Pain management in patients undergoing radiation therapy for head and neck cancer – a descriptive study

Abstract

ObjectivesPatients with head and neck cancer (HNC) experience serious pain related to tumour, surgery, chemotherapy, and radiotherapy treatment (RT). Oral mucositis, a painful complication of RT, may require opioid analgesics to control pain.This longitudinal study, during RT but also four weeks post-RT, examines the relationships between oral mucositis, pain, and opioid doses in in HNC patients. The aim was to evaluate the clinical effectiveness of an opioid treatment strategy.MethodsSixty-three patients with HNC undergoing radiotherapy answered self-reported questionnaires on pain intensity on a 0–10 numerical rating scale (NRS) three times a week. Oral mucositis signs were evaluated using the WHO mucositis index score, ranging from 0 (normal) to 4 (severe), and pharmacological treatment with opioids was registered prospectively once a week. All data were related to given radiation dose, and all outcome measures at each time point therefore relate to the same radiation dose (i.e., not to when the patient was included in the study).ResultsOpioids were used by 78% of the patients. Most of the patients experienced only mild pain (NRS 0–4), although the majority developed mucositis grade 2–4 according to WHO mucositis index. Function-related pain intensity and opioid doses were highest during the sixth week of RT, with 3.67 (0–9) in NRS and 84 (0–430) mg oral morphine equivalents per day (median, range). At that same time point, significant positive correlations were found between the grade of mucositis and pain intensities. Patients with mucositis grade 2–4 were investigated further; in this subgroup, we found that opioid doses did not differ between patients with mild pain and patients with moderate to severe pain. Our multivariate data analysis defined a cluster of patients characterized by the presence of mucositis, cancer site in pharynx, concomitant chemotherapy, and the absence of surgery.ConclusionsIn HNC patients who were followed closely by pain care personnel during and after RT, pain was often satisfactorily alleviated with a structured use of opioids, including stepwise increases of fentanyl patches and oral morphine as needed. However, some patients with oral mucositis grade 2–4 experienced severe pain. Strong opioids, i.e. the third step of the WHO pain ladder, remain the mainstay of analgesic therapy in treating moderate to severe cancer-related pain, including patients with HNC. This real-life study indicates that RT-related pain is not a fatality. A proactive stance, monitoring these patients closely and regularly, is probably crucial in order to achieve good treatment results. Further studies are needed to develop better pain treatment strategies for those patients who develop severe oral mucositis-related pain despite intensive opioid treatment.

Opioid Sparing Multimodal Analgesia for Transoral Robotic Surgery: Improved Analgesia and Narcotic Use Reduction

“…Up to 80% of HNC patients undergoing surgical treatment with adjuvant therapy experience pain requiring prescription opioids. 16 Paradoxically, patient satisfaction with narcotic‐based pain regimens is low, with 70% to 85% of patients reporting ineffective pain control. 17 Moreover, the surgical approaches to address HNC range from minimally invasive TORS to extensive ablation with tissue transfer reconstruction.…”

“…Narcotics have historically served as the cornerstone of pain protocols and can effectually moderate pain, but carry potentially deleterious side effects, including respiratory depression, nausea and vomiting, impaired mobilization, and the possibility of chronic dependence. Up to 80% of HNC patients undergoing surgical treatment with adjuvant therapy experience pain requiring prescription opioids 16 . Paradoxically, patient satisfaction with narcotic‐based pain regimens is low, with 70% to 85% of patients reporting ineffective pain control 17 .…”

Temporal Characterization of Longitudinal Sequelae Including Acute Pain, Physiologic Status, and Toxicity Kinetics in Head and Neck Cancer Patients Receiving Radiotherapy: A Prospective Electronic Health Record Embedded Registry Study

“…It also showed that most patients undergoing cancer treatment quickly escalated along the prescription ladder to requiring strong opioids for adequate pain management (9, 11). Schaller et al performed a descriptive study of pain management in HNC patients during RT revealed that strong opioids represented the majority of analgesics used for moderate to severe pain management, with alleviation of pain in patients receiving structured use of opioids, and severe pain was association with patients presenting with high grades of mucositis (2+) (32).…”

“…Prescribed analgesics data and the cumulative analgesics used by patients were collected from our EHR and categorized into the following groups: 1) Topical analgesics (xyloxylin and lidocaine), 2) Non-opioids (anti-inflammatory drugs: NSAID, acetaminophen), 3) Weak opioids (codeine, hydrocodone, dihydrocodeine, and tramadol) (12, 30), 4) Strong opioids (morphine, hydromorphone, fentanyl, methadone, and oxycodone) (30) and 5) gabapentin. A similar approach to categorizing weak versus strong opioids based on WHO has been described by Gupta et al (31) and colleagues (11,32).…”

Higher Toxicity Rates Following Hypofractionated Radiotherapy in Early Glottic Cancer Patients

“…Opioids are a cornerstone in the treatment of radiation-induced pain in head and neck cancer patients. Opioid dosages are often used as indicators of pain levels in these patients, as they are often correlate [23].…”