Guidelines for the Management of Breakthrough Pain in Patients With Cancer

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The moral imperative to adequately manage pain is being increasingly recognized worldwide. A comprehensive pain management approach that addresses the various presentations of pain in patients with cancer is required, including appropriate management of breakthrough pain. Breakthrough pain commonly occurs in patients with advanced cancer and is disabling to the individual and burdensome to society, yet it is often inadequately managed. Because pain is heterogeneous, the best management of an individual’s pain, including breakthrough pain in cancer, requires a thorough assessment to tailor the treatment strategies. Recently developed guidelines support this approach and recommend treating breakthrough pain using rapid- or short-acting opioids with pharmacodynamics that mirror the rapid onset and short duration of the presenting pain. This approach should be part of a comprehensive strategy to treat pain within the context of the primary disease trajectory, offering continuity of care and access to specialized palliative care when appropriate.

Correspondence: Augusto Caraceni, MD, via Venezian 1, Milan, Italy 20133. E-mail: augusto.caraceni@istitutotumori.mi.itDr. Caraceni is a consultant for Archimedes Pharma; is on the speakers’ bureaus of Grünenthal-Formenti, Molteni Farmaceutici, Mundipharma, and Pfizer; and has received grant/research support from Cephalon, Grünenthal-Formenti, Mundipharma, Novartis, and Pfizer. Dr. Davies is a consultant for Archimedes, Cephalon, Meda Pharmaceuticals, Nycomed, and ProStrakan; is on the speakers’ bureaus of Archimedes Pharma, Cephalon, Nycomed, and ProStrakan; and has received grant/research support from Cephalon, Nycomed, and ProStrakan. Dr. Poulain is on the speakers’ bureaus of Archimedes Pharma, Cephalon-Teva, Nycomed-Takeda Pharmaceuticals International, and Janssen Pharmaceuticals, Inc. Dr. Cortés-Funes has served as a consultant at an advisory board meeting on breakthrough pain for Archimedes. Dr. Panchal has served as a consultant for Johnson & Johnson, Endo Pharmaceuticals, DepoMed, and Archimedes. Dr. Fanelli reports no conflicts of interest; he served as a consultant at an advisory board meeting on breakthrough pain for Archimedes.
  • 1

    CousinsMJLynchME. The Declaration Montreal: access to pain management is a fundamental human right. Pain2011;152:26732674.

  • 2

    TuroneF. Italy sets up palliative care service after MPs vote in new law. BMJ2010; 340:c1481.

  • 3

    Loi n° 99-477 du 9 juin 1999 visant à garantir le droit à l’accès aux soins palliatifs [Act No. 99-477 of 9 June 1999 to ensure the right of access to palliative care]. Available at: Legifrance.gouv.fr. Accessed December 19 2012.

    • Search Google Scholar
    • Export Citation
  • 4

    ChinellatoATerrazzaniGDebettoP. Retrospective analysis of opioid prescriptions in cancer patients in a northern Italian region. Br J Clin Pharmacol2006;62:130133.

    • Search Google Scholar
    • Export Citation
  • 5

    ChinellatoASkaperSDGiustiP. Consumption of opioid analgesics in Italy: light at the end of the tunnel?Eur J Pain2011;15:220221.

  • 6

    European Association of Palliative Care. Bibliographic reports on the national development of palliative care in Europe. Available at: http://www.eapc-taskforce-development.eu/documents/national/eapc_france.pdf. 2012. Accessed September 17 2012.

    • Search Google Scholar
    • Export Citation
  • 7

    CaraceniAHanksGKaasaS. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol2012;13:e5868.

    • Search Google Scholar
    • Export Citation
  • 8

    KnudsenAKAassNFainsingerR. Classification of pain in cancer patients—a systematic literature review. Palliat Med2009;23:295308.

  • 9

    KnudsenAKBrunelliCKlepstadP. Which domains should be included in a cancer pain classification system? Analyses of longitudinal data. Pain2012;153:696703.

    • Search Google Scholar
    • Export Citation
  • 10

    DaviesANDickmanAReidC. The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain2009;13:331338.

    • Search Google Scholar
    • Export Citation
  • 11

    HaugenDFHjermstadMJHagenN. Assessment and classification of cancer breakthrough pain: a systematic literature review. Pain2010;149:476482.

    • Search Google Scholar
    • Export Citation
  • 12

    PortenoyRKHagenNA. Breakthrough pain: definition, prevalence and characteristics. Pain1990;41:273281.

  • 13

    PortenoyRKPayneDJacobsenP. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain1999;81:129134.

  • 14

    PortenoyRKBrunsDShoemakerB. Breakthrough pain in community-dwelling patients with cancer pain and noncancer pain, part 1: prevalence and characteristics. J Opioid Manag2010;6:97108.

    • Search Google Scholar
    • Export Citation
  • 15

    DaviesAZeppetellaGAndersenS. Multi-centre European study of breakthrough cancer pain: pain characteristics and patient perceptions of current and potential management strategies. Eur J Pain2011;15:756763.

    • Search Google Scholar
    • Export Citation
  • 16

    CaraceniAMartiniCZeccaE. Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey. Palliat Med2004;18:177183.

