The management of cancer-related breakthrough pain

Recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland


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Clinical features of breakthrough pain

  • Breakthrough pain is not a single entity, it may be related to a number of different causes (cancer-related, treatment-related, concomitant illness) and different pathophysiologies (nociceptive, neuropathic, mixed)
  • Breakthrough pain is usually classified into one of two categories:
    • spontaneous pain (‘idiopathic pain’)—the episodes are not related to an identifiable precipitant, and so are unpredictable in nature
    • incident pain (‘precipitated pain’)—the episodes are related to an identifiable precipitant, and so are somewhat predictable in nature. Incident pain is usually sub-classified into one of three categories:
      • volitional incident pain—is brought on by a voluntary act (e.g. walking)
      • non-volitional incident pain—is brought on by an involuntary act (e.g. coughing)
      • procedural pain—is related to a therapeutic intervention (e.g. wound dressing)
  • Clinical features of breakthrough pain vary from individual to individual, and may vary within an individual over time. Breakthrough pain is often reported to be frequent in occurrence, acute in onset, short in duration, and moderate-to-severe in intensity

Recommendations

  • Patients with pain should be assessed for the presence of breakthrough pain
    • it is important to differentiate patients with uncontrolled background pain experiencing transient exacerbations of that pain from patients with controlled background pain experiencing episodes of breakthrough pain
  • Patients with breakthrough pain should have this pain specifically assessed
    • the successful management of breakthrough pain depends on adequate assessment of the patient; therefore, it is important to take a detailed history and to perform a thorough examination
      • the objectives of assessment are to determine the aetiology of the pain, the pathophysiology of the pain and any factors that would indicate or contra-indicate specific interventions
    • inadequate assessment may lead to the utilisation of ineffective and/or inappropriate treatment
  • Currently, there is no validated clinical breakthrough pain assessment tool. The use of standard pain questions are recommended to determine the clinical features of the breakthrough pain
    • breakthrough pain questions:
      • onset of pain?
      • frequency of pain?
      • site of pain?
      • radiation of pain?
      • quality (character) of pain?
      • intensity (severity) of pain?
      • duration of pain?
      • exacerbating factors?
      • relieving factors?
      • response to analgesics?
      • response to other interventions?
      • associated symptoms?
      • interference with activities of daily living?
  • The management of breakthrough pain should be individualized; the optimal management of breakthrough pain depends on a variety of factors, including:
    • pain-related factors, such as:
      • aetiology of the pain (e.g. cancer-related, treatment-related, concomitant illness)
      • pathophysiology of the pain (nociceptive, neuropathic, mixed)
      • clinical features of the pain
    • patient-related factors, such as:
      • stage of the disease (early, advanced)
      • performance status of the patient (good, poor)
      • personal preferences of the patient
  • Consideration should be given to treatment of the underlying cause of the pain
    • in 65–76% cases, the underlying cause of the pain is a direct effect of the cancer
  • Consideration should be given to avoidance/treatment of the precipitating factors of the pain
    • avoidance or treatment of precipitating factors should be considered in patients with incident-type breakthrough pain. However, only certain precipitants are amenable to specific interventions
  • Consideration should be given to modification of the background analgesic regimen/’around the clock medication’
    • this has been shown to be a useful approach in managing breakthrough pain, and may involve one or more of the following treatment strategies:
      • titration of opioid analgesics
      • switching of opioid analgesics
      • addition of ‘adjuvant analgesics’ (co-analgesics)—agents whose primary function is not analgesia, but which provide pain relief in certain circumstances
      • addition of other ‘adjuvant drugs’ (agents whose function is not analgesia, but provide relief from the adverse effects of analgesic drugs, or the complications of the pain)
  • Opioids are the ‘rescue medication’ of choice in the management of breakthrough pain episodes
    • rescue medication is taken as required, rather than on a regular basis:
      • in the case of spontaneous pain or non-volitional incident pain, treatment should be taken at the onset of the breakthrough pain
      • in the case of volitional incident pain or procedural pain, treatment should be taken before the relevant precipitant of the pain
      • the decision to use a specific opioid preparation should be based on a combination of the pain characteristics (e.g. onset, duration), the product characteristics (e.g. pharmacokinetics, pharmacodynamics), the patient’s previous response to opioids (e.g. efficacy, tolerability), and particularly the patient’s preference for an individual preparation
      • the use of rescue medication is only one aspect of management
  • The dose of opioid ‘rescue medication’ should be determined by individual titration
  • Non-pharmacological methods may be useful in the management of breakthrough pain episodes
    • a variety of non-pharmacological methods are used by patients, such as rubbing/massage, application of heat, application of cold, distraction techniques and relaxation techniques. However, there is relatively little evidence to support the use of these interventions in the treatment of breakthrough pain episodes
  • Non-opioid analgesics may be useful in the management of breakthrough pain episodes
  • Interventional techniques may be useful in the management of breakthrough pain
  • Patients with breakthrough pain should have this pain specifically re-assessed
    • successful management of breakthrough pain depends on adequate re-assessment of the patient. The objectives of re-assessment are to determine the efficacy of the treatment, the tolerability of the treatment, and any change in the nature of the breakthrough pain. Inadequate re-assessment may lead to the continuance of ineffective and/or inappropriate treatment
    • currently there is no validated clinical breakthrough pain assessment tool. The use of standard pain scales are recommended to determine the response to the treatment (e.g. verbal rating scales, numerical rating scales). Choice of pain scale should be made on an individual basis, since different patients will be able/unable to complete different types of pain scale
    • patients with difficult-to-manage pain should be referred to a pain/palliative care specialist with an interest in cancer-related breakthrough pain

Algorithm for diagnosing patients with breakthrough pain

Algorithm for diagnosing patients with breakthrough pain

Dose titration scheme for opioid 'rescue medication'

References

full guideline available from…
Davies A, Dickman A, Reid C et al. The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 2009; 13 (4): 329–330.


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