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Current Opinion in Supportive and... Mar 2009To outline the impact of breakthrough pain, the evidence for the current management and new treatment options that are becoming available. (Review)
Review
PURPOSE OF REVIEW
To outline the impact of breakthrough pain, the evidence for the current management and new treatment options that are becoming available.
RECENT FINDINGS
Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. Despite its self-limiting nature, breakthrough pain can place significant physical, psychological, and economic burdens on both patients and their carers. The successful management breakthrough pain may require a combination of pharmacological and nonpharmacological treatment strategies; supplemental analgesia, known as rescue medication, is a common pharmacological treatment option. The ideal rescue medication should have a rapid onset, good efficacy, relatively short duration of action, and minimal adverse effects and is best administered before or soon after breakthrough pain has started. Although oral opioids are commonly used, there is increasing evidence that transmucosal opioids may be more effective.
SUMMARY
Breakthrough is a common heterogeneous pain state that can have a devastating impact on both patients and carers. Despite the growing literature on breakthrough pain, there are still many aspects yet to be addressed including an urgent need to standardize terminology, for carefully designed epidemiological studies and for well designed controlled trials comparing the different treatment options.
Topics: Analgesics, Opioid; Humans; Neoplasms; Pain; Pain Measurement; Palliative Care
PubMed: 19365156
DOI: 10.1097/SPC.0b013e3283260658 -
European Journal of Oncology Nursing :... Apr 2014The overall aim of the project was to update and inform nurses of current best practice based on previously published literature to enable nurses to assess and manage... (Review)
Review
PURPOSE
The overall aim of the project was to update and inform nurses of current best practice based on previously published literature to enable nurses to assess and manage breakthrough cancer pain (BTCP) and thereby to provide optimal management of BTCP.
METHODS
The EONS started a project in 2010 by recruiting a working group and a multidisciplinary advisory board to develop guidelines with the purpose of helping oncology nurses understand and recognise BTCP.
RESULTS
This paper presents and overview of the guideline. Key recommendations include; using an algorithm for assessment of BTCP, individualise treatment interventions, optimization of analgesia and reassessment of outcomes of interventions.
CONCLUSIONS
By implementing the EONS guidelines nurses will utilise the latest available knowledge in clinical practice and the understanding and management of BTCP will improve assessment and overall management of breakthrough pain in cancer patients.
Topics: Breakthrough Pain; Europe; Evidence-Based Medicine; Female; Humans; Male; Neoplasms; Oncology Nursing; Pain Management; Pain Measurement; Practice Guidelines as Topic; Severity of Illness Index; Societies, Nursing; Treatment Outcome
PubMed: 24369817
DOI: 10.1016/j.ejon.2013.11.009 -
Advances in Therapy Jul 2014Pain presents in 80% of patients with advanced cancer, and 30% have periods of increased pain due to fluctuating intensity, known as breakthrough cancer pain (BTcP).... (Review)
Review
Pain presents in 80% of patients with advanced cancer, and 30% have periods of increased pain due to fluctuating intensity, known as breakthrough cancer pain (BTcP). BTcP is high-intensity, short-duration pain occurring in several episodes per day and is non-responsive to treatment. The clinical approach to BTcP is variable. A review of the literature was performed to provide clinicians and practitioners with a rational synthesis of the ongoing scientific debate on BTcP and to provide a basis for optimal clinical approach to BTcP in adult Italian patients. Data show that circadian exacerbations of pain should be carefully monitored, differentiating, if possible, between fluctuations of background pain (BP), end-of-dose effect, and BTcP. BTcP should be monitored in all care contexts in clinical practice and each care facility must have all the medications and products approved for use in BTcP at their disposal. Data show that knowledge about medications for BTcP is lacking: medications for BTcP treatment are not interchangeable, although containing the same active substance; each physician must know the specific characteristics of each medication, its pharmacological properties, limitations in clinical practice, specifics relating to titration and repeatability of administration, and technical specifics relating to the accessibility and delivery. Importantly, before choosing a rapid-onset opioid (ROO), it is essential to deeply understand the status of patient and the characteristics of their family unit/caregivers, taking into account the patient's progressive loss of autonomy and/or cognitive-relational functionality. When BTcP therapy is initiated or changed, special attention must be paid to training the patient and family members/caregivers, providing clear instructions regarding the timing of drug administration. The patient must already be treated effectively with opioids before introducing ROOs for control of BTcP.
