Longitudinal Pain Assessment in Head and Neck …...Longitudinal Pain Assessment in Head and Neck...
1
Longitudinal Pain Assessment in Head and Neck Cancer Surgery Marisa R. Buchakjian, MD, PhD 1 ; Andrew B. Davis, MD 1 ; Steven M. Sperry, MD 1 1 University of Iowa Hospitals & Clinics, Department of Otolaryngology – Head and Neck Surgery Presenting Author: Marisa R. Buchakjian, MD, PhD Email: [email protected] Corresponding Author: Steven M. Sperry, MD Email: [email protected] Contact 1. Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Annals of Oncology. 2008;19(12):1985–1991. doi:10.1093/annonc/mdn419. 2. Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Annals of Oncology. 2009;20(8):1420–1433. doi:10.1093/annonc/mdp001. 3. Grond S, Zech D, Lynch J, Diefenbach C, Schug SA, Lehmann KA. Validation of World Health Organization guidelines for pain relief in head and neck cancer. A prospective study. Ann Otol Rhinol Laryngol. 1993;102(5):342–348. 4. Cleeland CS. Measurement of Pain by Subjective Report. Vol 12. (CR C, editors, eds.). New York: Advances in pain research and therapy; 1989. 5. Bennett MI, Smith BH, Torrance N, Potter J. The S-LANSS score for identifying pain of predominantly neuropathic origin: Validation for use in clinical and postal research. The Journal of Pain. 2005;6(3):149–158. doi:10.1016/j.jpain.2004.11.007. 6. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta psychiatr scand. 1983. 7. Wolfe F, Clauw DJ, Fitzcharles MA. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis care & …. 2010. References Outcome Objectives: (I) Longitudinally evaluate perioperative pain management in head and neck cancer patients undergoing ablative and reconstructive surgery. (II) Assess methods for measuring pain. (III) Identify the need for further interventions to improve pain control. Methods: This is a prospective observational study of perioperative pain in patients undergoing head and neck cancer surgery with flap reconstruction. Subjects completed validated assessment instruments preoperatively to establish baseline pain and screen for fibromyalgia/chronic pain and anxiety/depression. Patients received routine pain medications, which typically included opioid analgesics. For four weeks postoperatively, patients completed a daily diary reporting pain scores and quantity of pain medication consumed. Results: 78% of patients reported pain in the head and neck region preoperatively (average worst pain score, 6.5/10). 37% of patients screened positive for neuropathic pain, 52% for symptoms of anxiety, 30% for symptoms of depression, and 0% for symptoms of fibromyalgia/widespread pain. Patients with moderate/severe pain preoperatively continued to endorse higher pain scores postoperatively compared to patients with none/mild preoperative pain. Patients with the highest composite pain scores postoperatively were also found to be more likely to screen positive for neuropathic pain. Overall, patients with moderate/severe preoperative and postoperative pain were observed to consume a greater overall amount of narcotic analgesics. Conclusion: This is a pilot study to assess perioperative pain control and the utility of validated pain instruments in an effort to improve postoperative pain and reduce side effects for head and neck cancer patients. Completion of this study will identify pain control needs and guide further pain regimen protocol- design. Abstract • 27 patients were enrolled in the study • 13 patients (48%) completed at least 2 weeks of pain diary entries; 9 patients (33%) completed the entire pain diary • Of the 14 patients who did not return the diary, all had either lost it or felt unable to continue with the recording after discharge • 21 patients (78%) reported pain in the head and neck region prior to surgical resection and reconstruction • Of the patients with preoperative pain, 35% reported pain radiating to the ears, 35% in the jawline, 24% in the tongue, and 6% in the lower jaw • The average WORST pain score prior to surgery was 6.5/10 • The average LEAST pain score prior to surgery was 1.8/10 • 11 patients (41%) required narcotic pain medication for symptom control preoperatively • 2 patients (7%) were taking medication for neuropathic pain (gabapentin) preoperatively • 10 patients (37%) screened positive for neuropathic pain by the S-LANSS questionnaire • 14 patients (52%) screened positive for anxiety by the HADS questionnaire • 8 patients (30%) screened positive for depression by the