Page 293 Guide to Pain Management in Low-Resource Settings

Breakthrough Pain, the Pain Emergency, and Incident Pain
What are practical considerations for
breakthrough pain in my patient?
• Breakthrough pain refers to a cancer patient who
has a chronic pain problem, and is generally tak-
ing a long-term analgesic to treat his pain, but
still has episodes of increased pain additional to
his constant pain.
• Breakthrough pain in noncancer pain is a diff er-
ent story. Usually breakthrough pain has a dif-
ferent etiology than in cancer pain since there is
no obvious continuous tissue destruction. Th ere- • Alternative routes of administration and lipophil-
fore, the patient should not receive “free access”
to demand doses to avoid dose escalations in pain
etiologies where long-term analgesia by opioids
is very rare, e.g., chronic back pain or headache.
An exception to the rule would be infl ammatory
pain, as in advanced rheumatic arthritis or sys-
temic scleroderma.
• Not surprisingly, the pathophysiology of the
breakthrough pain is often the same as that of the
background pain. Th us, breakthrough pain may
be nociceptive, neuropathic, or of mixed origin.
• Breakthrough pain may result in a number of oth-
er physical, psychological, and social problems.
Indeed, breakthrough pain has a signifi cant nega-
tive impact on quality of life. Th e degree of inter- breakthrough pain, but is a bit diff erent, is called
ference seems to be related to the characteristics
of the breakthrough pain. Breakthrough pain is
associated with greater pain-related functional
impairment, worse mood, and more anxiety.
• Th e characteristics of breakthrough cancer pain
vary from person to person, including the dura-
tion of the breakthrough episode and possible
causes. Generally, breakthrough pain happens
fast, and may last anywhere from seconds to Pearls of wisdom
minutes to hours. Th e average duration of break-
through pain in some studies was 30 minutes.
Breakthrough pain episodes have the following
four key features: high frequency, high severity,
rapid onset, and short duration.
• Rescue medication should be taken at the fi rst
sign of breakthrough pain. Pain that is allowed to
build up is much harder to control. It is possible
to experience breakthrough pain just before or
just after taking the regular pain medication.
• Medications used for treating breakthrough pain
are called rescue medications. Th ey are the cor-
nerstone for the management of breakthrough
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pain episodes. Rescue medication is taken as re-
quired, rather than on a regular basis: in the case
of spontaneous pain or nonvolitional incident
pain, the treatment should be taken at the onset
of the breakthrough pain; in the case of volitional
incident pain or procedural pain, the treatment
should be taken before the relevant precipitant of
the pain. In many patients the most appropriate
rescue medication will be a normal-release (“im-
mediate-release”) opioid analgesic.
ic opioids would appear to be appropriate for pa-
tients with insuffi cient breakthrough pain control.
Oral transmucosal, sublingual, and intranasal fen-
tanyl, which has become available in some coun-
tries, would be a good choice for all patients for
whom the onset of eff ect of oral morphine is too
slow and the duration is too long.
• Another type of pain similar to breakthrough
pain is incident pain. It may be that certain ac-
tivities your patient does during the day are go-
ing to lead to more pain. Your patient needs to be
prescribed medications for this kind of activity,
to be taken before engaging in this extra activ-
ity. Th e other type of pain that is somewhat like
end-of-dose failure. Th ese patients are taking
an analgesic that becomes ineff ective after a few
hours, and then pain returns. Th e answer to that
problem is to choose a diff erent—longer-acting—
agent, choose a higher dose of the same agent, or
change the dosing interval to avoid low serum
levels with consecutive “end-of-dose” failure.
• About one-half to two thirds of patients with
chronic cancer-related pain also experience epi-
sodes of breakthrough cancer pain.
• Almost all people experiencing chronic cancer
pain should receive pain medications for around-
the-clock pain control AND a medication specifi -
cally for treatment of breakthrough pain. If you
have not off ered this option to your patients, al-
ways do so from now on.
• Morphine (oral and i.v.) is commonly used and
available. Although it has a delayed onset of ac-
tion, and a prolonged duration of eff ect, studies