Opioid switching and variability in response in pain cancer patients

Abstract

Introduction

Opioid switching is a possible strategy for inadequate analgesia or unmanageable side effects. Its effectiveness ranges from 50 to 90% and is still debated.

Purpose

We analyzed the impact of opioid switching in a cancer pain population treated with strong opioids for pain.

Methods

This is a post hoc analysis from a multicenter, randomized, four-arm, controlled, phase IV clinical trial. Outcome variables included the percentages of switches, the reasons for the switch, the dose changes before and after the switch, depending on the starting opioid, the response in case of inadequate analgesia, and unmanageable toxicity, and the variability of response among and within patients.

Results

We analyzed 498 patients. The opioid was switched in 79 patients (15.9%) 87 times, mainly for uncontrolled pain (52.3%), adverse opioid reactions (22.1%), both of these (4.8%), and dysphagia (20.8%). The reasons for switching varied depending on the starting opioid. Pain reduction was good after 51.45% of switches and control of opioid side effects was good after 43.5%. The relief of opioid-induced toxicity varied among adverse events and within each patient. The daily doses were higher after switching oral opioids and lower after transdermal drugs.

Conclusions

Half of the patients who underwent switching experienced improved relief of pain or amelioration of opioid toxicity. The switch can help in the management of some cases but with many limits and uncertainties.

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References

  1. 1.

    Mercadante S, Maddaloni S, Roccella S, Salvaggio L (1992) Predictive factors in advanced cancer pain treated only by analgesics. Pain 50:151–155

    Article  CAS  PubMed  Google Scholar 

  2. 2.

    Corli O, Floriani I, Roberto A, Montanari M, Galli F, Greco MT, Caraceni A, Kaasa S, Dragani TA, Azzarello G, Luzzani M, Cavanna L, Bandieri E, Gamucci T, Lipari G, di Gregorio R, Valenti D, Reale C, Pavesi L, Iorno V, Crispino C, Pacchioni M, Apolone G, CERP STUDY OF PAIN GROUP (List of collaborators), CERP STUDY OF PAIN GROUP (2016) Are strong opioids equally effective and safe in the treatment of chronic cancer pain? A multicenter randomized phase IV ‘real life’ trial on the variability of response to opioids. Ann Oncol Off J Eur Soc Med Oncol 27:1107–1115

    Article  CAS  Google Scholar 

  3. 3.

    Corli O, Roberto A, Greco MT, Montanari M (2015) Assessing the response to opioids in cancer patients: a methodological proposal and the results. Support Care Cancer 23:1867–1873

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Farrar J, Young J, Lamoreaux L et al (2001) Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94:149–158

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL (2000) Defining the clinically important difference in pain outcome measures. Pain 88:287–294

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Mercadante S, Bruera E (2016) Opioid switching in cancer pain: from the beginning to nowadays. Crit Rev Oncol Hematol 99:241–248

    Article  PubMed  Google Scholar 

  7. 7.

    Kloke M, Rapp M, Bosse B, Kloke O (2000) Toxicity and/or insufficient analgesia by opioid therapy: risk factors and the impact of changing the opioid. A retrospective analysis of 273 patients observed at a single center. Support Care Cancer 8:479–486

    Article  CAS  PubMed  Google Scholar 

  8. 8.

    Quigley C, Vora RR. Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev; 2013. DOI: https://doi.org/10.1002/14651858.CD004847.pub2

  9. 9.

    Benyamin R, Trescot A, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R (2008) Opioid complications and side effects. Pain Physician 11:S105–S120

    PubMed  Google Scholar 

  10. 10.

    Labianca R, Sarzi-Puttini P, Zuccaro SM, Cherubino P, Vellucci R, Fornasari D (2012) Adverse effects associated with non-opioid and opioid treatment in patients with chronic pain. Clinical Drug Investigation 32:53–63

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Oosten AW, Oldenmenger WH, Mathijssen RHJ (2015) A systematic review of prospective studies reporting adverse events of commonly used opioids for cancer-related pain: a call for the use of standardized outcome measures. J Pain 16:935–946

    Article  PubMed  Google Scholar 

  12. 12.

    Mercadante S, Portenoy RK (2001) Opioid poorly-responsive cancer pain. Part 3. Clinical strategies to improve opioid responsiveness. J Pain Symptom Manag 21:338–354

    Article  CAS  Google Scholar 

  13. 13.

