Spinal opioids in adult patients with cancer pain: a systematic review: a European Palliative Care Research Collaborative (EPCRC) opioid guidelines project

Efficacy of epidural analgesia for intractable cancer pain: A systematic review

BACKGROUND

Epidural analgesia is a common technique for managing perioperative and obstetric pain. Patients with cancer who cannot tolerate opioids or not responding to conventional treatment may benefit from epidural analgesia. Therefore, this systematic review aimed to analyze the efficacy and safety of epidural analgesia in patients with intractable cancer pain.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify studies on patients with cancer who received epidural analgesia. We assessed the quality of all included studies using the risk-of-bias tool or Newcastle-Ottawa scale. The primary outcome was pain relief after epidural analgesia, and the secondary outcome was quality of life, analgesic consumption, and adverse events. The studies were grouped based on the medications used for epidural analgesia. A descriptive synthesis was performed following the Synthesis Without Meta-analysis reporting guideline.

RESULTS

Our systematic review included nine randomized controlled trials (n = 340) and 15 observational studies (n = 926). Two randomized controlled trials suggested that epidural opioids were not superior to systemic opioids in relieving pain. Epidural opioids combined with local anesthetics or adjuvants, including calcitonin, clonidine, ketamine, neostigmine, methadone, and dexamethasone, offered better analgesic effects. No significant difference in pain relief between an intermittent bolus and a continuous infusion of epidural morphine was observed. Epidural opioids had more analgesic effects on nociceptive pain than neuropathic pain. The methods used to evaluate the quality of life and the corresponding results were heterogeneous among studies. Six observational studies demonstrated that some patients could have decreased opioid consumption after epidural analgesia. Adverse events, including complications and drug-related side effects, were reported in 23 studies. Five serious complications, such as epidural abscess and hematoma, required surgical management. The heterogeneity and methodological limitations of the studies hindered meta-analysis and evidence-level determination.

CONCLUSION

Coadministration of epidural opioids, local anesthetics, and adjuvants may provide better pain relief for intractable cancer pain. However, we must assess the patients to ensure that the benefits outweigh the risks before epidural analgesia. Therefore, further high-quality studies are required.

Optimal pain management for patients with cancer in the modern era

Pain is a common symptom among patients with cancer. Adequate pain assessment and management are critical to improve the quality of life and health outcomes in this population. In this review, the authors provide a framework for safely and effectively managing cancer-related pain by summarizing the evidence for the importance of controlling pain, the barriers to adequate pain management, strategies to assess and manage cancer-related pain, how to manage pain in patients at risk of substance use disorder, and considerations when managing pain in a survivorship population. CA Cancer J Clin 2018;68:182-196. © 2018 American Cancer Society.

Successful Control of Pain from Malignant Psoas Syndrome by Spinal Opioid with Local Anesthetic Agents

BACKGROUND

Malignant psoas syndrome (MPS) is a rare but distressing pain syndrome observed in advanced cancer patients. Pain due to MPS is often refractory to multimodal analgesic treatment, including opioid analgesics. As only 1 case demonstrating the efficacy of neuraxial analgesia in managing pain due to MPS has been reported, its role in MPS remains uncertain.

CASES

We present 3 cases demonstrating the successful management of pain due to MPS using spinal opioids with local anesthetic agents. All patients were under the care of the palliative care consultation service in an acute care hospital and refractory to multimodal analgesic treatment, including opioid, non-opioid, and adjuvant analgesics. Switching opioid administration to the epidural or intrathecal route with a local anesthetic agent provided good pain control in all 3 patients. Moreover, all patients showed improvements in both Palliative Performance Scale and Functional Independence Measure scores after starting a spinal opioid with a local anesthetic agent.

CONCLUSIONS

The findings in the present cases indicate neuraxial analgesia may be of benefit, in terms of managing pain and improving functional status, in MPS patients with insufficient pain control by multimodal analgesic treatment. Physicians should consider the use of neuraxial analgesia in cases of MPS where pain is uncontrolled with multimodal analgesic treatment to provide the best possible quality of life for patients with MPS.

