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presence of recurrent disease or serious complications of cancer that might require active
intervention.
The European Association for Palliative Care recommends the use of standardised symptom
assessment tools in the comprehensive assessment of cancer pain (Caraceni et al, 2002).
Validated tools include the revised Edmonton Staging System (rESS) (Fainsinger et al, 2005;
Nekolaichuk et al, 2005) and the McGill Pain Questionnaire and Brief Pain Inventory. All have
been validated in different cultures (Uki et al, 1998; Aisyaturridha et al, 2006; Yesilbalkan et al,
2008). Pain assessment tools are available for non‐verbal, cognitively impaired or dying
patients.
Comprehensive consensus guidelines relating to cancer pain management have now been
developed by several agencies worldwide (Hanks et al, 2001; Carr et al, 2002; Singapore Ministry of
Health, 2003; NHS Quality Improvement Scotland, 2004; Broadfield et al, 2005; Miaskowski et al, 2005;
SIGN, 2008; NCCN, 2009) all recommend best practice, but some sections are based on
systematic reviews.
9.7.2 Principles of management of acute cancer pain

A pain crisis has been defined as ‘an event in which the patient reports pain that is severe,
uncontrolled, and causing distress for the patient, family members, or both’ (Moryl et al, 2008).
An acute pain crisis should be treated with a degree of urgency and a similar methodological
approach as other medical crisis situations (Moryl et al, 2008).
In an acute pain crisis, rapid analgesic control may be achieved with a regular dose schedule
of a parenteral opioid, with frequent reassessment and dose adjustment, or use of PCA
technique. One clinical practical guideline for the administration of short‐acting opioids,
including IV morphine, in response to severe, moderate or increased pain has been published
by the United States National Comprehensive Cancer Network (NCCN, 2009).

9.7.3 Breakthrough pain
The term breakthrough pain typically refers to a transitory flare of pain in the setting of
chronic cancer pain managed with opioid drugs (Portenoy & Hagen, 1990). Despite stable
therapy, exacerbations of pain are common, frequently severe or excruciating, often
paroxysmal, occur a median 4 times daily and last from seconds to hours (Portenoy & Hagen,
1990 Level IV). Breakthrough pain may relate to waning opioid action prior to the next
maintenance opioid dose (end‐of‐dose failure), be predictably precipitated by some CHAPTER 9
movement or action (incident pain) or occur with some other random precipitant.
Consensus guidelines for management of breakthrough pain in adults have been based on
limited evidence (Zeppetella & Ribeiro, 2006 Level I; Zeppetella, 2008 Level IV; Davies et al, 2009
Level IV). Medications used should ideally have a pharmacokinetic profile that mirrors the
time‐course of the breakthrough pain, with rapid onset, high potency and fast offset (SIGN,
2008). Dose requirements are subject to enormous interindividual variability and breakthrough
medication doses should be titrated for each patient according to their response to these
doses and separate from the background medication (Hagen et al, 2007 Level II). Conventional
management guidelines dictate that the opioid breakthrough dose should be a proportion
(one‐sixth to one‐tenth) of the daily dose; for example, an oral breakthrough dose of
morphine would be equivalent to a 4‐hourly dose, or one‐sixth the oral morphine equivalent
daily dose (MEDD) (Hanks et al, 2001).
Oral transmucosal fentanyl citrate (OTFC) was effective for the management of breakthrough
pain (Zeppetella & Ribeiro, 2006 Level I). The effective dose was determined by upward titration
and found to be independent of the daily opioid dose (Portenoy et al, 1999 Level II). Analysis of
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