Topics: Analgesics, Opioid; Breakthrough Pain; Caregivers; Drug Administration Routes; Family; Fentanyl; Humans; Neoplasms; Pain Management; Pain Measurement; Patient Care Team; Time Factors
PubMed: 25005168
DOI: 10.1007/s12325-014-0130-z -
Current Review of Pain 2000Breakthrough pain is a well recognized but ill-defined phenomenon that occurs commonly in the presence of otherwise stable, persistent pain. It is defined now as a... (Review)
Review
Breakthrough pain is a well recognized but ill-defined phenomenon that occurs commonly in the presence of otherwise stable, persistent pain. It is defined now as a "transient pain episode that occurs, or breaks through from the otherwise stable background pain." Breakthrough pain is usually associated with moderate to severe pain and may form a predictor of poor response to treatment with routine pharmacotherapy. Breakthrough pain is also associated with functional impairment and psychological distress. The assessment and treatment should be multidimensional. Although primary therapies such as chemotherapy, radiation treatment, and surgical options are explored, the mainstay of treatment is pharmacotherapy. Nonpharmacologic methods, such as orthotic devices and joint stabilizations along with behavioral methods, should be explored. Anesthetic and neurosurgical procedures are performed on a limited number of patients based on the prognosis, intractable nature of pain, and favorable risk/benefit ratio. Newer oral transmucosal fentanyl offers a favorable pharmacokinetic and pharmacodynamic profile and ease of administration.
Topics: Analgesics; Drug Administration Routes; Humans; Neoplasms; Pain; Pain Management
PubMed: 10998740
DOI: 10.1007/s11916-000-0086-3 -
Journal of Pain and Symptom Management May 2019The objective of this study was to assess the characteristics of breakthrough cancer pain (BTcP) in patients with abdominal cancer pain, and the eventual factors...
OBJECTIVE
The objective of this study was to assess the characteristics of breakthrough cancer pain (BTcP) in patients with abdominal cancer pain, and the eventual factors associated with its presentation.
METHODS
Patients with abdominal visceral cancer presenting BTcP were included in the analysis. Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset (≤10 minutes or >10 minutes), duration, interference with daily activities, medications and doses currently used for BTcP, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded.
RESULTS
Four hundred fourteen patients were included in the study. The mean background pain was 2.7 (SD 1.19) and most patients (97.6%) were receiving opioids. The mean number of BTcP episodes/day was 2.2 (SD 1.51). The mean intensity of BTcP was 7.3 (SD 1.32). BTcP onset was ≤10 minutes and >10 minutes in 271 (65.5%) and 143 patients (35.5%), respectively, and the mean duration was 52.6 minutes (SD 38.1). Interference of BTcP with daily activity was relevant for 340 patients (82%). In 122 patients (29.5%), BTcP was predictable and ingestion of food (n = 63, 51.6%) was the most frequent trigger. In comparison with unpredictable BTcP, postprandial BTcP had a lower intensity (P = 0.039), had a faster onset (P = 0.042), and was associated with the use of oxycodone/naloxone (P = 0.003), and less use of nonsteroidal anti-inflammatory drugs (P = 0.006).
CONCLUSION
Patients with abdominal visceral BTcP represent a subgroup with specific features of BTcP, particularly those with predictable BTcP. Ingestion of food was the prominent trigger for BTcP, having a faster onset and a lower intensity. This group of patients more frequently used oxycodone/naloxone or no anti-inflammatory drugs. These findings suggest consequential therapeutic decisions.
