Support Care Cancer (1998) 6:482–485 © Springer-Verlag 1998
Sebastiano Mercadante
S. Mercadante, M.D. Pain Relief and Palliative Care, SAMOT, via Libertà 191, I-90143 Palermo, Italy Tel.: +39–91–302876 Fax: +39–91–303098 email:
[email protected]
SHORT COMMUNICATION
Opioid responsiveness in patients with advanced head and neck cancer
Abstract The degree of opioid responsiveness in patients with different pain syndromes associated with advanced head and neck cancer was studied with the aid of various indices that have proved to be easy to compare and capable of eliciting individual profiles of opioid responsiveness in cancer patients with pain. Thirty-seven patients requiring opioid therapy for more than 6 weeks were reviewed. The opioid escalation index (OEI) was lower in aged patients, albeit not significantly. Significant differences in OEI were found among patients belonging to the different categories of responses proposed.
Introduction In the Unites States and Europe 5% of all cancers originate in the head and neck area [1, 17, 19]. More than 60% of patients who present with locally advanced disease (stage 3 or 4) have a poor prognosis [16]. Pain is an important symptom in these patients and should be carefully treated. The majority of patients have pain caused by cancer (83%) and/or treatment (28%) [6]. Painful syndromes include deep tissue infiltration, tumor ulceration, cranial nerve involvement, mucositis and fibrosis as a result of radiotherapy or surgery, and they are usually multiple. Patients with advanced head and neck cancer are difficult to manage because of the multiple and complex problems, including difficulties in communication, nutritional deficits, generalized weakness, dental problems and mouth odor, various degrees of immobility of the head, neck and shoulder, anxiety and depression, tracheostomy care, wound management, and nutrition, that may occur simultaneously as a re-
Although higher doses were needed than reported in the general population, pain was considered acceptable and most patients were classified as partially responsive. Neuropathic pain was associated with higher OEIs. The indices applied will be useful in clinical research to demonstrate individual profiles of opioid responsiveness, from cases of easy and immediate pain control to unresponsiveness to opioid treatment, which can be difficult to evaluate in the clinical setting. Key words Cancer pain · Head and neck cancer · Opioid responsiveness
sult of advanced disease [5]. Different staging systems have been developed to predict the pain response [3, 9], although patients with a poor prognosis still achieve good pain control in more than 50% of cases [3]. There are continuing controversies over the relative differences in opioid responsiveness in different pain syndromes. Head and neck cancer and other factors, including gender, age, previous chemotherapy, and neuropsychiatric symptoms, have been found to influence the opioid escalation in a previous study on a general cancer population with pain requiring opioids [12]. Opioid escalation indices were higher in the five patients with head and neck cancer, although no patient was considered unresponsive to opioid treatment. This observation suggested that pain syndromes related to this kind of tumor would present more difficulties in treatment. The aim of this study was to establish the degree of opioid sensitivity and possible factors involved in patients with head and neck cancer in an advanced stage being followed up at home, using some indices that have proved to
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Table 1 Characteristics of patients in the two groups considered (good responsiveness and partial responsiveness respectively). No patients were classed as unresponsive (OEI% opioid escalation index)
Table 2 Explanation of the indices used to evaluate opioid responsiveness Index
Group 1
Group 2
12 62 6/6 77 60 2.5 0.5 2.2 (2)
25 60 15/10 70 82 * 5* 0.9 * 2.7 (3)
Explanation
OEI% Patients Age (median) Sex (M/F) Survival Maximum opioid dosage (mean) OEI% OEImg VAS (mean and median) Pain (no. of patients) Somatic Visceral Neuropathic Nonopioid analgesics Steroids Constipation Drowsiness Dry mouth Confusion Nausea and vomiting *
9 14 8 11 8 (OEI % 3.1) 11 (OEI % 6.2) 9 (75%) 18 (72%) 5 (41%) 1 (8%) 5 (41%) 1 (8%) 2 (16%)
17 (68%) 8 (32%) 12 (48%) 3 (12%) 4 (16%)
* *
Opioid escalation index per cent is the mean percentage increase in opioid dosage from the opioid starting dose (OSD) according to the formula [(OMD–OSD)/ OSD]/days × 100) OEImg Opioid escalation index in milligrams is the mean increase in opioid dosage in milligrams according to the formula (OMD–OSD)/days EAS Equianalgesic score, calculated at fixed weekly intervals from the formula VASx–VASy (1+M/10x)/(1+M/10y), where 1 indicates the administration of anti-inflammatory drugs, M indicates the dosage in milligrams of opioids in morphine-equivalents per os, x and y indicate the different weeks taken into consideration (e.g. the 3rd week versus the 2nd). A slow increase in EAS (100% compared with that calculated the previous week) represent difficulties in achieving adequate analgesia owing to periods of pain crisis
P
