The Challenges of Treating Patients with Cancer Pain

Breakthrough pain (BTP) is a temporary spike in pain that occurs in otherwise well-controlled persistent cancer pain.¹ BTP may be described as either incident pain that is related to movement, nonincident pain that is unpredictable in nature, or end-of-dose pain that occurs after insufficient dosing of persistent pain.^{[1], [2] and [3]} The authors analyzed a group of patients and found that half described pain related to particular activities. A significant number of patients with cancer experience these pain flares. In a single-population evaluation of cancer pain (n = 159), it was reported that of those patients with continuous pain, 57 (75%) experienced BTP. More than half (54%) of those patients who experienced cancer pain reported it being related to particular activities, while a little over one-quarter of patients (26%) experienced pain idiopathic in nature and 16% of patients experienced end-of-dose pain.³ In a survey of 545 cancer patients experiencing fluctuations in pain conducted by the American Pain Foundation, 96% of patients with cancer experienced episodes of BTP at least once a month, more than 70% experienced BTP episodes at least once a week, and more than one-fifth (22%) experienced BTP more than once a day.⁴

Fears relating to good pain management include a lack of technical knowledge about pain management and pain assessment. Attitudes about opioid addiction and regulatory guidelines influence the manner in which opioids are prescribed. Patients harbor a variety of fears and misconceptions such as opioid addiction, tolerance, side effects, and the meaning of pain, which can create a barrier to effective communication with health-care providers regarding cancer pain management and specifically BTP. Identifying these issues gives health-care professionals and patients an opportunity to develop strategies that can improve the treatment of BTP.

Many physicians lack the knowledge of proper around-the-clock (ATC) dosing. ATC treatment maintains drug concentrations and prevents peaks and troughs that can increase the risk of toxicity and result in lack of efficacy.

The authors recommend oral transmucosal delivery of opioids as an option for these challenges. Three formulations of the opioid fentanyl are available for transmucosal delivery: oral transmucosal fentanyl citrate (OTFC),⁵ fentanyl buccal tablets (FBTs),⁶ and fentanyl buccal soluble film (FBSF).⁷ OTFC is a fentanyl lozenge that has demonstrated an analgesic effect within 15 minutes of administration. Despite its rapid onset of action, the amount of fentanyl administered with the OTFC lozenge depends on the education provided to the patient on the use of this medication and the ability of the patient to actively use this product.⁵ While FBT (a tablet that utilizes an effervescent reaction to improve absorption) does not require substantial patient participation, its use has been associated with application-site side effects.⁶ Like OTFC and FBT, FBSF offers a rapid onset of action but does not require active patient participation and has minimal oral adverse side effects.⁷ These oral transmucosal fentanyl products should be administered only to opioid-tolerant patients, to avoid the risk of life-threatening respiratory depression. The reviewers stress that these products should be used only in opioid-tolerant patients.

Many physicians are quite aware when they have reached their “comfort level” of working with opioids. It is usually at that point that they will refer patients for consultation to the palliative care team or pain services. Patients may believe that pain is part of the cancer diagnosis and is to be expected. Some patients believe that use of opioids signifies the “end of life” is near. They may believe the side effects related to opioids are unavoidable and the burden of use of opioids outweighs the benefits.⁸

In summary, the article by Rhiner and von Gunten speaks to the challenges that we encounter in treating cancer patients' pain. BTP is often not recognized and at times not adequately treated. This article serves as a good review of the challenges of treating patients with cancer pain and offers suggestions on how to improve the management of cancer pain with our patients.

Breakthrough pain (BTP) is a temporary spike in pain that occurs in otherwise well-controlled persistent cancer pain.¹ BTP may be described as either incident pain that is related to movement, nonincident pain that is unpredictable in nature, or end-of-dose pain that occurs after insufficient dosing of persistent pain.^{[1], [2] and [3]} The authors analyzed a group of patients and found that half described pain related to particular activities. A significant number of patients with cancer experience these pain flares. In a single-population evaluation of cancer pain (n = 159), it was reported that of those patients with continuous pain, 57 (75%) experienced BTP. More than half (54%) of those patients who experienced cancer pain reported it being related to particular activities, while a little over one-quarter of patients (26%) experienced pain idiopathic in nature and 16% of patients experienced end-of-dose pain.³ In a survey of 545 cancer patients experiencing fluctuations in pain conducted by the American Pain Foundation, 96% of patients with cancer experienced episodes of BTP at least once a month, more than 70% experienced BTP episodes at least once a week, and more than one-fifth (22%) experienced BTP more than once a day.⁴

Fears relating to good pain management include a lack of technical knowledge about pain management and pain assessment. Attitudes about opioid addiction and regulatory guidelines influence the manner in which opioids are prescribed. Patients harbor a variety of fears and misconceptions such as opioid addiction, tolerance, side effects, and the meaning of pain, which can create a barrier to effective communication with health-care providers regarding cancer pain management and specifically BTP. Identifying these issues gives health-care professionals and patients an opportunity to develop strategies that can improve the treatment of BTP.

Many physicians lack the knowledge of proper around-the-clock (ATC) dosing. ATC treatment maintains drug concentrations and prevents peaks and troughs that can increase the risk of toxicity and result in lack of efficacy.

