Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain

Abstract

Background This study aimed to assess the characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain in comparison with patients receiving at least 60 mg of oral morphine equivalents (OME). Materials and Methods Patients with advanced cancer receiving less than 60 mg/day of OME with episodes of BTcP were included in the analysis (group L). Data were compared with patients receiving doses of opioids ≥60 mg of OME (group H). Pain intensity, current analgesic therapy, number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, and time to meaningful pain relief were collected. Adverse effects imputable to a BTcP medication were recorded. Results A total of 1,418 and 2,474 patients were included in groups L and H, respectively. A lower number of BTcP episodes (p = .005), a lower BTcP intensity (p = .0001), a faster BTcP onset (p = .024), and a longer time to meaningful pain relief after taking a BTcP medication (p = .009) were found in group L as compared with group H. In group L, BTcP interference on daily activity was less than in group H (p = .009). Patients in group L were less likely to be prescribed an opioid as BTcP medication in comparison with patients in group H (p = .0001). Opioid doses used for BTcP were significantly higher in group H. Patients in group L were more likely to be less satisfied (p = .003) than patients in group H. No adverse effects of severe intensity were reported in both groups. Conclusion Patients receiving lower doses of opioids exhibit some differences in BTcP presentation: fewer episodes with lower intensity and a faster onset, a longer time to meaningful pain relief, and less satisfaction with BTcP medication. A relevant percentage of patients was receiving fentanyl preparations normally reserved for patients receiving higher doses of opioids. Implications for Practice Breakthrough pain is present in patients receiving low doses of opioids. It has its own peculiarities: less frequent, lower intensity, faster onset, longer time to meaningful pain relief, and less satisfaction with medication. Many patients were prescribed fentanyl preparations, which are normally reserved for patients receiving higher doses of opioids.

The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain

“…In terms of mean meaningful time for pain relief after a BTcP medication, a significant number of patients reported to need more than 30 min to appreciate a significant change. Efficacy of BTcP medications was found to be none or mild in more than 63% of patients, which is a higher percentage compared to data reported in a similar population of patients on low doses of opioids (23%) [ 22 ]. Intuitively, these findings can be explained by the different pattern of opioids used for BTcP in the two studies (oral morphine and transmucosal fentanyl products).…”

“…Moreover, having a higher number of episodes was associated with limited efficacy of BTcP medications. As a consequence, patients receiving low OMEs could also have a suboptimal management of BTcP, as reported in recent secondary analysis of a large study [ 22 ]. One can argue that these patients could be undermedicated, although they reported to apparently have an acceptable analgesia.…”

“…A recent study has shown that patients receiving lower doses of opioids exhibit some differences in BTcP presentation in comparison with patients receiving ≥60 mg/day of OME. This group of patients reported less episodes of BTcP, with a faster onset, a lower intensity, a longer time to meaningful pain relief, and less satisfaction with BTcP medications [ 22 ]. However, this secondary analysis was performed in patients with a diagnosis of BTcP.…”

Opioids for Breakthrough Cancer Pain

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Mercadante et al are to be commended for adding to the science of breakthrough cancer pain in this large, recently published cohort study [1]. The authors described differences in the characteristics of pain and subsequent analgesia with the use of breakthrough medications in 3,892 people with cancer pain on regular low (<60 mg oral morphine equivalent daily [OME]) and high (≥60 mg OME) dose opioids.The characteristics of breakthrough cancer pain vary from person to person and across populations [2].

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The Endless Question of Opioid Doses for Breakthrough Pain

“…I read with interest the comments [1] on a paper describing the differences of breakthrough pain (BTP) between patients with cancer receiving lower and higher doses of opioids for background pain [2]. I thank the colleagues because they allow me to express my thoughts better on the opioid doses to be used for BTP.…”