Breakthrough Cancer Pain

1. Breakthrough Cancer Pain Educational Slides

2. Definition “A transitory exacerbation of pain experienced by the patient who has relatively stable and adequately controlled baseline pain” Portenoy RK, Forbes K, Lussier D, Hanks G (2004). Difficult pain problems: an integrated approach. In Doyle D, Hanks G, Cherny N, Calman K, ed. Oxford Textbook of Palliative Medicine, 3rd edn, pp. 438-58. Oxford University Press, Oxford.

3. Definition “A transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain” Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G (2009). 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. European Journal of Pain, 13, 331-8.

4. Epidemiology 40-80% patients with cancer pain Mercadante S, Radbruch L, Caraceni A et al (2002). Episodic (breakthrough) pain. Consensus conference of an Expert Working Group of the European Association for Palliative Care. Cancer, 94, 832-9.

5. Aetiology • Direct effect of cancer • Indirect effect of cancer • Effect of cancer treatment • Effect of concurrent disease

6. Aetiology

7. Aetiology • Nociceptive - visceral - somatic • Neuropathic • Mixed

8. Aetiology

9. Classification • Spontaneous pain ‘idiopathic pain’) – pain cannot be predicted • Incident pain (‘precipitated pain’) – pain can be predicted - Volitional (voluntary act) - Non-volitional (involuntary act) - Procedural (therapeutic intervention)

10. Clinical features • Frequent in occurrence Mean number of episodes - 4 / day (range 1 - 14 / day) Zeppetella G, O’Doherty CA, Collins S (2000). Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. Journal of Pain and Symptom Management, 20: 87-92.

11. Clinical features • Short in duration Median duration - 30 min (range 1 - 240 min) Portenoy RK, Hagen NA (1990). Breakthrough pain: definition, prevalence and characteristics. Pain, 41: 273–281.

12. Clinical features • Intense in nature Slight - 16% Moderate - 46% Severe - 36% Excruciating - 2% Zeppetella G, O’Doherty CA, Collins S (2000). Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. Journal of Pain and Symptom Management, 20: 87-92.

13. Clinical features • Complications - Physical - Psychological - Social - Decreased quality of life

14. Clinical features • Complications - Physical a) Immobility b) Insomnia

15. Clinical features • Complications - Psychological a) Anxiety b) Depression

16. Clinical features • Complications - Social a) Inability to work b) Inability to undertake activities of daily living c) Social isolation

17. Clinical features • Complications - Social d) Increased use of healthcare resources e) Increased use of social care resources Fortner BV, Okon TA, Portenoy RK (2002). A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. Journal of Pain, 3, 38-44.

18. Assessment • History (pain, general) • Examination (area of pain, general) • Investigations • (Assessment tools)

19. Assessment Pain history: • Frequency episodes • Precipitating factors • Site pain • Radiation pain • Character / quality pain • Severity / intensity pain • Duration pain

20. Assessment Pain history: • Exacerbating factors • Relieving factors • Response analgesics • Response other treatment • Associated physical symptoms • Interference activities of daily living

21. Management Principles: • Management needs to be individualised (breakthrough pain is heterogeneous in nature)

22. Management Principles: • Assessment • Treatment • Re-assessment

23. Management • Treatment: - treatment of cause of pain - symptomatic treatment of pain - treatment of complications of pain

24. Management • Treatment: - treatment of cause of pain a) Treatment for cancer (e.g. radiotherapy, chemotherapy) b) Treatment for effects of cancer (e.g. bisphosphonate, orthopaedic surgery) c) Treatment of precipitating factors of pain

25. Management

26. Management • Treatment: - symptomatic treatment of pain a) Non-pharmacological methods b) Pharmacological methods c) Interventional techniques d) Combination of treatments

27. Management • Treatment: - symptomatic treatment of pain a) Non-pharmacological methods Rubbing / massage Heat application Cold application TENS Distraction techniques Relaxation techniques

28. Management • Treatment: - symptomatic treatment of pain b) Pharmacological methods (i) Modification of the background analgesia / “around the clock” analgesia -Titration of opioid drug - Opioid switching (drug, route) - Addition of additional analgesic - Addition of “adjuvant” analgesic

29. Management • Treatment: - symptomatic treatment of pain b) Pharmacological methods (ii) Use of rescue analgesia / “as required” analgesia - Opioid analgesics - Non-opioid analgesics

31. APM Recommendations Davies AN, Dickman A, Reid C, Stevens A-M, Zeppetella G. The management of cancer-related breakthrough pain: Recommend-ations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 2009; 13: 331-8.

32. APM Recommendations Breakthrough pain is “a transient ex-acerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain”.

34. APM Recommendations • Patients with pain should be assessed for the presence of breakthrough pain (grade of recommendation: D) • Patients with breakthrough pain should have this pain specific-ally assessed (D)

35. APM Recommendations • The management of breakthrough pain should be individualised (D)

36. APM Recommendations • Consideration should be given to treat-ment of the underlying cause of the pain (D) • Consideration should be given to avoid-ance / treatment of the precipitating factors of the pain (D)

37. APM Recommendations • Consideration should be given to modification of the background analgesic regimen / “around the clock” medication (D)

38. APM Recommendations • Opioids are the “rescue medication” of choice in the management of break-through pain episodes (D)

39. APM Recommendations “...oral opioids are not the optimal rescue medication for most breakthrough pain episodes”.

40. APM Recommendations • The dose of opioid “rescue medication” should be determined by individual titration (B)

41. APM Recommendations • Non-opioid analgesics may be useful in the management of breakthrough pain episodes (D)

42. APM Recommendations • Non-pharmacological methods may be useful in the management of break-through pain episodes (D) • Interventional techniques may be useful in the management of breakthrough pain (D)

43. APM Recommendations • Patients with breakthrough pain should have this pain specifically re-assessed (D)

45. Rescue medication “Ideal” rescue medication: • Good efficacy • Rapid onset of action • Short duration of effect • Good tolerability • Easy to use • Acceptable to the patient • Available / affordable

46. Oral morphine

47. Oral transmucosal opioids Buccal preparations: • Actiq™ (Cephalon) • Effentora™ (Cephalon)

48. Oral transmucosal opioids Sublingual preparations: • Abstral™ (Prostrakan) • Effentora™ (Cephalon)

49. Intranasal opioids • Instanyl™ (Nycomed) • PecFent™ (Archimedes)