Breakthrough Cancer Pain Remains a Challenge

BOSTON—As every oncology nurse knows, pain is no stranger to patients with advanced cancer. Even if background pain appears under control, studies show 23% to 89% of patients experience intermittent bouts of pain known as breakthrough cancer pain (BTCP). Variation in the incidence rates reflects variation in the definition of BTCP.

 

Jeannine M. Brant, PhD, APRN, AOCN, Oncology Clinical Nurse Specialist, Research Scientist, Billings Clinic Cancer Center, Montana, who copresented a satellite symposium on Challenges in Managing Breakthrough Cancer Pain, described BTCP thusly: “A transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain." Brant said BTCP episodes can be as brief as 1 second to as long as 30 minutes and range from moderate to severe.

 

She divided BTCP into incident pain, which occurs after voluntary or involuntary movement; and idiopathic pain, which arises spontaneously. Patients often have a mix of both types. Patients who have no background pain also experience BTCP. Prostate, head and neck, genitourinary, breast, uterine, and pancreatic cancers are the most painful malignancies. Bone metastases also cause pain.

 

Assessment

BTCP seriously impairs the patient's physical and psychological well-being, said Carol P. Curtiss, MSN, RN, BC, Clinical Nurse Specialist, Curtiss Consulting, Greenfield, Massachusetts. Properly assessing pain is crucial to providing proper treatment. Curtiss said nurses must question patients often about their pain and believe their responses. She recommended asking questions such as:

• Do you have periods during the day when your pain is uncontrolled?
• How long is it from when you noticed the pain to when it is at its worst?
• Describe it to me.
• Does it interfere with your ability to do the things you like to do or that I'm asking you to do?
• Does anything lessen its severity?

She advised doing separate assessments for breakthrough pain and background pain.

 

Nurses should work with patients to establish realistic goals for pain control. She suggested asking the patient to identify on a scale of 1 to 10 the level of pain they consider acceptable. The primary goal in managing BTCP is to provide quick pain relief that persists for the duration of pain and rapidly dissipates afterward.

 

Curtiss warned against confusing aberrant behavior (taking an extra pill or requesting another dose of pain medication before it is due) with addiction. Aberrant behavior typically results when pain is not properly controlled. "99% of the time, it's the plan, not the patient," she said.

 

Assessing pain in nonverbal patients is difficult, requiring careful observation. Curtiss said to watch for changes in facial expression, verbalizations or vocalizations, mental status changes, body movements, differences in activities or routine, and other subtle cues.

 

Treatment Options

Medications to treat BTCP should have rapid onset and control pain effectively but also have a short half-life to prevent accumulation and oversedation. Brant said the drug should be simple to use and acceptable to the patient.

 

Morphine is the gold standard. Opiates are highly effective, but growing restrictions sometimes make it hard to deliver the drug quickly. Commonly used opiates are oxycodone, hydromorphone, oxymorphone, and fentanyl in various preparations.

 

Immediate-release oral agents typically take 15 minutes to work. Brant warned they are absorbed in the gastrointestinal mucosa and must be swallowed to be effective. They often do not act fast enough to address idiopathic BTCP and sometimes peak after the incident resolves. Many last up to 6 hours, increasing the risk of oversedation.

 

Several rapid-onset fentanyl preparations are available, including transmucosal fentanyl citrate, fentanyl buccal tablets, fentanyl buccal soluble film, and sublingual fentanyl. An aerosolized version and a nasal spray are being studied. Fentanyl preparations tend to have a quicker onset, ranging from 1 to 15 minutes. This is because they are lipophilic and absorbed by the buccal mucosa. Their duration ranges from 1 to 3 hours, allowing them to clear the system faster than many other opiates.

 

The US Food and Drug Administration has mandated Risk Evaluation and Mitigation Strategies (REMS) for all rapid-acting opioids, which may require prescribers to receive special training and to provide additional education to patients. The goal is to prevent misuse and abuse. Curtiss advised oncology nurses to become familiar with the REMS for the various opioids used.

 

The educational symposium was presented by Meniscus Educational Institute and sponsored by Cephalon.