Topics: Abdominal Pain; Adult; Aged; Aged, 80 and over; Breakthrough Pain; Cancer Pain; Eating; Female; Humans; Male; Middle Aged; Viscera
PubMed: 30822530
DOI: 10.1016/j.jpainsymman.2019.02.014 -
Expert Review of Neurotherapeutics Aug 2011The purpose of this article is to systematically review the use of fentanyl as an analgesic for breakthrough pain. This article found that the oral transmucosal fentanyl... (Review)
Review
The purpose of this article is to systematically review the use of fentanyl as an analgesic for breakthrough pain. This article found that the oral transmucosal fentanyl (OTFC) had a quicker onset to analgesia than oral immediate-release opioids. Intranasal fentanyl (INFS) had a quicker onset to analgesia than buccal tablets, which in turn had a quicker onset to analgesia than OTFC. Patient acceptance and global rating of efficacy were greater for INFS than for buccal fentanyl. OTFC and INFS have been used effectively to reduce acute pain in children who are opioid-naive. Abuse and addiction to OTFC, fentanyl buccal tablets and INFS was low, owing to patient selection.
Topics: Acute Pain; Administration, Buccal; Administration, Intranasal; Administration, Mucosal; Administration, Oral; Analgesics, Opioid; Breakthrough Pain; Fentanyl; Humans
PubMed: 21797660
DOI: 10.1586/ern.11.63 -
Pain Medicine (Malden, Mass.) Dec 2011Intrathecal therapy (ITT) via an implanted pump has become an accepted practice for the treatment of refractory cancer pain by infusing opioids and adjuncts directly... (Review)
Review
OBJECTIVE
Intrathecal therapy (ITT) via an implanted pump has become an accepted practice for the treatment of refractory cancer pain by infusing opioids and adjuncts directly to the neuraxis. Until recently, only a programmed basal rate of infusion could be delivered, and therefore, breakthrough pain required ongoing use of oral or transmucosal opioids. Recently, an implanted pump manufacturer has introduced a handheld device to bolus additional medication for breakthrough pain. We hypothesize that patient-controlled intrathecal analgesia (PCIA) for the treatment of breakthrough cancer pain reduces the need for breakthrough opioids and improves the patient perception of pain.
METHODS
A retrospective chart review was done on all patients who underwent ITT for cancer pain between January 2009 and February 2011. Clinical outcomes of interest were reduction in nonintrathecal opioid use and reduction in numerical rating score (NRS) for pain. The data was collected prior to ITT and at a 4-6 week postimplant visit.
RESULTS
After initiation of ITT with PCIA, 50% of patients had discontinued all nonintrathecal opioids at follow-up, and 46% of the patients on breakthrough medications no longer required their use. At follow-up, there was a significant reduction in total nonintrathecal opioid use, with an average of 796 mg pre-ITT vs 64 mg post-ITT of daily oral morphine equivalent dosing (P = <0.001). There was a significant difference between mean NRS pain score at follow-up-6.5 vs 3.1 pre-ITT (P<0.001). 65% of patients reported their pain as severe (NRS of 7 or greater) prior to ITT; this decreased to 3% at follow-up.
CONCLUSIONS
In patients with refractory cancer pain, intrathecal drug therapy with PCIA is associated with improved pain reporting, reduced nonintrathecal around-the-clock, and breakthrough opioid requirements.
Topics: Analgesia, Patient-Controlled; Breakthrough Pain; Catheters; Clinical Trials as Topic; Humans; Injections, Spinal; Neoplasms; Pain Measurement; Retrospective Studies; Treatment Outcome
PubMed: 22054042
DOI: 10.1111/j.1526-4637.2011.01262.x -
Expert Review of Clinical Pharmacology Jan 2015Fentanyl buccal tablet (FBT) (FENTORA) is indicated for the management of breakthrough pain (BTP) in patients with cancer pain and who are tolerant to ≥60 mg of oral... (Review)
Review
Fentanyl buccal tablet (FBT) (FENTORA) is indicated for the management of breakthrough pain (BTP) in patients with cancer pain and who are tolerant to ≥60 mg of oral morphine equivalents, at least with the current availability of the minimal strength of 100 μg. FBT uses the OraVescent technology to further increase the rate and extent of absorption of fentanyl. Short-term, randomized, controlled, clinical studies of FBT in patients with cancer pain have shown the efficacy of FBT in the management of breakthrough cancer pain. The efficacy was also confirmed in long-term studies on the safety and tolerability of FBT. It has been recommended that administration should be tailored to the patient's individual requirement, through dose titration starting from the lowest dose to find the effective dose. However, recent studies have demonstrated that predictable doses calculated from the basal opioid regimen are safe and more effective than doses achieved after dose titration.
