Factors influencing the use of opioids for breakthrough cancer pain: A secondary analysis of the IOPS‐MS study

Abstract

Background Controversies exist about the choice and the doses of opioid medication in breakthrough cancer pain (BTcP). Methods The aim was to assess factors influencing the use and the doses of opioids prescribed for BTcP. There was performed a secondary analysis of a national, multicentre study that involving 32 centres performed in patients having BTcP. Diagnosis of BTcP was based on a definite algorithm. Patients using opioids for background pain and for BTcP were selected. Average pain intensity and opioids used for background pain and BTcP, and adverse effects were assessed, as well as patient’s satisfaction and the grade of mucositis. Results The analysis was performed in 2,771 patients. Opioid doses given for BTcP were significantly associated with those given for background pain. No relationship between adverse effects and the use and the doses of opioids used for BTcP was found. Drugs and doses were not correlated to the grade of oral mucositis. Nasal fentanyl preparations provided the fastest meaningful pain relief in comparison with other fentanyl transmucosal preparations or morphine preparations (P = 0.000). The majority of patients were satisfied with opioid medications given for BTcP. Only 2.8% of patients reported adverse effects related to opioid medication used for BTcP. Age and gender were independently associated with dosages of some fentanyl products. Conclusions Opioids for BTcP were effective and safe in a large sample of cancer patients with different stages of disease. Doses of opioids proportional to doses used for background pain seem to guarantee both efficacy and safety. Significance The use of opioids for breakthough cancer pain was effective and safe in a large sample of advanced cancer patients recruited in different stages of disease and settings. Doses of opioids proportional to opioid doses used for background analgesia, seem to guarantee both effectiveness and safety.

<p>Cancer Pain Management: An Italian Delphi Survey from the Rational Use of Analgesics (RUA) Group</p>

“…The steering committee discussed 50 statements, on which literature seems not to be completely in accordance, elaborated from publications focused on pain management in oncology. 1,4,8,9,14 These statements were structured into seven categories, mirroring the section of the ESMO guidelines (assessment; principles of pain management, treatment of mild to moderate pain, treatment of moderate to severe pain, end of life pain, BTcP, cancer-related and neuropathic pain). The steering committee rated and suggested the statements and relevant items (27 in total) to be included in the two rounds of questionnaires.…”

“…7 In some cases, despite stable and well-controlled background pain, breakthrough cancer pain (BTcP) can occur spontaneously or in response to a trigger. 8 In this case, opioids providing rapid analgesia are commonly given as needed in addition to the background analgesic medication, such as oral opioids and nasal/transmucosal preparations of fentanyl, also named rapid-onset opioids (ROO). 9 Furthermore, if necessary, it is possible to combine adjuvant drugs at any step of WHO ladder, including tricyclic antidepressants, serotonin norepinephrine-reuptake inhibitors, gabapentinoids, lidocaine 5% patches or later-line adjuvants (eg, older anticonvulsants, corticosteroids, and N-methyl-D-aspartate [NMDA] receptor antagonists) that may help some patients.…”

The Patient with Difficult Cancer Pain

“…Of interest, only 4% of these patients had this aspect documented in their medical records. Alcoholism, younger age, better performance status pain, as well poor well-being were associated with chemical coping [45].…”

The Endless Question of Opioid Doses for Breakthrough Pain

“…Patients who recur to three or more BTP medications per day should be better reevaluated. For instance, in a noninterventional study, the majority of clinicians have been using BTP opioid doses proportional to basal opioid doses successfully and safely [9].…”

“…Patients who recur to three or more BTP medications per day should be better reevaluated. For instance, in a noninterventional study, the majority of clinicians have been using BTP opioid doses proportional to basal opioid doses successfully and safely [9]. Currow et al recently performed an interesting study, the first one to the best of my knowledge, assessing oral morphine for the management of BTP in different dose ranges proportional to the background opioid dose [10].…”