Opioid treatment for radiating cancer pain: oral administration vs. epidural techniques

Abstract

In order to determine the optimal pain treatment for patients with cancer involvement of the brachial or lumbar nerve plexuses, a prospective comparative study was carried out using peroral opioid therapy (SO), epidural opioid by a conventional tunnelled epidural catheter (CE) or an epidural catheter connected to an implanted injection port (Port). Pain relief, measured by a visual analog scale (VAS), was similar and adequate in every group already after the first 24 h. CNS side-effects were less frequent and the Karnofsky performance grades slightly superior in the epidural groups. Occlusion and catheter disconnection complicated the pain therapy of five epidural port patients. Epidural dislocation occurred three times in the conventional epidural group. One local infection in the CE group and two in the Port group were recorded. However, no signs of epidural infection were seen at autopsy. The results suggest that due to a lower incidence of side-effects, epidural catheter techniques are superior to peroral opioid in treating pain in these patients. However, complete pain relief was not achieved in all patients, suggesting neurogenic, non-nociceptive pain components. Both epidural techniques seem suitable for long-term pain therapy. Technical improvements are needed in the epidural catheter and the port. The long-term epidural catheter does not seem to cause any major changes in the histology of the dura mater or the connective tissue of the epidural space.

Intraspinal techniques for pain management in cancer patients: a systematic review

“…Systematic reviews, consensus conferences, and randomized controlled trials Three systematic reviews [5][6][7], three consensus conferences [8][9][10], and 12 RCTs [11][12][13][14][15][16][17][18][19][20][21][22] met the selection criteria of studies examining clinical effectiveness. Although the systematic reviews and consensus conferences included some relevant RCTs, no single systematic review or consensus conference included all relevant RCTs or sufficiently discussed the effectiveness of intraspinal analgesia for cancer-related pain to support recommendations.…”

“…In a three-arm trial, Vainio [11] (n=30) compared morphine given orally by conventional tunneled catheter or by implanted catheter. All three groups achieved marked pain relief and did not differ statistically from one another, but a higher rate of side effects was observed in the oral morphine group (16 occurrences compared with seven occurrences in the conventional epidural group and three occurrences in the port group).…”

Controversies over spinal treatment in advanced cancer patients

“…The administration of opioids by the epidural route has been compared with other less invasive forms of analgesia. Oral morphine has been reported to provide similar pain control to that from epidural morphine in patients with plexus involvement, and although fewer side effects were reported with epidural opioids technical problems were frequent [60]. No differences were found between continuous reaction time values and pain intensity in cancer patients treated with chronic oral opioids versus epidural opioids.…”

Spinal analgesia: where is the evidence?

“…The authors identified three randomized controlled trials comparing intraspinal with systemic analgesia [2][3][4]. The first study by Vanino et al found no statistically significant difference in pain [2]; the second study by Smith et al revealed a borderline statistical significance of questionable clinical value [3], while the third council study revealed no difference in pain control between epidural and subcutaneous administration of morphine [4]. The methodologic quality of the three included studies needs to be highlighted.…”

“…The methodologic quality of the three included studies needs to be highlighted. Two studies reported no sample size calculations, and both appeared to be under-powered [2,4]. Two were open-label studies [2,3] which could significantly affect how pain and side effects were assessed.…”