Boston: Butterworth–Heine-mann, 1997:69–90.

4. Glare PA, Walsh D. Oxycodone: a substitute formorphine in cancer pain management [letter]. Pal-liat Med 1992;6:79–80.

5. Zhukovsky DS, Walsh D, Doona M. The relativepotency between high dose oral oxycodone and in-travenous morphine: a case illustration. J PainSymptom Manage 1999;18:53–55.

6. Glare PA, Walsh TD. Dose-ranging study of oxy-codone for chronic pain in advanced cancer. J ClinOncol 1993;11:973–978.

7. Kalso E, Vainio A. Morphine and oxycodone hy-drochloride in the management of cancer pain.Clin Pharmacol Ther 1990;47:639–646.

8. Houde RW. Systemic analgesics and relateddrugs: narcotic analgesics. In: Bonica JJ, VentafriddaV, eds. Advances in pain research and therapy, Vol2. New York: Raven Press, 1979:263–273.

Nebulized Scopolamine

To the Editor:Excessive oral secretions or difficulty swal-

lowing saliva can cause unacceptable symptomsin some patients, particularly those with headand neck cancer, motor neuron disease, andParkinson’s disease. Various drug treatmentshave been tried including scopolamine, atro-pine, and glycopyrrolate, with varying degrees

of response. Following the recent publicationregarding nebulized scopolamine for the man-agement or oral dribbling,

1

we wish to reportour experience with two patients.

The first was a 57-year-old woman sufferingfrom familial amyotrophic lateral sclerosis. Onadmission she had great difficulty swallowingor speaking and was fed via a gastrostomy. Shehad profuse oral secretions, for which she con-stantly kept absorbent gauze in her mouth, anddrooling, which necessitated wearing a bib.She previously received propantheline bro-mide 7.5 mg 3 times a day orally with no im-provement in the dribbling. She agreed to atrial of nebulized scopolamine and this wascommenced at a dose of 800

m

g 3 times daily.Within 24 hours, nursing staff and family re-ported a noticeable reduction in oral secre-tions. However, the patient was not happy withthe frequency of administration. She agreed totry once-daily administration only. The secre-tions quickly increased and she then agreed toreturn to the original scopolamine dose. Thisprovided good symptom relief, and no side ef-fects were noted.

After 8 days of treatment it became apparentthat she was concerned about dryness of hermouth immediately following nebulizations,and, to a lesser extent, change in taste sensa-tion. We offered to stop the medication, butthe patient refused this option. We thereforereduced the scopolamine dose to 400

m

g 3times daily and then to 200

m

g 3 times dailydue to persistent dry mouth. Rescue doses of200

m

g were allowed, and these were acceptedby the patient. At this lower regular dose, thepatient was observed to be drooling more, re-quiring more changes of the gauze swabs andneeding more suctioning for oral secretion. Asthe patient was requesting 1–2 extra nebuliza-tions per day, the dose was increased to 200

m

g4 times daily.

In this brief clinical experience with this newroute of administering scopolamine, the pa-tient, family and staff were impressed with thereduction in oral secretions that occurred. In-deed, the most significant complication ap-peared to be excess dryness of the mouth im-mediately following the drug’s administration,which the patient found uncomfortable andwhich at one point produced a small fissurewith resultant bleeding of the upper lip. We

328 Letters Vol. 19 No. 5 May 2000

continue to find that her oral salivation fluctu-ates between producing copious amounts orbeing excessively dry, depending on the timingof the nebulizations. However, overall we be-lieve that this has resulted in a significantimprovement in this patient’s problem. Noevidence of CNS or gastrointestinal anticholin-ergic side effects was seen, and this suggeststhat the drug’s action was occurring throughlocal absorption at the level of the salivarygland as proposed by Dr. Zeppetella.

1

The second patient was a 75-year-old womanwith metastatic squamous cell carcinoma of thefloor of the mouth causing complete dysphagiafor which a gastrostomy tube was inserted. Shewas referred to our outpatient Pain and Symp-tom Clinic with excessive oral secretions andpain. The secretions were causing her greatdistress and embarrassment and limiting hersocial activities. She also reported disturbedsleep, having to get up and suction the secre-tions several times each night. She scored thisproblem as 8/10 on the visual analogue scale.

We prescribed scopolamine nebulizations400

m

g 4 times daily and she used these regu-larly for 7 days. At review, the patient and herfamily reported that her oral secretions had re-duced dramatically and her rating score of thisproblem had fallen to 3/10. No adverse side ef-fects were reported and she is very keen to con-tinue with this therapy.

This appears to be an interesting new routefor administration of scopolamine, which war-rants further study. Further research in thisarea could include an

N

of 1 study with multi-

ple crossovers between nebulized saline andnebulized scopolamine. Outcome could bemeasured using subjective sensation by the pa-tient and blinded observer rating of oral secre-tions. A similar approach has been used previ-ously to study the role of oxygen for dyspnea.

2

In addition, to further investigate the benefitsand side effects of nebulized vs. subcutaneousscopolamine, a double-blind, double-dummy,crossover study could be conducted using neb-ulized scopolamine vs. subcutaneous scopola-mine with nebulized saline and subcutaneoussaline as placebo controls.

Julia Doyle, MB, BChPembridge Palliative Care UnitLondon, United Kingdom

Paul Walker, MDGrey Nuns Community Hospital & Health CentreEdmonton, Alberta, Canada

Eduardo Bruera, MDUniversity of Texas, M. D. Anderson Cancer CenterHouston, TX, USA

PII S0885-3924(00)00132-9

References

1. Zeppetella G. Nebulized scopolamine in themanagement of oral dribbling. J Pain SymptomManage 1999;17:293–295.

2. Bruera E, Schoeller T, MacEachern T. Symptom-atic benefit of supplemental oxygen in hypoxemicpatients with terminal cancer: the use of the

N

of 1randomized controlled trial. J Pain Symptom Man-age 1992;7:365–368.