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Drugs Mar 2016Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to... (Review)
Review
Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five 'things to do' and five 'things not to do' in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.
Topics: Analgesics, Opioid; Breakthrough Pain; Humans; Medication Adherence; Neoplasms; Pain Management; Pain Measurement; Practice Guidelines as Topic; Quality of Life; Surveys and Questionnaires
PubMed: 26755179
DOI: 10.1007/s40265-015-0519-2 -
The Oncologist Feb 2020This study aimed to assess the characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain in comparison with...
BACKGROUND
This study aimed to assess the characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain in comparison with patients receiving at least 60 mg of oral morphine equivalents (OME).
MATERIALS AND METHODS
Patients with advanced cancer receiving less than 60 mg/day of OME with episodes of BTcP were included in the analysis (group L). Data were compared with patients receiving doses of opioids ≥60 mg of OME (group H). Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded.
RESULTS
A total of 1,418 and 2,474 patients were included in groups L and H, respectively. A lower number of BTcP episodes (p = .005), a lower BTcP intensity (p = .0001), a faster BTcP onset (p = .024), and a longer time to meaningful pain relief after taking a BTcP medication (p = .009) were found in group L as compared with group H. In group L, BTcP interference on daily activity was less than in group H (p = .009). Patients in group L were less likely to be prescribed an opioid as BTcP medication in comparison with patients in group H (p = .0001). Opioid doses used for BTcP were significantly higher in group H. Patients in group L were more likely to be less satisfied (p = .003) than patients in group H. No adverse effects of severe intensity were reported in both groups.
CONCLUSION
Patients receiving lower doses of opioids exhibit some differences in BTcP presentation: fewer episodes with lower intensity and a faster onset, a longer time to meaningful pain relief, and less satisfaction with BTcP medication. A relevant percentage of patients was receiving fentanyl preparations normally reserved for patients receiving higher doses of opioids.
IMPLICATIONS FOR PRACTICE
Breakthrough pain is present in patients receiving low doses of opioids. It has its own peculiarities: less frequent, lower intensity, faster onset, longer time to meaningful pain relief, and less satisfaction with medication. Many patients were prescribed fentanyl preparations, which are normally reserved for patients receiving higher doses of opioids.
Topics: Analgesics, Opioid; Breakthrough Pain; Cancer Pain; Humans; Neoplasms; Pain Measurement; Treatment Outcome
PubMed: 31862860
DOI: 10.1634/theoncologist.2019-0542 -
Neuroscience Letters Dec 2013Cancerous cells can originate in a number of different tissues such as prostate, breast and lung, but often go undetected and are non-painful. Many types of cancers have... (Review)
Review
Cancerous cells can originate in a number of different tissues such as prostate, breast and lung, but often go undetected and are non-painful. Many types of cancers have a propensity to metastasize to the bone microenvironment first. Tumor burden within the bone causes excruciating breakthrough pain with properties of ongoing pain that is inadequately managed with current analgesics. Part of this failure is due to the poor understanding of the etiology of cancer pain. Animal models of cancer-induced bone pain (CIBP) have revealed that the neurochemistry of cancer has features distinctive from other chronic pain states. For example, preclinical models of metastatic cancer often result in the positive modulation of neurotrophins, such as NGF and BDNF, that can lead to nociceptive sensitization. Preclinical cancer models also demonstrate nociceptive neuronal expression of acid-sensing receptors, such as ASIC1 and TRPV1, which respond to cancer-induced acidity within the bone. CIBP is correlated with a significant increase in pro-inflammatory mediators acting peripherally and centrally, contributing to neuronal hypersensitive states. Finally, cancer cells generate high levels of oxidative molecules that are thought to increase extracellular glutamate concentrations, thus activating primary afferent neurons. Knowledge of the unique neuro-molecular profile of cancer pain will ultimately lead to the development of novel and superior therapeutics for CIBP.
Topics: Acid Sensing Ion Channels; Animals; Bone Neoplasms; Cytokines; Disease Models, Animal; Humans; Mice; Nerve Growth Factors; Oxidative Stress; Pain; Rats
PubMed: 24076008
DOI: 10.1016/j.neulet.2013.08.003 -
Children (Basel, Switzerland) Apr 2024Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is...
Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.
PubMed: 38671702
DOI: 10.3390/children11040485 -
Journal of Pain and Symptom Management Jan 2014Despite the large body of literature on breakthrough cancer pain (BTcP), an accurate estimate of BTcP prevalence is still not available. (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Despite the large body of literature on breakthrough cancer pain (BTcP), an accurate estimate of BTcP prevalence is still not available.
OBJECTIVES
To provide an estimate of BTcP prevalence and investigate the association between different prevalence rates and possible determinants.
