Dealing with Breakthrough Cancer Pain

CURE, Spring 2012, Volume 11, Issue 1

What to do when cancer pain becomes sudden and severe.

Breakthrough cancer pain (BTCP) is pain that “breaks through” persistent pain that may be otherwise controlled with a long-acting analgesic. Often of sudden onset, short duration and more moderate to severe, BTCP affects about 65 percent of cancer patients.

BTCP can generally be divided into two categories: spontaneous pain with no evident precipitating event and incident pain with an evident precipitating cause or event, such as walking, sneezing or coughing.

But just because it breaks through the barrier medication for persistent pain doesn’t mean that BTCP can’t be managed. Background pain management consists of around-the-clock medication, usually with long-acting opioids, such as morphine, oxycodone, methadone and fentanyl products; whereas short-acting or rapid-acting oral opioids can effectively treat BTCP episodes.

Rescue pain medication: Patients can manage BTCP with short-acting formulations of opioids, such as morphine, oxycodone, hydromorphone, buprenorphine and methadone. A rescue dose is an as-needed administered medication for BTCP and generally consists of an immediate-release preparation of the same drug used on an around-the-clock basis for background pain. According to the National Cancer Institute (NCI), the rescue dose is 10 to 20 percent of the total amount of the scheduled background pain medication.

The characteristics of an individual’s pain determine the optimal use of opioid treatment for BTCP. Optimizing pain control means matching the characteristics of the pain (onset, duration, type) with the characteristics of the medication (onset, duration, type), according to the American Pain Foundation.

Rapid-acting fentanyl: The recent development and FDA-approval of new rapid-onset opioid pain medications offers patients the possibility of faster and better management of BTCP. Rapid-onset pain medications are delivered transmucosally, meaning the medication is absorbed through the mucus membrane. Transmucosal fentanyl is a rapid-onset opioid that can be administered inside the cheek (buccal), under the tongue (sublingual) or inside the nose (nasal). Other opioids are not suited for buccal or sublingual administration.

Because pain usually starts and intensifies quickly (in approximately three minutes) and lasts 30 to 60 minutes, the faster-acting and shorter duration forms of transmucosal fentanyl fit better with peak pain periods of BTCP. The newer quick-acting fentanyl products peak in 30 minutes whereas most immediate release pain medications peak in one hour. And the onset of analgesia (pain relief) with transmucosal fentanyl has been shown to occur 5 to 15 minutes after administration.

According to the NCI, side effects of fentanyl are similar to other opioid therapies, including sedation, constipation, stomatitis (inflammation and sores in the mouth) and nausea.

Non-medical management of BTCP: A number of physical interventions, such as using heating pads or ice packs, light massage or acupuncture, may be used in addition to pharmacological treatments. Cognitive interventions may include distraction techniques, focusing one’s attention on something else to help temporarily relieve pain, especially while waiting for medications to take effect. Meditation, imagery and other integrative approaches can also complement medications.

Patients can take short-acting medications to minimize incident BTCP or prevent it by taking the drugs before a situation known to trigger BTCP. Because oral opioids often have slow analgesic peaks, patients might want to take these medications 15 to 30 minutes prior to an activity known to cause incident pain.