HADS questionnaire • 0 patients screened positive for fibromyalgia by the WP/SS score Introduction This is a prospective observational study of perioperative pain control in patients undergoing cancer-directed ablative surgery with reconstruction. Subjects complete a panel of validated pain assessment instruments preoperatively including a Brief Pain Inventory 4 , Neuropathic Pain Screen (S- LANSS) 5 , Anxiety and Depression Screen (HADS) 6 , and Fibromyalgia Screen (WP/SS) 7 . Patients are treated with routine pain medications postoperatively, which typically includes as needed narcotic analgesics. Starting on postoperative day one and continuing for four weeks, patients complete a daily pain diary consisting of pain scores reported on a numerical scale (0 least-10 worst) as well as recording quantity of medication consumed and location(s) of pain. Patients also record any complications such as nausea, vomiting, or constipation. Enrolled patients are assisted with recording during their hospital stay, and perform the recording on their own once discharged. The study coordinators contact the participants weekly to check progress and answer any questions. The completed pain diary is collected at the one-month postoperative appointment at which time pain scores and medication consumption are recorded for analysis. Initial pain was characterized as none/moderate if the preoperative composite pain score was <=3, or moderate/severe pain if >3. The primary outcome measure is the patient- reported pain score, with the secondary outcome measures being correlation with neuropathic pain and pain medication consumption. Methods and Materials • Patients with moderate/severe pain preoperatively continued to endorse higher pain scores postoperatively and required greater amounts of narcotic pain medication. • 41% of patients consumed narcotic pain medication preoperatively, and 100% of patients required narcotics postoperatively. • Patients with the highest composite pain scores postoperatively were also found to be more likely to screen positive for neuropathic pain. 37% of all patients reported neuropathic pain in preoperative screening. • Future directions include prospectively evaluating a standardized pain treatment algorithm to include treatment of neuropathic pain with gabapentin. Conclusions/Directions Positive Score Negative Score % Positive S-LANSS 10 17 37% HADS - Anxiety 14 13 52% HADS - Depression 8 19 30% WP/SS 0 27 0% Pain is frequently underrecognized and undertreated in cancer patients. Approximately 1 in 2 cancer patients report that their pain is undertreated 1 , and head and neck cancer is ranked as one of the more painful cancers, with 86% of survey respondents rating their pain as >5 out of 10 and occurring at least several times per month 2 . Pain may occur in many different forms, which may respond to different treatment algorithms. A common treatment regimen for pain following head and neck surgery is based on an “analgesic ladder” strategy 3 , however there are limited studies dedicated to examining and improving perioperative pain in head and neck cancer patients. Results Figure 1. Daily pain diary provided to each study subject. Patients rated pain on a scale of 0 (none) to 10 (worst) and recorded amounts of pain medication required daily. They also recorded adverse events and marked the location(s) of pain. Table 1. Results of Preoperative Pain and Anxiety/Depression Scales. S-LANSS positive score 12 or greater HADS - Anxiety positive score 8 or greater HADS – Depression positive score 8 or greater WP/SS positive score WP 7 and SS 5; or WP 3-6 and SS 9 or greater Figure 2. Daily pain scores. Daily pain scores as recorded in pain diary entries. Patients are stratified by initial preoperative pain levels, and daily pain was reported as A) worst pain level, B) least pain level, C) patient-rated average pain level, and D) composite pain score. A) B) C) Figure 3. Daily composite pain scores and associated symptoms. Association between daily composite pain scores and A) initial preoperative pain, B) neuropathic pain, C) anxiety, and D) depression. D) A) B) C) D) Figure 4. Daily narcotic analgesic consumption based on initial pain stratification. Patients are stratified by initial preoperative pain levels, and equivalent daily oral morphine intake is provided over the course of the four week study.
Transcript of Longitudinal Pain Assessment in Head and Neck …...Longitudinal Pain Assessment in Head and Neck...