METHODS
We conducted MEDLINE and EMBASE searches for studies published from 1990 to 2012 reporting data on BTcP prevalence in adult cancer populations. Pooled prevalence rates from observational studies with an acceptable methodological quality were computed. The association between BTcP prevalence and possible predictors was investigated using subgroup analyses and meta-regression.
RESULTS
Twenty-seven observational studies were identified. When quality criteria were applied, only 19 studies were included in the pooled analysis. The overall pooled prevalence was 59.2%, with high heterogeneity. The lowest prevalence rates were detected in studies conducted in outpatient clinics (39.9%), and the highest prevalence was reported in studies conducted in hospice (80.5%). The association between BTcP prevalence and other determinants such as publication year, age, gender, metastatic disease prevalence, or baseline pain intensity did not reach statistical significance.
CONCLUSION
In the context of a large between-studies heterogeneity, more than one in two patients with cancer pain also experiences BTcP, with some variability according to clinical and organizational variables.
Topics: Breakthrough Pain; Humans; Neoplasms; Prevalence
PubMed: 23796584
DOI: 10.1016/j.jpainsymman.2013.02.015 -
In Vivo (Athens, Greece) 2004Fentanyl, a surgical analgesic and general anaesthetic, is a lipophilic short-acting synthetic opioid, having a selective potent effect on mu receptors. The transdermal... (Review)
Review
Fentanyl, a surgical analgesic and general anaesthetic, is a lipophilic short-acting synthetic opioid, having a selective potent effect on mu receptors. The transdermal therapeutic fentanyl-system (TTS-F) allows for a continued and sustained titratable amount of fentanyl to be delivered without the inconvenience of the typical 24-h administration of other analgesics. Although incidences of respiratory depression led to TTS-F being contraindicated for postoperative analgesia, it is currently undergoing Phase III trials for nociceptive, neuropathic and chronic moderate to severe pain in a variety of settings. It demonstrates a slow pharmacokinetic profile and incidences of breakthrough pain may still require rapid analgesia, for which intravenous and bolus administration of rapid acting opioids remain 'gold standard' However, TTS-F is finding uses for chronic pain of cancer origin where it offers a solution for step 3-pain (WHO) management on the WHO analgesic ladder. More recent data indicates that TTS-F is not only effective for neuropathic but also nociceptive non-cancer and cancer pain alike. This review presents an overview of the synthesis, delivery, pharmacokinetics, toxicity and clinical pharmacology of the transdermal delivery of fentanyl.
Topics: Administration, Cutaneous; Analgesics, Opioid; Chronic Disease; Clinical Trials, Phase III as Topic; Fentanyl; Humans; Pain
PubMed: 15523905
DOI: No ID Found -
Journal of Pain and Symptom Management Sep 1998Current guidelines on the treatment of moderate to severe cancer pain recommend the use of scheduled doses of opioids for persistent pain combined with "as needed" doses... (Review)
Review
Current guidelines on the treatment of moderate to severe cancer pain recommend the use of scheduled doses of opioids for persistent pain combined with "as needed" doses of similar agents for breakthrough pain. Oral drugs given on an "as needed" basis can be problematic for patients with difficulty in swallowing or for those who suffer from nausea and vomiting. Further, breakthrough pain can become excruciating in a relatively short time, a drawback for analgesics that require gastrointestinal (GI) absorption before pain relief can begin. Hence, there is considerable interest in the development of novel drug administration routes to provide rapid relief of breakthrough pain, particularly through a route that bypasses the GI system. Sublingually administered morphine has sometimes been used in the treatment of breakthrough pain because some believe it provides effective analgesia via an appropriate alternate route. Available pharmacological data, however, do not consistently support the rapid absorption of morphine through the sublingual mucosa, and clinical data concerning the efficacy of sublingual morphine for the treatment of cancer pain are limited, not well-controlled, and inconclusive. While there seems to be a need for provision of rapid, effective analgesia to cancer patients by an alternative route, sublingual morphine may not satisfy this requirement. Newer formulations of analgesics should be tested in the treatment of breakthrough pain due to cancer.
Topics: Administration, Sublingual; Analgesics, Opioid; Humans; Morphine
PubMed: 9769621
DOI: 10.1016/s0885-3924(98)00046-3 -
Oncology (Williston Park, N.Y.) Dec 2001Cancer patients experience pain in multiple sites and from several pathophysiologies of the symptom complex. The fluctuating nature of cancer pain intensity is a... (Review)
Review
Cancer patients experience pain in multiple sites and from several pathophysiologies of the symptom complex. The fluctuating nature of cancer pain intensity is a relevant clinical feature and depends on disease patterns and pain mechanisms. Breakthrough pain is defined as episodes of pain that "break through" the control of an otherwise effective analgesic therapy. Traditional ways of classifying pain in the cancer population include distinguishing pain associated with the treatments, the tumor, or unrelated to both and between chronic and acute pain. In focusing on the care of the cancer patient with pain, it is useful to be familiar with the characteristics of the typical syndrome found in association with different tumor types and anatomic locations. An understanding of the etiology of pain in relation to the cancer is useful in recognizing these complications and in treating them. This article reviews the methods presently applied to the classification of cancer pain and highlights the need for more research in this area.