    • Search Google Scholar
    • Export Citation
  • 17

    PortenoyRKBrunsDShoemakerB. Breakthrough pain in community-dwelling patients with cancer pain and noncancer pain, part 2: impact on function, mood, and quality of life. J Opioid Manag2010;6:109116.

    • Search Google Scholar
    • Export Citation
  • 18

    AbernethyAPWheelerJLFortnerBV. A health economic model of breakthrough pain. Am J Manag Care2008;14(5 Suppl 1):S129140.

  • 19

    World Health Organization. Cancer pain relief and palliative care: report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1990.

    • Search Google Scholar
    • Export Citation
  • 20

    HanksGWde ConnoFChernyN. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer2001;84:587593.

  • 21

    PoulainPMichenotNAmmarD. Mise au point sur l’utilisation du fentanyl transmuqueux: chez le patient présentant des douleurs d’origine cancéreuse. Douleurs2012;13:3439.

    • Search Google Scholar
    • Export Citation
  • 22

    CaraceniAPortenoyRK. An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. International Association for the Study of Pain. Pain1999;82:263274.

    • Search Google Scholar
    • Export Citation
  • 23

    CaraceniABertettoOLabiancaR. Episodic (breakthrough) pain prevalence in a population of cancer pain patients. Comparison of clinical diagnoses with the QUDEI—Italian questionnaire for intense episodic pain. J Pain Symptom Manage2012;43:833841.

    • Search Google Scholar
    • Export Citation
  • 24

    PortenoyRKBennettDSRauckR. Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. J Pain2006;7:583591.

    • Search Google Scholar
    • Export Citation
  • 25

    HwangSSChangVTKasimisB. Cancer breakthrough pain characteristics and responses to treatment at a VA medical center. Pain2003;101:5564.

    • Search Google Scholar
    • Export Citation
  • 26

    LavertyDDaviesA. Assessment. In: DaviesA ed. Cancer-related Breakthrough Pain. New York, NY: Oxford University Press; 2006:2330.

  • 27

    HagenNAStilesCNekolaichukC. The Alberta Breakthrough Pain Assessment Tool for cancer patients: a validation study using a Delphi process and patient think-aloud interviews. J Pain Symptom Manage2008;35:136152.

    • Search Google Scholar
    • Export Citation
  • 28

    ZeppetellaGRibeiroMD. Episodic pain in patients with advanced cancer. Am J Hosp Palliat Care2002;19:267276.

  • 29

    DaviesAN. The management of breakthrough cancer pain. Br J Nurs2011;20:803807.

  • 30

    ZeppetellaGRibeiroMD. Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database Syst Rev2006;CD004311.

    • Search Google Scholar
    • Export Citation
  • 31

    HagenNAFisherKVictorinoC. A titration strategy is needed to manage breakthrough cancer pain effectively: observations from data pooled from three clinical trials. J Palliat Med2007;10:4755.

    • Search Google Scholar
    • Export Citation
  • 32

    PigniABrunelliCGibbinsJ. Content development for EUROPEAN GUIDELINES on the use of opioids for cancer pain: a systematic review and Expert Consensus Study. Minerva Anestesiol2010;76:833843.

    • Search Google Scholar
    • Export Citation
  • 33

    Haute Autorité de Santé (HAS). Bon usage du médicament: les médicaments des accès douloureux paroxystiques du cancer [HAS Good use of medicine: cancer-related breakthrough pain relieving drugs]. Available at: http://www.has-sante.fr/portail/upload/docs/application/pdf/2011-09/acces_douloureux_paroxystiques_-_fiche_bum.pdf. Accessed December 19 2012.

    • Search Google Scholar
    • Export Citation
  • 34

    Consenso sobre dolor irruptivo oncologico. 2012. Available at: http://www.actasanitaria.com/fileset/doc_65005_FICHERO_NOTICIA_49088.pdf. Accessed January 18 2013.

    • Search Google Scholar
    • Export Citation
  • 35

    VirizuelaJAEscobarYCassinelloJ. Treatment of cancer pain: Spanish Society of Medical Oncology (SEOM) recommendations for clinical practice. Clin Transl Oncol2012;14:499504.

    • Search Google Scholar
    • Export Citation
  • 36

    Acta Sanitario. Consenso sobre dolor irruptivo oncolgico. Available at: http://www.actasanitaria.com/fileset/doc_65005_FICHERO_NOTICIA_49088.pdf. 2012. Accessed September 7 2012.

    • Search Google Scholar
    • Export Citation
  • 37

    Escobar Álvarez Y. New approaches to the diagnosis and treatment of breakthrough cancer pain consensus document. Presentation at: XIV Simposio de Revisiones En Cancer; February 8-10, 2012; Madrid, Spain.

    • Search Google Scholar
    • Export Citation
  • 38

    SwarmRAbernethyAPAnghelescuDL. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Version 22012. Available at: www.NCCN.org. Accessed September 17 2012.

    • Search Google Scholar
    • Export Citation
  • 39

    KaasaSApoloneGKlepstadP. Expert conference on cancer pain assessment and classification—the need for international consensus: working proposals on international standards. BMJ Support Palliat Care2012;1:281287.

    • Search Google Scholar
    • Export Citation
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