Longitudinal Pain Assessment in Head and NeckCancer Surgery
Marisa R. Buchakjian, MD, PhD1; Andrew B. Davis, MD1; Steven M. Sperry, MD1
1University of Iowa Hospitals & Clinics, Department of Otolaryngology – Head and Neck Surgery
Presenting Author:Marisa R. Buchakjian, MD, PhDEmail: [email protected]
Corresponding Author:Steven M. Sperry, MDEmail: [email protected]
Contact1. Deandrea S, Montanari M, Moja L, Apolone G. Prevalence of undertreatment in cancer pain. A review of published literature. Annals of Oncology. 2008;19(12):1985–1991. doi:10.1093/annonc/mdn419. 2. Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Annals of Oncology. 2009;20(8):1420–1433. doi:10.1093/annonc/mdp001. 3. Grond S, Zech D, Lynch J, Diefenbach C, Schug SA, Lehmann KA. Validation of World Health Organization guidelines for pain relief in head and neck cancer. A prospective study. Ann Otol Rhinol Laryngol.
1993;102(5):342–348. 4. Cleeland CS. Measurement of Pain by Subjective Report. Vol 12. (CR C, editors, eds.). New York: Advances in pain research and therapy; 1989.5. Bennett MI, Smith BH, Torrance N, Potter J. The S-LANSS score for identifying pain of predominantly neuropathic origin: Validation for use in clinical and postal research. The Journal of Pain. 2005;6(3):149–158.
doi:10.1016/j.jpain.2004.11.007. 6. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta psychiatr scand. 1983. 7. Wolfe F, Clauw DJ, Fitzcharles MA. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis care & …. 2010.
References
Outcome Objectives: (I) Longitudinally evaluate perioperative painmanagement in head and neck cancer patients undergoing ablative andreconstructive surgery. (II) Assess methods for measuring pain. (III) Identify theneed for further interventions to improve pain control.
Methods: This is a prospective observational study of perioperative pain inpatients undergoing head and neck cancer surgery with flap reconstruction.Subjects completed validated assessment instruments preoperatively toestablish baseline pain and screen for fibromyalgia/chronic pain andanxiety/depression. Patients received routine pain medications, whichtypically included opioid analgesics. For four weeks postoperatively, patientscompleted a daily diary reporting pain scores and quantity of pain medicationconsumed.
Results: 78% of patients reported pain in the head and neck regionpreoperatively (average worst pain score, 6.5/10). 37% of patients screenedpositive for neuropathic pain, 52% for symptoms of anxiety, 30% for symptomsof depression, and 0% for symptoms of fibromyalgia/widespread pain. Patientswith moderate/severe pain preoperatively continued to endorse higher painscores postoperatively compared to patients with none/mild preoperativepain. Patients with the highest composite pain scores postoperatively werealso found to be more likely to screen positive for neuropathic pain. Overall,patients with moderate/severe preoperative and postoperative pain wereobserved to consume a greater overall amount of narcotic analgesics.
Conclusion: This is a pilot study to assess perioperative pain control and theutility of validated pain instruments in an effort to improve postoperative painand reduce side effects for head and neck cancer patients. Completion of thisstudy will identify pain control needs and guide further pain regimen protocol-design.