Interventional options for the management of refractory cancer pain--what is the evidence?

PURPOSE

Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70-90% of cancer patients. Refractory pain is defined as not responding to "standard" treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients.

METHODS

Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews.

RESULTS

Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects.

CONCLUSIONS

Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today's best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.

The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review

BACKGROUND

The present systematic review analysed the existing evidence of analgesic efficacy and side effects of opioids without and with adjuvant analgesics delivered by neuraxial route (epidural and subarachnoid) in adult patients with cancer.

METHODS

Search strategy was elaborated with words related to cancer, pain, neuraxial route, analgesic and side effects. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. Studies were analysed according to methods, results, quality of evidence, and strength of recommendation.

RESULTS

The number of abstracts retrieved was 2147, and 84 articles were selected for full reading. The final selection comprised nine articles regarding randomised controlled trials (RCTs) divided in four groups: neuraxial combinations of opioid and adjuvant analgesic compared with neuraxial administration of opioid alone (n = 4); single neuraxial drug in bolus compared with continuous administration (n = 2); single neuraxial drug compared with neuraxial placebo (n = 1); and neuraxial opioid combined with or without adjuvant analgesic compared with other comprehensive medical management than neuraxial analgesics (n = 2). The RCTs presented clinical and methodological diversity that precluded a meta-analysis. They also presented several limitations, which reduced study internal validity. However, they demonstrated better pain control for all interventions analysed. Side effects were described, but there were few significant differences in favour of the tested interventions.

CONCLUSION

Heterogeneous characteristics and several methodological limitations of the studies resulted in evidence of low quality and a weak recommendation for neuraxial administration of opioids with or without adjuvant analgesics in adult patients with cancer.

Audit of intrathecal drug delivery for patients with difficult-to-control cancer pain shows a sustained reduction in pain severity scores over a 6-month period

BACKGROUND

Intrathecal drug delivery is known to be effective in alleviating cancer pain in patients for whom the conventional World Health Organization approach has proved insufficient. A multidisciplinary interventional cancer pain service was established in the West of Scotland in 2008 with the aim of providing a safe and effective intrathecal drug delivery service for patients with difficult-to-control cancer pain.

AIM

The aim of the intrathecal drug delivery service is to improve pain scores as evaluated by pain scores before and after insertion of an intrathecal drug delivery device.

DESIGN

Pain is monitored before and after intrathecal drug delivery implantation using the Brief Pain Inventory. Following implantation, pumps are refilled fortnightly and repeat Brief Pain Inventory assessments are undertaken. This prospective case series analyses change in Brief Pain Inventory domains for patients who had an intrathecal drug delivery implanted using a paired sample t-test.

RESULTS

Data are presented from 2008-2013 for 22 patients receiving an intrathecal drug delivery system who experienced an immediate improvement in their pain that was both clinically and statistically significant. One week after insertion, the average pain score on the Brief Pain Inventory fell from 6.8 (pre-intrathecal drug delivery) to 3.0 (post-intrathecal drug delivery). Improvement in pain scores was sustained over a 6-month period.

CONCLUSION

Evaluation of results of this case series shows that with the appropriate use of intrathecal drug delivery systems, patients with difficult-to-control cancer pain can benefit from effective pain relief for many months.

Brief review: Neuraxial analgesia in refractory malignant pain

PURPOSE

This narrative review aims to inform health care practitioners of the current literature surrounding the use of intrathecal (IT) and epidural analgesia in cancer patients with refractory pain at end of life. Topics discussed and reviewed include: patient selection, treatment planning, procedure, equipment, medications, complications, policies and procedures, as well as directions for future research.

