Ahmedzai 1997.

Methods	Design: multicentre, randomised, open label, two‐period cross‐over study. Initial opioid dose calculated using manufacturers recommendations, with dose titration at start of each period to achieve pain control. Assessed at baseline and 8, 16, 23, 31 days, and by daily patient diary Duration: 2 x 15 days, no washout between periods + titration Setting: Palliative care centres, UK
Participants	Adult cancer patients requiring strong opioid analgesia and receiving stable dose of morphine for at least 48 hours Life expectancy > 1 month N = 202 M 112, F 90 Mean age 62 years (range 18 to 89)
Interventions	Transdermal fentanyl patch, new patch every 72 hours Sustained release oral morphine, given 12‐hourly MIR was used freely to titrate pain at the start of study and at cross‐over Where possible other medication remained unchanged, but other analgesics allowed: e.g. NSAIDs, permitted radiotherapy, nerve blocks
Outcomes	Sleep, rescue medication, drowsiness: VAS, daily diary Pain and mood: Memorial Pain Assessment Card, twice daily QoL (self‐rated): EORTC (European Organisation for Research and Treatment of Cancer) QLQ‐C30 Performance status (clinician rated): WHO scale Treatment preference Adverse events
Notes	Oxford Quality Score: R = 1, DB = 0, W = 1. Total = 2/5
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Method used to generate sequence not clearly stated
Allocation concealment (selection bias)	Unclear risk	Method not described
Blinding of participants and personnel (performance bias) All outcomes	High risk	Open study
Blinding of outcome assessment (detection bias) All outcomes	High risk	Open study
Incomplete adverse event outcome data‐ patient level	Unclear risk	Presented as numbers of AEs but not clear whether this is events or participants. Denominator unclear.
Selective reporting bias for adverse events	High risk	Only commonest events reported
Size	Low risk	> 200 participants per treatment arm