Morphine Mouthwash

To investigate the efficacy of topical morphine compared to routine therapy (magic mouthwash) in the management of oral mucositis in patients with head and neck cancer

In the study group, 10 ml of morphine sulfate 2% was given every three hours, six times per day for six days while the control group received 10 ml magic mouthwash (240 ml of magnesium hydroxide, 25 ml of 2% viscous lidocaine, and 60 ml of diphenhydramine) on the same schedule. The intervention was initiated when patients with head and neck cancer presented with grade 3 or 4 mucositis from chemotherapy, radiotherapy, or chemoradiotherapy. Patients in both arms were instructed to hold the solution in thier mouths for at least two minutes and to not swallow.

• N = 28  
• MEAN AGE = 49.5 years
• MALES: 36.7%, FEMALES: 63.3%
• KEY DISEASE CHARACTERISTICS: Head and neck cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Adults receiving chemotherapy, radiotherapy, or chemoradiotherapy; World Health Organization (WHO) grade 3 or 4 oral mucositis; no current alcohol or smoking  

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Omid Oncology Hospital in Isfahan, Iran (April–July 2011)

• PHASE OF CARE: Active antitumor treatment

Randomized, double-blinded, controlled study

• A blinded radiation oncologist graded mucositis according to WHO guidelines at baseline, day 3, and day 6.
• Patients were asked if pain or discomfort was relieved by mouthwash, and if so, for how long (less than one hour, one to two hours, or greater than two hours).
• Patients also were asked to grade their satisfaction with treatment (satisfied, tolerable, or intolerable).

No significant difference in treatments were found on the third day. On day 6, there was a significant reduction in mucositis severity in patients in the morphine arm (p = 0.045). The trend in mucositis change showed a decrease in severity in both arms.

Both morphine and magic mouthwash were effective in reducing mucositis severity. However, topical morphine was more effective, and its results were more satisfactory to patients than the magic mouthwash.

• Small sample (< 30)
• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results 
• Other limitations/explanation: This study had a small sample size, and there were not enough patients in the study to make recommendations. There was a single inpatient site, a heterogeneous population, and it was unclear how many different medical oncologists assessed mucositis (inter-rater reliability). This study had a short observation period. It was unclear if mucositis would have improved if saline mouth rinses were used instead of magic mouthwash. The act of performing oral care six times per day might have caused the change in mucositis grade.

More studies in larger populations are needed for this intervention. Its comparison to magic mouthwash was questionable because it is not effective in reducing mucositis severity.