PRINCIPAL FINDINGS

Cancer pain is inadequately treated in an estimated 10% of patients with malignant pain despite the implementation of the World Health Organization three-step analgesic ladder. This has prompted some to advocate for the addition of a fourth step that would include neuraxial interventions. There is moderate evidence supporting the safety and efficacy of IT drug therapy in cancer patients with refractory pain. A detailed assessment and interdisciplinary team approach is necessary to develop and implement care plans for patients requiring neuraxial analgesia. Neuraxial analgesia can significantly improve pain and reduce side effects, but this must be balanced against the increased complexity of care and the risk of uncommon but serious complications.

CONCLUSION

Neuraxial drug delivery gives clinicians more options to manage refractory pain at end of life and should be offered to patients with intractable cancer pain. Teams should be interprofessional with clear delineation of roles and responsibilities. They should discuss advanced discharge planning with the patient prior to implantation as well as provide on-call support.

Epidural methadone results in dose-dependent analgesia in cancer pain, further enhanced by epidural dexamethasone

Background:

This study was designed to evaluate the role of epidural methadone-lidocaine in cancer pain combined or not to epidural dexamethasone.

Methods:

In all, 72 cancer patients, 32- to 67-year-old were randomized to six groups (n=12) and prospectively studied to examine analgesia and adverse effects for 3 weeks. Patients received single-dose protocol epidural test drugs: Control group (CG) received epidural 40-mg lidocaine diluted to 10-ml volume with saline. Dexamethasone group (DG) 40-mg lidocaine plus 10-mg dexamethasone. The 2.5MetG 2.5-mg epidural methadone with 40-mg lidocaine; the 5MetG, 5-mg epidural methadone plus 40-mg lidocaine, the 7.5MetG, 7.5-mg epidural methadone plus 40-mg lidocaine and finally the 7.5Met-DexG, 7.5-mg methadone with 40-mg lidocaine and 10-mg dexamethasone.

Results:

Groups CG, DG and 2.5MetG were similar regarding analgesia and side effects. Patients from 5MetG and 7.5MetG took 3±1 and 5±1 days, respectively, to restart oral morphine. Patients from 7.5MetDG took 14±2 to restart oral morphine (P<0.001). Daily somnolence and appetite improved in the 7.5MetDG during 2-week evaluation (P<0.005). Fatigue improved for both DG and 7.5MetDG during 2-week evaluation (P<0.005). By the third week of evaluation, all patients were similar.

Conclusions:

Epidural methadone plus lidocaine resulted in dose-dependent analgesia, further improved by epidural dexamethasone, which also improved fatigue.

Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC

Here we provide the updated version of the guidelines of the European Association for Palliative Care (EAPC) on the use of opioids for the treatment of cancer pain. The update was undertaken by the European Palliative Care Research Collaborative. Previous EAPC guidelines were reviewed and compared with other currently available guidelines, and consensus recommendations were created by formal international expert panel. The content of the guidelines was defined according to several topics, each of which was assigned to collaborators who developed systematic literature reviews with a common methodology. The recommendations were developed by a writing committee that combined the evidence derived from the systematic reviews with the panellists' evaluations in a co-authored process, and were endorsed by the EAPC Board of Directors. The guidelines are presented as a list of 16 evidence-based recommendations developed according to the Grading of Recommendations Assessment, Development and Evaluation system.

Neuraxial (epidural and intrathecal) opioids for intractable pain

1. Neuraxial opioids are considered for use in patients who have resistant intractable pain that fails to respond to other treatment options or pain that responds to analgesia but for which the doses required result in unacceptable side-effects. 2. Neuraxial opiods can be considered for both chronic non-malignant pain and chronic cancer-related pain. 3. Effectiveness in chronic non-malignant pain and cancer pain is exerted through the use of either single-agent drugs (opioids) or a combination of drugs: opioids, local anaesthetics and other drugs such as clonodine and ziconotide. 4. Complications of long-term continuous infusion therapy are related to the insertion process (haematoma), the mechanical device (both pump and catheter) and the long-term effects of the drugs. 5. Patients will require ongoing ambulatory monitoring and supportive care.