Opioid Responsiveness-Primary Diagnosis Relationship in Advanced Cancer Patients Followed At Home

Abstract

The aim of this study was to evaluate the influence of the primary cancer on pain characteristics and opioid response, in terms of analgesia and adverse effects, in advanced cancer patients followed at home. A prospective study was carried out in a sample of 434 consecutive advanced cancer patients who required opioids during the last four weeks of life. One hundred eighty-one patients received opioids for longer than the four weeks and were considered for this analysis. Demographic data, primary diagnosis, and pain mechanisms were recorded, and mean opioid doses, pain intensity, and symptoms were assessed at weekly intervals during the last four weeks of life. In the group of 181 patients, somatic pain was associated with lung, head and neck, breast, and prostate cancer (p < 0.0005), while visceral pain was associated with colorectal, gastric, liver, pancreatic, and uterine cancer (p < 0.0005). Considering all primary diagnoses, there was a significant increase in the mean opioid dose (p < 0.0005) across the four weekly periods. There was a significant decrease in pain intensity scores (p < 0.0005) in all cases. A significant dose increase was observed only for mesothelioma (p = 0. 027) when compared with other types of cancer. In all 181 cases, a significant worsening in symptom intensity was observed during the last two weeks of life (p < 0.01). This study shows that primary cancer may have an influence on pain characteristics and opioid response. Patients with some kinds of cancer may be at risk of developing severe pain syndromes or more adverse effects.

Predicting pain and pain responses to opioids

“…no currently identifiable physical cause and often with suggestive psycho-neuro-immunological components, to so-called nociceptive, neuropathic and mixed pain, there is a substantial overlap of variables predicting a poorer pain prognosis (Table 3). Individuals with the following characteristics have a (Mercandante et al, 1992;Gwee et al, 1999;Mercandante et al, 2000;Mercandante et al, 2001;Edwards et al, 2003;Staud et al, 2003;Attal et al, 2004;Payne, 2004;Staud, 2004;Diatchenko et al, 2005;Edwards, 2005;Gunnarsdottir et al, 2005;Spiller and Campbell, 2006;Moller et al, 2006). In addition, psychosocial factors again emerged as relevant, with negative affect, somatisation, patient beliefs, education and expectations, life events stressors, depression and past abuse correlating with increased chronic pain.…”

“…Prediction of dose responses would allow a more rapid attainment of pain control and a reduction in adverse events. Prediction of responses to opioids has been evaluated in cancer pain and Up to 50% prediction Mercandante, 1992, 2000, 2001Gwee, 1999Edwards 2003Staud 2003Attal, 2004Payne, 2004Edwards, 2005Gunnarsdottir, 2005Spiller, 2005Moller, 2006 in neuropathic pain, with fewer studies in postoperative and chronic non-cancer pain studies (Table 4). The majority of factors predictive for pain also are predictive for analgesia from opioids.…”

“…The majority of factors predictive for pain also are predictive for analgesia from opioids. Additional interesting variables include a history of addiction, opioid side-effects and increased white cell and platelet counts (Mercandante et al, 2000;Riley et al, 2004;Fainsinger et al, 2005). These factors may be related to differences in opioid receptor properties.…”

Morphine in cancer pain management: a practical guide

“…Morphine is the recommended opioid for chronic severe pain, and in 85% of patients it is effective when given by mouth every 4 h [105,141,176,282,284]. The preference for morphine is grounded not only in its analgesic efficacy, but also in extensive clinical experience, dose flexibility, and multiple formulations and routes of administration [182,270,282,284]. Concerns about addiction, tolerance, dependence, and respiratory depression, previously exaggerated, have now been put into the correct context [127, 176,282,283,284].…”

“…Concerns about addiction, tolerance, dependence, and respiratory depression, previously exaggerated, have now been put into the correct context [127, 176,282,283,284]. Morphine is a safe, effective medication when used correctly, even in severely debilitated people [182,283]. Pain management in cancer is nevertheless frequently unsatisfactory owing to ignorance about morphine pharmacology, fear of addiction, or side effects.…”