Management of Breakthrough Pain in the Cancer Patient
Management of Breakthrough Pain in the Cancer Patient
US Oncological Disease 2006 - Issue II
Published: October 2008
Published: October 2008
Effective pain management in the cancer patient requires an understanding of pain control strategies. Within this context, on-going assessment of pain is crucial. It is also important to determine whether the pain is nociceptive (somatic or visceral pain) or neuropathic since the two forms of pain are treated differently. Pain can also be a combination of these two types. Opioids and other traditional analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), are the cornerstone of nociceptive pain management. Although evidence is emerging of the efficacy of opioids in controlling neuropathic pain,1 antidepressants and anticonvulsants are considered first-line in the treatment of neuropathic pain.
Breakthrough Pain
Breakthrough pain is pain that is over and above the background pain that is being addressed by on-going pain control medications. Breakthrough pain is highly prevalent in cancer patients. In one study it was estimated that approximately one-half to two-thirds of patients with chronic cancer-related pain also experience episodes of breakthrough pain.2 Moreover, the pathophysiology of the breakthrough pain was believed to be somatic in 33% of the patients, visceral in 20%, neuropathic in 27%, and mixed in 20%. Although it is an important component of cancer pain management, breakthrough pain is often overlooked.
Breakthrough pain in the cancer population is usually abrupt, acute, and can be very intense. The characteristics of breakthrough cancer pain vary from person to person, including the duration of the breakthrough episode and possible causes. The most common form is incidental breakthrough pain, which is associated with an activity. Other categories include idiopathic breakthrough pain, which occurs spontaneously, and breakthrough pain known as ‘endof- dose failure’, which typically occurs at the end of the dosage interval of pain medication used to control the patient’s persistent pain.
Management of Breakthrough Pain
Breakthrough pain can sometimes be alleviated by nonpharmacological methods such as repositioning or distraction methods. However, most breakthrough pain is of a moderate-to-severe nature and pharmacological intervention is considered first-line, with nonpharmacological methods used as a supplement.
Many physicians managing pain in cancer patients use a variety of breakthrough pain medications based on personal experience, past experience and the patient’s pain scenario.3 The current recommendation is to use a long-acting opioid formulation to treat persistent cancer pain and provide the patient with a fast-acting, short-duration analgesic to take when breakthrough pain occurs.4 Whenever possible, the same opioid that is used in the long-acting form to manage the persistent pain should be prescribed for breakthrough pain. For example, if long-acting morphine is used for the persistent pain, immediate-release morphine should be used for the breakthrough pain. The recommended dose of the breakthrough pain medication is usually 10–15%, and sometimes more, of the total daily dose of the long-acting analgesic the patient is taking.4
References:
- Eisenberg E, McNicol E, Carr DB, “Opioids for neuropathic pain (Cochrane Review)”, Cochrane Database Syst Rev (2006);3.
- Portenoy RK, Hagen NA,“Breakthrough pain: definition, prevalence and characteristics”, Pain (1990);41(3): pp. 273–281.
- Hwang SS, Chang VT, Kasimis B,“Cancer breakthrough pain characteristics and responses to treatment at a VA medical center”, Pain (2003);101: pp. 55–64.
- McCaffery M, Pasero CL, “Opioid analgesics”, Pain: clinical manual 2nd ed. (1999); pp. 161–299.
- Levy MH,“Pharmacologic treatment of cancer pain”, N Engl J Med (1996);335: pp. 1124–1132.
- Paice JA, Noskin GA,Vanagunas A,“Efficacy and safety of scheduled dosing of opioid analgesics: a quality improvement study”, J Pain (2005);6: pp. 639–43.