Topics: Humans; Neoplasm Staging; Neoplasms; Pain; Pain Measurement; Severity of Illness Index
PubMed: 11780704
DOI: No ID Found -
Journal of Pain and Symptom Management May 2016There are disparities in the level of symptom severity as perceived by patients and health professionals. There is limited information about patients' and clinicians'... (Observational Study)
Observational Study
CONTEXT
There are disparities in the level of symptom severity as perceived by patients and health professionals. There is limited information about patients' and clinicians' global assessment of breakthrough pain control, the need to change analgesics, and change in breakthrough pain over time.
OBJECTIVES
To establish whether patients and clinicians independently agree on adequacy of breakthrough pain control, management strategy, and impression of change over time.
METHODS
One hundred patients with breakthrough cancer pain were assessed and followed up one week later by a palliative medicine specialist. The patient and clinician independently answered the same questions about the adequacy of the patient's breakthrough pain control and breakthrough pain management. The results were compared with items on the Breakthrough Pain Assessment Tool (BAT).
RESULTS
At initial consultation, 35% of patients rated their breakthrough cancer pain as inadequately controlled compared with 72% of clinicians. Breakthrough pain analgesics were changed in 68% of cases. At one-week follow-up consultation, 62% of patients considered their breakthrough cancer pain to be better, and in 57% of cases, the clinicians also categorized the pain this way.
CONCLUSION
There are significant differences in global impressions of breakthrough pain between patients and pain clinicians that become less disparate as a therapeutic relationship evolves. Therapeutic decisions were based on clinical rather than patient perceptions.
Topics: Adult; Aftercare; Aged; Aged, 80 and over; Analgesics; Attitude of Health Personnel; Breakthrough Pain; Cancer Pain; Female; Humans; Male; Middle Aged; Pain Management; Pain Measurement; Pain Perception; Palliative Care; Patient Satisfaction; Prospective Studies; Treatment Outcome
PubMed: 26740387
DOI: 10.1016/j.jpainsymman.2015.12.309 -
Pain Physician 2011Treatment of chronic non-cancer pain with opioid therapy has escalated in recent years, resulting in exploding therapeutic use and misuse of prescription opioids and... (Review)
Review
Treatment of chronic non-cancer pain with opioid therapy has escalated in recent years, resulting in exploding therapeutic use and misuse of prescription opioids and multiple adverse drug events. Breakthrough pain is defined as a transient exacerbation of pain experienced by individuals who have relatively stable and adequately controlled baseline cancer pain. Further, the definition of breakthrough pain, prevalence, characteristics, implications, and treatment modalities have been extensively described for chronic cancer pain. However, the literature for breakthrough pain in chronic non-cancer pain including its terminology, prevalence, relevance, characteristics, and treatments, have been poorly described and continue to be debated. The philosophy of breakthrough pain in chronic non-cancer pain raises multiple issues leading almost all patients to be on high dose long-acting opioids, followed by supplementing with short-acting drugs, instead of treating the patients with only short-acting drugs as required. Consequently, the subject of breakthrough pain in chronic non-cancer pain is looked at with suspicion due to the lack of evidence and inherent bias associated with its evaluation, followed by escalating use and abuse of opioids. Multiple issues related to the concept of breakthrough pain in chronic non-cancer pain evolve around extensive use, overuse, misuse, and abuse of opioids. In the era of eliminating opioids or significantly curtailing their use to only appropriate indications, the concept of breakthrough pain raises multiple questions without any scientific evidence. This review illustrates that there is no significant evidence for any type of breakthrough pain in chronic non-cancer pain based on available literature, methodology utilized, and response to opioids in chronic non-cancer pain. The advocacy for increased usage of opioids in the treatment of chronic pain dates back to the liberalization of laws governing opioid prescription for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and is exploding with new pain management standards for inpatient and outpatient medical care implemented by the Joint Commission on Accreditation of Health Care Organizations in 2000, and the advocacy by many physicians and organizations for increased use of opioids. This comprehensive review critically evaluates the available evidence of breakthrough pain in chronic non-cancer pain including its existence, prevalence, and managing symptoms which are described as breakthrough pain or episodic pain.
Topics: Analgesics, Opioid; Chronic Disease; Humans; Pain; Prevalence
PubMed: 21412376
DOI: No ID Found