Abstract
• 27 patients were enrolled in the study• 13 patients (48%) completed at least 2 weeks of pain diary entries; 9
patients (33%) completed the entire pain diary • Of the 14 patients who did not return the diary, all had either lost it or felt
unable to continue with the recording after discharge
• 21 patients (78%) reported pain in the head and neck region prior to surgical resection and reconstruction
• Of the patients with preoperative pain, 35% reported pain radiating to the ears, 35% in the jawline, 24% in the tongue, and 6% in the lower jaw
• The average WORST pain score prior to surgery was 6.5/10• The average LEAST pain score prior to surgery was 1.8/10• 11 patients (41%) required narcotic pain medication for symptom control
preoperatively• 2 patients (7%) were taking medication for neuropathic pain (gabapentin)
preoperatively
• 10 patients (37%) screened positive for neuropathic pain by the S-LANSS questionnaire
• 14 patients (52%) screened positive for anxiety by the HADS questionnaire• 8 patients (30%) screened positive for depression by the HADS
questionnaire• 0 patients screened positive for fibromyalgia by the WP/SS score
Introduction
This is a prospective observational study of perioperative pain control inpatients undergoing cancer-directed ablative surgery with reconstruction.Subjects complete a panel of validated pain assessment instrumentspreoperatively including a Brief Pain Inventory4, Neuropathic Pain Screen (S-LANSS)5, Anxiety and Depression Screen (HADS)6, and Fibromyalgia Screen(WP/SS)7. Patients are treated with routine pain medications postoperatively,which typically includes as needed narcotic analgesics. Starting onpostoperative day one and continuing for four weeks, patients complete adaily pain diary consisting of pain scores reported on a numerical scale (0least-10 worst) as well as recording quantity of medication consumed andlocation(s) of pain. Patients also record any complications such as nausea,vomiting, or constipation. Enrolled patients are assisted with recording duringtheir hospital stay, and perform the recording on their own once discharged.The study coordinators contact the participants weekly to check progress andanswer any questions. The completed pain diary is collected at the one-monthpostoperative appointment at which time pain scores and medicationconsumption are recorded for analysis. Initial pain was characterized asnone/moderate if the preoperative composite pain score was <=3, ormoderate/severe pain if >3. The primary outcome measure is the patient-reported pain score, with the secondary outcome measures being correlationwith neuropathic pain and pain medication consumption.
Methods and Materials
• Patients with moderate/severe pain preoperatively continued to endorse higher pain scores postoperatively and required greater amounts of narcotic pain medication.
• 41% of patients consumed narcotic pain medication preoperatively, and 100% of patients required narcotics postoperatively.
• Patients with the highest composite pain scores postoperatively were also found to be more likely to screen positive for neuropathic pain. 37% of all patients reported neuropathic pain in preoperative screening.
• Future directions include prospectively evaluating a standardized pain treatment algorithm to include treatment of neuropathic pain with gabapentin.
Conclusions/DirectionsPositive Score Negative Score % Positive
S-LANSS 10 17 37%
HADS - Anxiety 14 13 52%
HADS - Depression 8 19 30%
WP/SS 0 27 0%
Pain is frequently underrecognized and undertreated in cancer patients.Approximately 1 in 2 cancer patients report that their pain is undertreated1,and head and neck cancer is ranked as one of the more painful cancers, with86% of survey respondents rating their pain as >5 out of 10 and occurring atleast several times per month2. Pain may occur in many different forms, whichmay respond to different treatment algorithms. A common treatment regimenfor pain following head and neck surgery is based on an “analgesic ladder”strategy3, however there are limited studies dedicated to examining andimproving perioperative pain in head and neck cancer patients.
Results
Figure 1. Daily pain diary provided to each study subject. Patients rated painon a scale of 0 (none) to 10 (worst) and recorded amounts of pain medication requireddaily. They also recorded adverse events and marked the location(s) of pain.
Table 1. Results of Preoperative Pain and Anxiety/Depression Scales.
S-LANSS positive score 12 or greaterHADS - Anxiety positive score 8 or greaterHADS – Depression positive score 8 or greaterWP/SS positive score WP 7 and SS 5; or WP 3-6 and SS 9 or greater
Figure 2. Daily pain scores. Daily pain scores as recorded in pain diary entries. Patientsare stratified by initial preoperative pain levels, and daily pain was reported as A) worst painlevel, B) least pain level, C) patient-rated average pain level, and D) composite pain score.
A) B)
C)
Figure 3. Daily composite pain scores and associated symptoms. Associationbetween daily composite pain scores and A) initial preoperative pain, B)neuropathic pain, C) anxiety, and D) depression.
D)
A) B)
C) D)
Figure 4. Daily narcoticanalgesic consumption basedon initial pain stratification.Patients are stratified byinitial preoperative painlevels, and equivalent dailyoral morphine intake isprovided over the course ofthe four week study.
