Page 290 Guide to Pain Management in Low-Resource Settings

278 Gona Ali and Andreas Kopf

a family member or friend should be around to help pain specialists from North America, Australasia, and
her in case she feels dizzy. Western Europe reported more breakthrough pain
In case Mrs. Nadhari needs more than three or than did pain specialists from South America, Asia,
four demand doses of morphine daily, Dr. Foud should and Southern and Eastern Europe. Th us, there is a
consider increasing the background morphine dose ac- need for specifi c educational initiatives about break-
cordingly, perhaps to 40 mg morphine q.i.d. through pain for all groups of health care profession-
als involved in pain management, since the diagnosis
What is breakthrough pain? and treatment of breakthrough pain should be inde-
pendent from the region in which the patient lives.
Th e WHO has issued guidelines for matching the po- Many patients with cancer-related pain are inad-
tency of analgesics with the intensity of pain. Th e three- equately managed, and this problem relates to treat-
step approach was recommended in 1990 and revised in ment of both background pain and breakthrough pain.
1996. Th e WHO guidelines do not specifi cally address Unsatisfactory treatment of breakthrough pain relates
breakthrough pain. to inadequate assessment, inadequate use of available
Th e transitory exacerbation of pain is de- treatments, and, in many instances, inadequate treat-
scribed in the medical literature by a number of diff er- ments. Health care professionals need to be aware of
ent terms, such as breakthrough pain, transient pain, the diff erent treatment options, and patients need to
exacerbation of pain, episodic pain, transitory pain, or have access to all of these diff erent treatment options
pain fl ow. An Expert Working Group of the European (e.g., anticancer treatment, nonpharmacological inter-
Association for Palliative Care (EAPC) has suggested ventions, and pharmacological interventions).
that the term “breakthrough pain” should be replaced
by the terms “episodic pain” or “transient pain.” How- What are the causes

ever, the term “breakthrough pain” is still widely used of breakthrough pain?
in the medical literature; therefore, this term will be
used in this chapter, too. Breakthrough pain appears to be more common in pa-
Breakthrough pain is usually abrupt, acute, tients with
and can be very intense. Th e characteristics of break- • Advanced disease;
through cancer pain vary from person to person, in- • Poor functional status;
cluding the onset, duration, frequency of each episode • Pain originating from the vertebral column and to
and possible causes. a lesser extent from other weight-bearing bones
Breakthrough pain could be described as or joints;
short-term pain exacerbation which is experienced by • Pain originating from the nerve plexuses and to a
a patient who has relatively stable and adequately con- lesser extent from nerve roots.
trolled baseline pain. But currently, there is no univer- Other categories include idiopathic break-
sally accepted defi nition of breakthrough pain. Th ere through pain, which occurs spontaneously, and break-
are diagnostic algorithm and assessment tools for through pain known as “end of-dose failure,” which
breakthrough pain, although they are not used very typically occurs at the end of the dosage interval of pain
often in clinical practice. Breakthrough pain should be medication used to control the patient’s persistent pain.
assessed in a similar manner to background pain, with Th is transitory increase in pain should be greater than
a pain history and physical examination. of moderate intensity (e.g., “severe” or “excruciating”). A
widely used set of diagnostic criteria for breakthrough
Why should attention to pain is by Russell Portenoy, from Memorial Sloan-Ket-
breakthrough pain be increased? tering Cancer Center, New York. Th e criteria are:
• Th e presence of stable analgesia in the previous
Breakthrough pain is common in cancer patients, 48 hours
and also in patients with other types of pain. Unfor- • Th e presence of controlled background pain in
tunately, it is underdiagnosed and under-recognized the previous 24 hours (i.e., average pain intensity
by health care professionals. An IASP survey on can- of no more than 4 out of 10 on a numeric rating
cer pain characteristics and syndromes found that scale [NRS])