No abstract

A task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland (APM) was convened to produce some up-to-date, evidence-based, practical, clinical guidelines on the management of cancer-related breakthrough pain in adults. On the basis of a review of the literature, the task group was unable to make recommendations about any individual interventions, but was able to make a series of 12 recommendations about certain generic strategies. However, most of the aforementioned recommendations are based on limited evidence (i.e., case series, expert opinion). The task group also proposed a definition of breakthrough pain, and some diagnostic criteria for breakthrough pain.

Breakthrough cancer pain is an extremely heterogeneous condition.

A prospective survey was undertaken to determine the prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. Of 414 consecutive admissions, 33 patients were confused or too unwell to take part and 136 were pain-free. The remaining 245 reported 404 pains (range 1-5 per patient); of these patients, 218 (89%) had breakthrough pain and identified 361 pains (range 1-5 per patient). Breakthrough pain was classified as somatic (46%) visceral (30%), neuropathic (10%) or mixed etiology (16%). Thirty-eight percent of pains were severe or excruciating. The average number of daily breakthrough pain episodes was 4 [corrected] (range 1-14); 49% occurred suddenly. Most (59%) were unpredictable, and 72% lasted less than 30 minutes. Seventy-five percent of patients were dissatisfied with their pain control. Breakthrough pain is common among patients admitted to our hospice. It is frequent, short lasting, often unpredictable and not necessarily related to chronic pain making treatment difficult.

This study involved 320 cancer patients from four Northern European countries. Patients with breakthrough pain were questioned about the characteristics of their pain, the current management of their pain, and the acceptability/utility of alternative routes of administration. The median number of episodes was 3/day. Forty-four percent patients reported incident-type pain, 39% spontaneous-type pain, and 17% a combination of these pains. The median duration was 60 min, and the median time to peak intensity was 15 min. Three percent patients reported "mild" pain, 37% "moderate" pain, and 60% "severe" pain. Ninety percent patients stated that the pain interfered with their daily activities. All patients were using opioids as rescue medication (mainly oral morphine/oxycodone), whilst 28% patients were using non-opioids, and 50% patients were using non-pharmacological interventions. Only 55% patients took rescue medication every time they experienced breakthrough pain. Sixty-five percent patients would definitely consider using an oral transmucosal product; patients from Denmark were less likely to answer positively, and a positive response was associated with previous use of the route for breakthrough pain. Seventy-three percent patients reported regular oral problems. Forty-two percent patients would definitely consider using an intranasal product, with 26% patients stating they would definitely not use such a preparation; patients from Denmark and Sweden were less likely to answer positively, and a positive response was associated with male gender, and previous use of the route. Forty-four percent patients reported regular nasal problems. Sixty percent patients would definitely consider using a subcutaneous product, and 44% patients would definitely consider using an intrapulmonary product.