Published 2020-07-16
Keywords
- cancer pain,
- epidural analgesia,
- morphine,
- fentanyl,
- butorphanol
How to Cite
Abstract
Intractable cancer pain is a chronic severe pain, affecting patient’s quality of life and presents aheavy health, social and family problem in many countries. Different methods for pain relief are proposed by the WHO. Epidural analgesia with opioids is one of the proposed methods. Aim of the study was to determine the effects of morphine, fentanyl and butorphanol used for epidural analgesia in intractable pain and to comment our experiences over a five-year-period, with regard to its actuality nowadays. Material and methods: Retrospective longitudinal observational study was carried at the University Clinic for Anesthesiology, Reanimation and Intensive Care in Skopje, Macedonia, between 2005-2010 and evaluated in 2017-2018. A total of 116 patients suffering from intractable pain were enrolled in the study. Exclusion criteria were: infective and metastatic processes in the spine, allergy to opioids, psychological problems and language barrier. After the pretreatment evaluation of the pain, patients were randomly assigned to receive three different opioids through epidural catheter placed from Th8-10 or L2-3. Results: There were no differences in pretreatment pain scores between the three groups (p>0.05). A significant onset of analgesia after 15 minutes was found for butorphanol, 20 minutes for fentanyl and 30 minutes for morphine group (p<0.05). The duration of the pain relief of butorphanol vs. fentanyl vs. morphine was 6h vs. 8h vs. 24 hours respectively. Morphine had the longest duration of pain relief (p<0.05). Because of an increase in the pain threshold, the need of an increase of opioid doses was necessary. The most often patient’s reports of side effects were: itching, constipation, urine retention and bradypnea and there were no reports of nausea and vomiting. Conclusions: It was concluded that epidural analgesia with opioids is an effective and safe method for suppression of intractable pain. In spite of the other alternatives in treatment of cancer pain, epidural analgesia with opioids still has an eminent place and its use is a challenge for professionals
Downloads
References
2. Morrison LJ, Morrison RS. Palliative care and pain management. Med Clin Nort Am 2006; 90(5):983-1004.
3. Rizk D. Palliative care: Pain management, cancer therapy adviser. Hospital Medicine 2018; 1:1-14
4. World Health Organization. WHO's pain relief ladder. [Last accessed on 2015 Jan 11]. Available from: http://www.who.int/cancer/palliative/painladder/en/
5. Chen Sh-L, Sweigart KL, Lakovski JM at al. Functional μ opioid receptors are reduced in the spinal cord dorsal horn of diabetic rats. Anesthesiology 2002; 97 (12) :1602-08
6. Sholjakova M. The effects of epidural applied morphine on metabolism of the leg during general and regional anesthesia. Doctoral thesis. 1987; Medical faculty UKIM Skopje, RN Macedonia
7. Chahl LA. Opioids – mechanisms of action. Aust Prescr 1996; 19:63-5.
8. Treede R-D, Rief W, Barke A, at al. Chronic pain as a symptom or a disease the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). PAIN 2019; 160(10):19-27.
9. Choi DH, Lee SM, Cho HS at al. Relationship between the bevel of the Tuohy needle and catheter direction in thoracic epidural anesthesia. Reg Anesth Pain Med 2006; 31(2):105-12.
10. de Leon-Casasola OA, Lema MJ. Postoperative Epidural opioid Analgesia: What are the Choices? Anasth & Analg 1996; 83:867-75
11. Wolfe D, Wechuck J, Krisky D, at al. A clinical trial of gain therapy for chronic pain. Pain Medicine 2009; 10 (7):1325-30.
12. Yaksh TL. Multiple opioid receptor systems in brain and spinal cord: Part I. Eur J Anaethesiol 1984;1(2):171-99.
13. McDonald J, Lambert DG. Opioid receptors. Continuing education in Anesthesia. Critical Care & Pain 2005; 5(1) :22–25.
14. Harden RD, Oaklander AL, Burton AW, at al. Complex regional pain syndrome: practical diagnostic and treatment Guidelines, 4th Edition. Pain Medicine 2013; 14:180–229
15. Chen SR, Pan HL. Blocking mu opioid receptors in the spinal cord prevents the analgesic action by subsequent systemic opioids. Barin Res 2006; 1081(1):119-25
16. Goodchild CS, Nadeson R, Cohen E. Supraspinal and spinal cord opioid receptors are responsible for antinociception following intrathecal morphine injections. Eur J Anaesthesiol 2004;21(3):179-85
17. Bree D. Mu and Delta opioid receptors: where are they, and do they interact? Pain research forum 2018;
18. www. Guide to pharmacology: Opioids, 2018
19. Wang D, Tawfik VL, Corder G at al. Functional divergence of delta and mu opioid receptor organization in CNS pain circuits. Neuron 2018; 98(1):90-108.
20. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphine and respiratory depression: finding the right balance. Drugs 2011; 71(14):1807-19.
21. Orlov D, Ankichetty S, Chung F, Brull R. Cardiorespiratory complications of neuraxial opioids in patients with obstructive sleep apnea: a systematic review. Journal of Clinical Anesthesia 2013; 25(7): 591-99.
22. American Society of Anesthesiologists Task force on acute pain management. Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists. Task force on acute pain management. Anesthesiology 2004;100:1573–81
23. Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. Journal of Pain and Symptom Management 1999; 18 (6) :438-46
24. Bodian CA, Freedman G, Hossain S, at al. The Visual analog scale for pain, clinical significance in postoperative patients. Anesthesiology 2001; 95:1356 –61
25. Kersten P, White PJ, Tennant A. Is the pain Visual analogue scale linear and responsive to change? An exploration using rasch analysis. PLOS 2014; https://doi.org/10.1371/journal.pone.0099485
26. Sung Y-T, Wu J-Sh. The Visual analogue scale for rating, ranking and paired-comparison (VAS-RRP): A new technique for psychological measurement. Behavior Research Methods 2018; 50 (4):1694–715.
27. Bhatnagar S, Grupta M. Evidence-based clinical practice guidelines for interventional pain management in cancer pain. Indian J Palliat Care 2015; 21(2): 137–47.
28. Dahan A, Aasrts L, SmithTW. Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology 2010; 12:226-38.
29. Richards P, Riff D, Kelen R, Stern W. A phase 3, randomized, double-blind comparison of analgesic efficacy and tolerability of Q8003 vs Oxycodone or morphine for moderate-to-severe postoperative pain following bunionectomy surgery. Pain Medicine 2013; 14(8):1230–38.
30. Liu SS, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology1995; 83:757-65
31. Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiologica Scandinavica 1987; 31(2): 161–64.
32. Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987; 31:161-64
33. Douglas MJ, Mc Morland GH, Janzen JA. Influence of bupivacaine as an adjuvant to epidural morphine for analgesia after cesarean section. Anesth Analg 1988; 67(12) :1138-41.
34. Sholjakova M. The influence of different modalities of postoperative analgesia on bowel motility and enhanced recovery after abdominal surgery. ARUD 2017; Sarajevo, BIH, May 17-20, Book of proceedings: 58-67.