Randomized trial of opioids versus tricyclic antidepressants for radiation-induced mucositis pain in head and neck cancer

Patients who receive radiotherapy for head and neck cancer are likely to de velop painful mucositis. The pain is characterized by a burning or stinging sensation similar to neuropathic pain sensations. The purpose of the prese nt study was to compare the analgesic effect of a tricyclic antidepressant (TC), commonly used in the treatment of neuropathic pain, with the effect o f opioids on radiation-induced mucositis pain, Forty-three patients receivi ng 66-68 Gy external radiation according to the DAHANCA guidelines (the Dan ish Head and Neck Cancer Study Group) were randomized to either morphine or TC when mucositis pain was insufficiently managed with weak analgesics. Pa tients with insufficient pain control in either treatment arm received supp lementary medication from the opposite treatment arm. Pain was evaluated we ekly using a VAS scale and the McGill Pain Questionnaire. The degree of muc ositis and the degree of depression were measured at the same time interval s. Twenty-two patients entered the opioid arm and 21 the TC arm. Two patien ts in each arm were non-evaluable. VAS pain scores were significantly reduc ed in the opioid treatment arm one week after randomization (p = 0.01). Eig ht patients in the TC arm were managed with TC alone,, but for 11 patients it was necessary to add morphine. The 20 evaluable patients in the morphine arm required no additional treatment. There were no significant difference s in side effects between the two groups. Higher pain scores in the TC arm, but not in the opioid arm, were significantly correlated with higher BDI s cores. Some head and neck cancer patients with radiation-induced nucositis pain may have sufficient pain control on TC alone. This might be useful in patients with relative counter-indications to opioid treatment.