What is breakthrough pain relief?

Breakthrough Pain Relief: Definition and Management

Breakthrough pain relief refers to the treatment of transient exacerbations of pain that occur despite otherwise stable background pain control with regular analgesic medication. 1, 2

Definition and Characteristics of Breakthrough Pain

• Breakthrough pain is defined as a transitory flare of pain that occurs in patients with otherwise stable, persistent pain that is being managed with regular analgesic therapy 2, 3
• It typically has a rapid onset (peaks within 3-10 minutes) and relatively short duration (approximately 30 minutes) 3, 4
• Breakthrough pain is common among cancer patients, particularly those with moderate to severe background pain, and can significantly impact quality of life 2, 4

Types of Breakthrough Pain

Breakthrough pain can be categorized into several subtypes:

• End-of-dose failure: Pain that occurs toward the end of the dosing interval for regularly scheduled analgesics due to decreased blood concentrations 1
• Incident pain: Pain associated with specific activities or events that can often be anticipated (e.g., physical therapy, exercise) 1, 4
• Spontaneous pain: Pain that occurs unpredictably without an identifiable trigger, common with neuropathic pain 1, 4

Pharmacological Management of Breakthrough Pain

General Principles

• Most patients with continuous pain who are receiving long-acting or sustained-release preparations should also have fast-onset short-acting drugs available for breakthrough pain 1
• The breakthrough dose is typically calculated as 10-15% of the total daily opioid dose 1
• If more than four breakthrough doses per day are necessary, the baseline around-the-clock opioid treatment should be adjusted 1

Medication Selection

• Fast-acting opioids are preferred for breakthrough pain due to its rapid onset and short duration 2, 3
• Immediate-release morphine has traditionally been used, but its onset may not be rapid enough for some breakthrough pain episodes 3
• Transmucosal fentanyl formulations (buccal, sublingual, intranasal) have a more rapid onset of action and may be more effective than oral morphine for breakthrough pain in opioid-tolerant patients 1, 3
• Buccal fentanyl has been shown to be effective in treating breakthrough pain in cancer patients 1

Route of Administration

• The route of administration should be selected based on the patient's needs and the desired speed of onset 1
• Oral route is generally preferred for convenience and relatively steady blood concentrations 1
• Intravenous administration provides the most rapid onset and shortest duration of action but requires more technical skill and monitoring 1, 5
• Transmucosal routes (buccal, sublingual, intranasal) offer rapid onset without the need for invasive procedures 1, 3

Clinical Application and Dosing

• For opioid-tolerant patients experiencing breakthrough pain, the rescue dose should be individualized based on the patient's total daily opioid requirement 1, 6
• Intravenous morphine at a dose equivalent to 20% of the basal oral dosage has been shown to be safe and effective for breakthrough pain episodes 5
• When using oral immediate-release morphine, the breakthrough dose is typically one-sixth of the total daily opioid requirement 1

Non-Pharmacological Approaches

• Primary antineoplastic therapies (radiation, chemotherapy) may alleviate the cause of some breakthrough pain 2, 7
• Surgical interventions may be appropriate for specific causes of breakthrough pain (e.g., kyphoplasty for vertebral fractures) 3
• Orthotic devices, joint stabilization, and behavioral methods should be considered as adjuncts to pharmacotherapy 7

Monitoring and Adjustment

• Regular reassessment of breakthrough pain frequency, intensity, and response to treatment is essential 6
• If a patient requires more than four breakthrough doses per day, the around-the-clock analgesic regimen should be adjusted 1
• The goal is to achieve a balance between pain relief and medication adverse effects 1, 6

Common Pitfalls to Avoid

• Inadequate dosing: Using insufficient doses of rescue medication that fail to provide relief 3
• Inappropriate timing: Using medications with onset times that don't match the rapid nature of breakthrough pain 3, 4
• Failure to adjust baseline therapy: Not increasing around-the-clock analgesia when breakthrough pain occurs frequently 1
• Overlooking non-pharmacological options: Relying solely on medications without addressing underlying causes or utilizing complementary approaches 2, 7