    Smith HS, Peppin JF (2014) Toward a systematic approach to opioid rotation. J Pain Res 7:589–608

    CAS  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Mercadante S, Bruera E (2006) Opioid switching: a systematic and critical review. Cancer Treat Rev 32:304–315

    Article  CAS  PubMed  Google Scholar 

  15. 15.

    Vadalouca A, Moka E, Argyra E, Sikioti P, Siafaka I (2008) Opioid rotation in patients with cancer: a review of the current literature. J Opioid Manag 4:213–250

    Article  PubMed  Google Scholar 

  16. 16.

    González-Barboteo MDJ, Alentorn MD, Manuel FAC et al (2014) Effectiveness of opioid rotation in the control of cancer pain: the ROTODOL Study. J Opioid Manag 10:395–403

    Article  PubMed  Google Scholar 

  17. 17.

    Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking A, Jafari-Schluep H, Lantéri-Minet M, Laurent B, Mick G, Serrie A, Valade D, Vicaut E (2005) Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 114:29–36

    Article  PubMed  Google Scholar 

  18. 18.

    Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G, Science Committee of the Association for Palliative Medicine of Great Britain and Ireland (2009) The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 13:331–338

    Article  PubMed  Google Scholar 

  19. 19.

    Tamburini M, Rosso S, Gamba A, Mencaglia E, de Conno F, Ventafridda V (1992) A therapy impact questionnaire for quality-of-life assessment in advanced cancer research. Ann Oncol 3:565–570

    Article  CAS  PubMed  Google Scholar 

  20. 20.

    Caraceni A, Et A (2012) Use of opioids analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol 2012:e58–e68

    Article  CAS  Google Scholar 

  21. 21.

    Mercadante S, Valle A, Porzio G, Fusco F, Aielli F, Adile C, Casuccio A, Home Care—Italy Group (2013) Opioid switching in patients with advanced cancer followed at home. A retrospective analysis. J Pain Symptom Manag 45:298–304

    Article  CAS  Google Scholar 

  22. 22.

    Lawlor PG, Turner KS, Hanson J, Bruera ED (1998) Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study. Cancer 82:1167–1173

    Article  CAS  PubMed  Google Scholar 

  23. 23.

    Reddy A, Yennurajalingam S, Pulivarthi K, Palla SL, Wang X, Kwon JH, Frisbee-Hume S, Bruera E (2013) Frequency, outcome, and predictors of success within 6 weeks of an opioid rotation among outpatients with cancer receiving strong opioids. Oncologist 18:212–220

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, Haythornthwaite JA, Jensen MP, Kerns RD, Ader DN, Brandenburg N, Burke LB, Cella D, Chandler J, Cowan P, Dimitrova R, Dionne R, Hertz S, Jadad AR, Katz NP, Kehlet H, Kramer LD, Manning DC, McCormick C, McDermott MP, McQuay HJ, Patel S, Porter L, Quessy S, Rappaport BA, Rauschkolb C, Revicki DA, Rothman M, Schmader KE, Stacey BR, Stauffer JW, von Stein T, White RE, Witter J, Zavisic S (2008) Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. Journal of Pain 9:105–121

    Article  PubMed  Google Scholar 

  25. 25.

    De Conno F, Groff L, Brunelli C et al (1996) Clinical experience with oral methadone administration in the treatment of pain in 196 advanced cancer patients. J Clin Oncol 14:2836–2842

    Article  PubMed  Google Scholar 

  26. 26.

    Holzer P, Ahmedzai SH, Niederle N et al (2009) Opioid-induced bowel dysfunction in cancer-related pain: causes, consequences, and a novel approach for its management. J Opioid Manag 5:145–151

    Article  PubMed  Google Scholar 

  27. 27.

    Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation (2009) Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manag 38:418–425

    Article  Google Scholar 

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Correspondence to N. Corsi.

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Corli, O., Roberto, A., Corsi, N. et al. Opioid switching and variability in response in pain cancer patients. Support Care Cancer 27, 2321–2327 (2019). https://doi.org/10.1007/s00520-018-4485-6

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Keywords

  • Cancer pain
  • Opioid switching
  • Pain relief
  • Toxicity relief