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PURPOSE Supplemental, "as-needed," administration of an opioid is a common approach to the problem of breakthrough pain in cancer patients. Oral transmucosal fentanyl citrate (OTFC) is undergoing investigation as a new treatment for breakthrough pain. The primary purpose of the study was to demonstrate that a single-unit dose of OTFC can safely and effectively treat breakthrough pain. A secondary goal was to determine appropriate dosing guidelines. PATIENTS AND METHODS This was a multicenter, randomized, double-blind, dose-titration study in 62 adult cancer patients using transdermal fentanyl for persistent pain. Consenting patients provided 2 days of baseline data to evaluate the performance of their usual breakthrough pain medication. Patients then randomly received 200 microg or 400 microg OTFC in double-blind fashion. (Patients were always assigned, rather than randomized, to 200 microg if 400 microg represented > 20% of around-the-clock medication.) Pain intensity (PI), pain relief (PR), and global satisfaction scores were recorded. OTFC was then titrated until the patient received adequate PR for each episode using one OTFC unit. Orders to titrate up were ignored one third of the time to improve the blind. Two days of baseline data were compared with 2 days of OTFC data after titration identified an effective dose of OTFC. RESULTS Most patients (76%) found a safe and effective dose of OTFC. There was no meaningful relationship between the around-the-clock opioid regimen and the effective dose of OTFC. In open-label comparisons, OTFC produced a faster onset of relief and a greater degree of PR than patients' usual breakthrough medication. Somnolence, nausea, and dizziness were the most common side effects associated with OTFC. CONCLUSION Most patients find a single OTFC dosage that adequately treats breakthrough pain. The optimal dose is found by titration and is not predicted by around-the-clock dose of opioids.

Using national yield tables as a basis, the growth of Scots pine Pinus sylvestris L., Lodgepole pine Pinus contorta Douglas ex Loud., Norway spruce Picea abies (L.) Karst. and Sitka spruce Picea sitchensis (Bong.) Carr. have been compared. From the trends of height growth with age and the levels of total volume production the paper attempts to relate the differences in growth in the various countries climatic factors. In the first part broad comparisons are made between the climatic types in Britain with those of Northern Europe and N.W. America and certain aspects such as growing season length, accumulated temperature, frost-free season, day-length and availability of water are high-lighted. Forest trees differ biologically from low-growing vegetation in growth response to climatic factors and as only one of the four species is native to Britain the yield tables considered may be based on different genotypes. In the second part the productivity of each species is examined separately and tentative conclusions are offered for the observed differences, which may be very large. Part of this variation may be due directly to climatic effects or climatic/genotype interactions, largely appearing as a latitudinal cline with increased growth at lower latitudes and/or as better growth under the longer growing season of maritime climates. The rest (varying with species) is attributed to differences between provenances, soil factors, stocking or silvicultural treatment. In general forest productivity in Britain is shown to compare very favourably with that in N. Europe and N.W. America.