Revisiting Pain Management in Cancer Patients: Breakthrough Pain and Its Treatments

BALTIMORE, Md.—At the 29th Annual Scientific Meeting of the American Pain Society, Perry G. Fine, MD, of the University of Utah, Salt Lake City, Utah, defined breakthrough pain as “a transitory pain that lasts seconds or hours, is more severe than the background pain and has a negative effect on function or quality of life.” Comprehensive strategies must be implemented in cancer pain management during active treatment, as well as in cancer survivors with chronic pain. These strategies must also address the potential for opioid abuse in cancer patients, particularly those at high risk for dependence.

Opioids approved for breakthrough pain include oral transmucosal fentanyl citrate lozenge, fentanyl buccal tablet, and fentanyl buccal soluble film. The rapid onset (relief typically reported within 10-15 minutes), durability of response, flexibility of dosing, and ease of dose adjustment make these agents ideal for breakthrough pain. Rapid onset opioids also combine well with around-the-clock medications and are easy for patient self-administration, which provides patients with an aspect of pain control. Limitations of these therapies, however, include opioid tolerance, indiscrete administration, requirement to hold the product in the mouth for an extended time, and tolerability issues. Investigational delivery systems (e.g., intranasal, sublingual, or oral inhalation formulations of fentanyl) may improve pharmacokinetics, provide more flexible and consistent dosing, and improve tolerability. Dr. Fine presented current data to attendees on intranasal fentanyl spray, which demonstrated a more rapid median onset of action compared with oral transmucosal fentanyl citrate (11 minutes vs 16 minutes) and more patients (65.7%) attaining faster time to “meaningful” pain-relief onset. Results from a phase III trial showed that sublingual fentanyl oral disintegrating tablet significantly improved summed pain intensity difference (SPID) scores relative to placebo at 30 and 60 minutes postdose.

“Cancer doesn’t protect against addiction,” states Stephen D. Passik, PhD, of Memorial Sloan Kettering Cancer Center. Measures for addiction risk include the Opioid Risk Tool (ORT), the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Screening Tool for Addiction Risk (STAR). Adequate pain control must also be assessed as aberrant opioid use behaviors are more prevalent in cancer patients with poorly managed pain. Cancer patients at high risk of addiction can be treated solely with a long-acting agent as short-acting or rapid onset opioids are too risky. Still, Dr. Passik emphasizes that “every patient on long-term opioid treatment should be monitored for development of abuse or addiction.” A comprehensive strategy for mitigating abuse risk includes monitoring through urine toxicology, frequent follow-up visits, psychotherapy, plus family and provider support for recovery efforts. Additionally, Risk Evaluation and Mitigation Strategies (REMS) have been implemented by the FDA to prevent serious risk by ensuring that these drugs are prescribed and dispensed by trained or certified practitioners and pharmacists at certified healthcare institutions, and received by appropriate patients.

Pain remains highly prevalent in cancer survivors and may be an adverse effect of the disease itself or the chemotherapeutic or surgical interventions. Larry C. Driver, MD, of the University of Texas, M.D. Anderson Cancer Center, Houston, Texas states, “healthcare providers must take into consideration a patient’s ‘total’ pain, which includes the sum of physical pains, psychological issues, social problems, cultural milieu, and spiritual issues.” Thus, management of chronic pain in the cancer survivor is complex and requires integration of pharmacotherapy, procedural interventions, rehabilitative therapies, psychological strategies, education, lifestyle changes, and complementary and alternative medicines.