Topics: Administration, Buccal; Analgesics, Opioid; Breakthrough Pain; Clinical Trials as Topic; Dose-Response Relationship, Drug; Fentanyl; Humans; Neoplasms; Randomized Controlled Trials as Topic; Tablets
PubMed: 25359295
DOI: 10.1586/17512433.2015.977254 -
Clinical & Translational Oncology :... Jul 2013Breakthrough cancer pain (BCP) is common in patients with cancer, causing a negative impairment in quality of life. Recent diagnostic criteria allow for differentiation... (Review)
Review
Breakthrough cancer pain (BCP) is common in patients with cancer, causing a negative impairment in quality of life. Recent diagnostic criteria allow for differentiation of background chronic pain and BCP, for which proportion of unpredictable episodes is very high. Five characteristics define BCP: rapid onset, high intensity, maximum intensity (minutes), mean duration 30 min, and unpredictable onset. Fentanyl is a synthetic opioid characterized by rapid absorption and start of the analgesic effects. In addition to comparing some of the marked differences between the four pharmaceutical forms of fentanyl marketed in Spain, this paper discusses the data collected in a comprehensive clinical trial program with fentanyl pectin nasal spray (FPNS), a formulation that takes advantage of the intranasal route and the PecSys™ technology. The FPNS formulation achieves analgesic action 5 min after application and significant pain relief at 10 min. FPNS, therefore, has key features to be an optimal treatment for BCP.
Topics: Administration, Intranasal; Analgesics, Opioid; Breakthrough Pain; Fentanyl; Humans; Nasal Sprays; Neoplasms
PubMed: 23263914
DOI: 10.1007/s12094-012-0981-1 -
Journal of Geriatric Oncology Jul 2019We aimed to generate expert-based recommendations on the management of breakthrough cancer pain (BTcP) in older patients with cancer.
OBJECTIVES
We aimed to generate expert-based recommendations on the management of breakthrough cancer pain (BTcP) in older patients with cancer.
MATERIAL AND METHODS
A two-round multidisciplinary Delphi study. Specialists rated their agreement with a set of statements using a nine-point Likert scale (one = totally disagree and nine = totally agree). Statements were classified as appropriate (median ranged from seven to nine), irrelevant (median ranged from four to six) or inappropriate (median ranged from one to three). Consensus was established when at least two thirds of the panel scored within any of the ranges.
RESULTS
A total of 64 specialists from pain units (44.4%), palliative care units (25.4%), medical oncology (19.1%), geriatric medicine (7.9%) and others (3.2%), participated in two consultation rounds. Specialists agreed that effective coordination between the different specialties and levels of care is essential for proper management of BTcP. Most participants (81.3%) supported the assessment of frailty and resolved (96.8%) that frailty status is a better indicator of patient needs than biological age. Participants agreed (75.8%) in the application of the Davies algorithm for diagnosis of BTcP in older patients. A strong consensus was achieved regarding which pharmacological treatment (transmucosal fentanyl) and dosing method (start low and go slow) are the most suitable for the older population. No agreement was reached on how interventionist techniques should be integrated into the therapeutic strategy for BTcP.
CONCLUSIONS
The present Delphi has generated a set of recommendations that will help healthcare professionals in the management of BTcP in older patients.
Topics: Administration, Mucosal; Aged; Analgesics, Opioid; Breakthrough Pain; Cancer Pain; Central Nervous System Depressants; Cytochrome P-450 Enzyme Inducers; Cytochrome P-450 Enzyme Inhibitors; Decision Making, Shared; Delphi Technique; Drug Interactions; Fentanyl; Frailty; Geriatric Assessment; Geriatrics; Humans; Medical Oncology; Morphine; Oxycodone; Pain Management; Pain Measurement; Palliative Medicine; Patient Care Team; Practice Guidelines as Topic
PubMed: 31036463
DOI: 10.1016/j.jgo.2019.03.012