Monitoring of opioid therapy in advanced cancer pain patients

Abstract

Until now, there have not been any parameters to monitor opioid therapy in cancer patients with pain. In this study, 325 consecutive advanced cancer patients were scheduled for a prospective longitudinal survey. After exclusions, 67 patients were surveyed. All included patients were advanced cancer patients with pain that required opioid therapy for more than 6 weeks before death. Opioid escalation, symptoms associated with opioid therapy, pain mechanism, and pain intensity were recorded. Indices were calculated to categorize the response to opioids. The opioid escalation index (OEI) was used to index the mean increase of the starting opioid dosage, expressed as a percentage or in mg. The length of the period of stable dose (MLD) and the effective analgesic score (EAS), that is, the analgesic consumption/pain relief ratio calculated at fixed intervals, were also used. Patients with a mean visual analogue scale score (VAS) of less than 4 and regular OEI and EAS were considered responsive; patients with a mean VAS less than 4 but with an OEI more than 5 or increases of more than 100% of EAS when compared to that calculated the week before were considered mildly responsive; and patients with a mean VAS more than 4 were considered unresponsive. Advanced age, female gender, and previous chemotherapy were all factors reducing OEI. Head and neck cancer was associated with a higher OEI. Regarding the influence of the opioid-related symptoms, an increased OEI was associated with the presence of confusion. Moreover the presence of confusion was associated with neuropathic pain. Neuropathic pain taken alone, however, did not influence this score. Gender-specific cancer, such as breast cancer, influenced the gender differences reported for MLD (significantly longer than that reported for males and other primary tumor). Good responsiveness was observed in 28 patients, partial responsiveness in 33 patients, unresponsiveness in six patients. Psychological factors were associated with poor pain relief, probably reducing the patient's compliance. The tools used in this study may be useful in monitoring the effects of opioid therapy in cancer pain patients. Simple numbers are easy to compare and make it possible to profile opioid responsiveness and differences among patients.

Opioid-induced or pain relief-reduced symptoms in advanced cancer patients?

“…Opioid doses at the end of titration were relatively large presenting an OEI of 59 mg per day, which is extremely higher Table 1 Pain intensity and well being (scale 0-10), symptoms and other variables examined (scale 0-3), expressed as mean (CI 95%), opioid dose in oral morphine equivalents (mg). Patients who presented a symptom intensity of 2-3 (scale 0-3, see text) in comparison with a previous observation in home care patients (Mercadante et al, 1997). Opioid doses were relatively stable at the following intervals.…”

“…Opioid escalation index in mg (OEI mg) was calculated as the mean increase of opioid dosage in mg using the following formula: (OMD À OSD)/days. The meaning of this score, improved by this formula, has been discussed in previous studies (Mercadante et al, 1997).…”

Long-term efficacy of botulinum toxin A for treatment of blepharospasm, hemifacial spasm, and spastic entropion: a multicentre study using two drug-dose escalation indexes

“…In our study, we have for the first time used two indexes that are already widely used in other drug therapy studies 53,60 for assessing the medium, long-term effects of a specific treatment with uncertain duration. These indexes, namely 'botulin toxin escalation index-U' (BEI-U) and 'botulin toxin escalation index percentage' (BEI-%), include several factors, but are easy to calculate for different settings and periods and can be used to compare data in clinical trials.…”

“…To assess the inter-and intra-group variations among BEB, HFS, and EN patients for scheduling dosage regimens of BoNT-A, we used two new, modified indexes already used in other fields of drug therapy and considered effective in evaluation of drug-dose escalation. 53 For the calculation of these indexes (evaluated in U and in per cent of BoNT-A-dose escalation), the botulinum toxin starting dose (BSD), the botulinum toxin maximum dose (BMD), and the total days of duration effect between treatments were recorded for each patient. The botulinum toxin escalation index in U (BEI-U) was calculated as the mean increase in botulinum toxin dosage (in U) using the following formula: (BMD-BSD)/ days.…”

“…In particular, we examined the variations in therapeutic dosage using new, modified indexes already used in other drug therapies and considered effective in the evaluation of drug-dose escalation. 53 Finally, we assessed the effectiveness of BoNT-A treatment in relationship to patient variables, such as age and gender.…”