Breakthrough pain and its treatment: critical review and recommendations of IOPS (Italian Oncologic Pain Survey) expert group

Abstract

Controversies exist about the definition and epidemiology of breakthrough cancer pain (BTcP), the pharmacological treatment options, drug dosing, and how to select the medications for BTcP among the new fentanyl products. Existing data were critically evaluated to provide recommendations by an expert group. An algorithm to diagnose BTcP should be used followed by a careful assessment. Fentanyl products provide efficacy and rapidity of action to counteract the temporal pattern of BTcP. The doses of opioids used for background pain should guide the choice of the doses of fentanyl products. The choice of fentanyl products should be based on individual clinical conditions.

Breakthrough Cancer Pain: Preliminary Data of The Italian Oncologic Pain Multisetting Multicentric Survey (IOPS-MS)

“…BTP has been reported to produce a negative impact on quality of life and is associated with a significant physical, psychological, and economic burden [4]. Several studies have assessed the epidemiology of this phenomenon, reporting largely variable data in different settings by using different definitions and methodologies, e.g., without an a priori definition of BTP, without clearly distinguishing background pain intensity and BTP intensity, or without considering the level of opioids used for background analgesia [5–7]. In recent years, BTP has been more meaningfully characterized through a diagnostic algorithm.…”

“…From this data, the IOPS expert group planned a new multicenter survey, with the aim of providing further information on BTP and the factors influencing its characteristics in a large number of patients, diagnosed according to a specific algorithm. The use of BTP medications and factors interfering with administration of transmucosal opioids, commonly used for the management of BTP because their PK profile fits with BTP onset and duration, were also evaluated [5]. Reported here is a preliminary analysis of data from the first 1500 patients of 4056 patients globally enrolled in this second IOPS study.…”

From “Breakthrough” to “Episodic” Cancer Pain? A European Association for Palliative Care Research Network Expert Delphi Survey Toward a Common Terminology and Classification of Transient Cancer Pain Exacerbations

“…The lack of consensus on the statements presenting specific cut-off points for BTCP intensity and meaningful changes in pain intensities must be interpreted in the light of the ongoing research. Also the definition of a controlled background pain is currently being discussed (26), and the absence of consensus must be viewed against this background.…”

Breakthrough cancer pain (BTcP) management: a review of international and national guidelines

“…The search also revealed French guidelines that discuss the use of the so-called rapid-onset opioids (ROOs) for BTcP, rather than the general management of BTcP 20 21. It appears that four of these guidelines received practical support from pharmaceutical companies to write the guidelines (eg, medical writer),11 12 14 18 19 and one organisation receives an unrestricted educational grant from a pharmaceutical company (ie, Italian Oncological Pain Survey) 16. However, it appears that none of the pharmaceutical companies had input into the content of any of the guidelines (ie, the recommendations).…”

“…The algorithm differentiates patients with BTcP from patients without breakthrough pain (ie, those having uncontrolled pain or those having intermittent/‘transitory’ pain). Again, certain guidelines use the APM algorithm,11 14 18 19 while some use either another established set of diagnostic criteria15 or an original/unique set of diagnostic criteria 16. Another Spanish Delphi clinician survey found absolute consensus regarding the APM diagnostic algorithm 32…”