The authors recommend oral transmucosal delivery of opioids as an option for these challenges. Three formulations of the opioid fentanyl are available for transmucosal delivery: oral transmucosal fentanyl citrate (OTFC),⁵ fentanyl buccal tablets (FBTs),⁶ and fentanyl buccal soluble film (FBSF).⁷ OTFC is a fentanyl lozenge that has demonstrated an analgesic effect within 15 minutes of administration. Despite its rapid onset of action, the amount of fentanyl administered with the OTFC lozenge depends on the education provided to the patient on the use of this medication and the ability of the patient to actively use this product.⁵ While FBT (a tablet that utilizes an effervescent reaction to improve absorption) does not require substantial patient participation, its use has been associated with application-site side effects.⁶ Like OTFC and FBT, FBSF offers a rapid onset of action but does not require active patient participation and has minimal oral adverse side effects.⁷ These oral transmucosal fentanyl products should be administered only to opioid-tolerant patients, to avoid the risk of life-threatening respiratory depression. The reviewers stress that these products should be used only in opioid-tolerant patients.

Many physicians are quite aware when they have reached their “comfort level” of working with opioids. It is usually at that point that they will refer patients for consultation to the palliative care team or pain services. Patients may believe that pain is part of the cancer diagnosis and is to be expected. Some patients believe that use of opioids signifies the “end of life” is near. They may believe the side effects related to opioids are unavoidable and the burden of use of opioids outweighs the benefits.⁸

In summary, the article by Rhiner and von Gunten speaks to the challenges that we encounter in treating cancer patients' pain. BTP is often not recognized and at times not adequately treated. This article serves as a good review of the challenges of treating patients with cancer pain and offers suggestions on how to improve the management of cancer pain with our patients.

Breakthrough pain (BTP) is a temporary spike in pain that occurs in otherwise well-controlled persistent cancer pain.¹ BTP may be described as either incident pain that is related to movement, nonincident pain that is unpredictable in nature, or end-of-dose pain that occurs after insufficient dosing of persistent pain.^{[1], [2] and [3]} The authors analyzed a group of patients and found that half described pain related to particular activities. A significant number of patients with cancer experience these pain flares. In a single-population evaluation of cancer pain (n = 159), it was reported that of those patients with continuous pain, 57 (75%) experienced BTP. More than half (54%) of those patients who experienced cancer pain reported it being related to particular activities, while a little over one-quarter of patients (26%) experienced pain idiopathic in nature and 16% of patients experienced end-of-dose pain.³ In a survey of 545 cancer patients experiencing fluctuations in pain conducted by the American Pain Foundation, 96% of patients with cancer experienced episodes of BTP at least once a month, more than 70% experienced BTP episodes at least once a week, and more than one-fifth (22%) experienced BTP more than once a day.⁴

Fears relating to good pain management include a lack of technical knowledge about pain management and pain assessment. Attitudes about opioid addiction and regulatory guidelines influence the manner in which opioids are prescribed. Patients harbor a variety of fears and misconceptions such as opioid addiction, tolerance, side effects, and the meaning of pain, which can create a barrier to effective communication with health-care providers regarding cancer pain management and specifically BTP. Identifying these issues gives health-care professionals and patients an opportunity to develop strategies that can improve the treatment of BTP.

Many physicians lack the knowledge of proper around-the-clock (ATC) dosing. ATC treatment maintains drug concentrations and prevents peaks and troughs that can increase the risk of toxicity and result in lack of efficacy.

The authors recommend oral transmucosal delivery of opioids as an option for these challenges. Three formulations of the opioid fentanyl are available for transmucosal delivery: oral transmucosal fentanyl citrate (OTFC),⁵ fentanyl buccal tablets (FBTs),⁶ and fentanyl buccal soluble film (FBSF).⁷ OTFC is a fentanyl lozenge that has demonstrated an analgesic effect within 15 minutes of administration. Despite its rapid onset of action, the amount of fentanyl administered with the OTFC lozenge depends on the education provided to the patient on the use of this medication and the ability of the patient to actively use this product.⁵ While FBT (a tablet that utilizes an effervescent reaction to improve absorption) does not require substantial patient participation, its use has been associated with application-site side effects.⁶ Like OTFC and FBT, FBSF offers a rapid onset of action but does not require active patient participation and has minimal oral adverse side effects.⁷ These oral transmucosal fentanyl products should be administered only to opioid-tolerant patients, to avoid the risk of life-threatening respiratory depression. The reviewers stress that these products should be used only in opioid-tolerant patients.

Many physicians are quite aware when they have reached their “comfort level” of working with opioids. It is usually at that point that they will refer patients for consultation to the palliative care team or pain services. Patients may believe that pain is part of the cancer diagnosis and is to be expected. Some patients believe that use of opioids signifies the “end of life” is near. They may believe the side effects related to opioids are unavoidable and the burden of use of opioids outweighs the benefits.⁸

In summary, the article by Rhiner and von Gunten speaks to the challenges that we encounter in treating cancer patients' pain. BTP is often not recognized and at times not adequately treated. This article serves as a good review of the challenges of treating patients with cancer pain and offers suggestions on how to improve the management of cancer pain with our patients.