What are the management options for breakthrough pain in patients on sustained-release (SR) pain medications?

Management of Breakthrough Pain in Patients on Sustained-Release Pain Medications

For breakthrough pain in patients on sustained-release pain medications, immediate-release opioid formulations should be used, with transmucosal fentanyl preparations being the preferred option for rapid onset pain relief, particularly for unpredictable breakthrough pain episodes. 1

Understanding Breakthrough Pain

Breakthrough pain is defined as transient exacerbations of pain that occur despite otherwise stable pain controlled with around-the-clock (ATC) analgesics. It can be categorized as:

• Incident pain: Associated with specific activities or events
• End-of-dose failure pain: Recurs toward the end of dosing interval
• Persistent pain: Pain routinely inadequately managed by existing scheduled medication 1

First-Line Management Options

1. Immediate-Release Opioids

• Standard approach: Immediate-release (IR) opioid formulations of the same medication used for baseline pain
• Dosing: Rescue dose should be 10-15% of the total daily opioid dose 1
• Frequency: Can be administered up to hourly for uncontrolled pain, for up to 4 consecutive doses before reassessment 1

2. Rapid-Onset Opioids (Preferred for Unpredictable Pain)

• Transmucosal fentanyl formulations (buccal, sublingual, or oral/nasal) are superior options for episodic breakthrough pain due to their rapid onset of action 1
• Available formulations include:
  • Oral transmucosal fentanyl citrate
  • Fentanyl buccal tablet
  • Transnasal fentanyl spray 1

Algorithm for Managing Breakthrough Pain

1. Assess the pattern of breakthrough pain:

   • Is it predictable (incident) or unpredictable?
   • Is it end-of-dose failure?
   • How many episodes occur per day?

2. Select appropriate medication based on pain pattern:

   • For predictable incident pain: Administer short-acting oral opioid preemptively before the pain-inducing activity 2
   • For unpredictable incident or idiopathic pain: Use rapid-onset transmucosal fentanyl preparations 1, 2
   • For end-of-dose failure: Consider increasing the dose or frequency of the sustained-release medication 1

3. Titrate the rescue medication:

   • Start with a dose equivalent to 10-15% of the total daily opioid dose 1
   • If more than 4 breakthrough doses are needed per day, adjust the baseline sustained-release opioid regimen 1

Special Considerations

Rapid-Onset Opioid Selection

• Transmucosal fentanyl products should only be used in opioid-tolerant patients (those taking at least 60mg oral morphine equivalent daily for a week or longer) 3
• These products provide onset of analgesia within 10-15 minutes 4
• The pharmacokinetic properties allow better control of pain with potentially lower total opioid burden 5

Adjusting Baseline Therapy

• If a patient consistently requires breakthrough medication (more than 4 doses per day), increase the dose of the sustained-release opioid 1
• For patients with end-of-dose failure, consider increasing the dose or frequency of the sustained-release medication 1

Common Pitfalls to Avoid

1. Using oral immediate-release opioids for rapid-onset pain: Standard oral opioids have too slow an onset for effective management of sudden breakthrough pain 4

2. Underdosing rescue medication: The breakthrough dose should be proportional (10-15% of daily dose) to the baseline opioid regimen 1

3. Failing to reassess: If a patient requires more than 4 breakthrough doses per day, the baseline regimen needs adjustment 1

4. Not considering the type of breakthrough pain: Different types of breakthrough pain require different management approaches 1, 2

5. Using rapid-onset opioids in opioid-naïve patients: Transmucosal fentanyl products should only be used in opioid-tolerant patients to avoid respiratory depression 3

By following this structured approach to breakthrough pain management, clinicians can provide effective pain relief while minimizing side effects and optimizing quality of life for patients on sustained-release pain medications.