Breakthrough pain in cancer patients: new therapeutic approaches to an old challenge

A real-world study of the quality of Outpatient Pain Management in patients with Cancer

PURPOSE

Up to 40% patients with cancer reporting pain may not receive optimal analgesia indicating inadequate treatment of pain. We examined the patterns of outpatient pain management in patients with cancer who reported pain.

METHODS

We used the National Ambulatory Medical Care Survey data for outpatient visits from 2006 to 2018 for patients with any cancer and reporting pain. The primary outcome was prescription of pain medications among these patients. We performed multinomial logistic regression to identify factors associated with analgesic prescriptions among patients with cancer who reported pain.

RESULTS

We captured an estimated total of 412 million outpatient visits of which 22 million visits dealt with patients with cancer reporting pain. An estimated total of 13.8 million (61.33%) patient visits had pain reported but were not prescribed any pain medications. 5.5 million (24.44%) patient visits had non-opioid analgesic prescription while opioid analgesics were prescribed during 3.2 million (14.22%) visits. Patients who were black, aged 45-64 years, residing in rural geographical areas, visiting medical subspecialty practices, and having cancers of the respiratory and digestive systems had higher odds of receiving opioid prescription.

CONCLUSIONS

As one of the largest pain management studies among patients with cancer in the outpatient setting, covering 412 million patient visits, our study shows that a significant proportion of patients with cancer who reported pain did not receive a prescription for analgesics suggesting a possibility of undertreatment of pain.

IMPLICATIONS FOR CANCER SURVIVORS

Undertreatment of pain continues to remain a major unmet need in patients with cancer.

A network meta-analysis of the efficacy of opioid analgesics for the management of breakthrough cancer pain episodes

CONTEXT

With many medications available for the management of breakthrough cancer pain (BTCP), physicians may require additional guidance in selecting an appropriate medication to suit an individual patient's needs.

OBJECTIVES

To identify all the evidence and assess the relative clinical value of currently approved BTCP medications.

METHODS

Following a systematic literature search (2007-2010), the results of 10 randomized controlled trials investigating the effects of BTCP medications (intranasal fentanyl spray [INFS], fentanyl pectin nasal spray, fentanyl sublingual tablets, fentanyl buccal soluble film, fentanyl buccal tablets, oral transmucosal fentanyl citrate, and morphine sulfate immediate release) were synthesized using a network meta-analysis. The main outcome was pain intensity difference (PID) relative to placebo up to 60 minutes after the intake of medication.

RESULTS

INFS, fentanyl pectin nasal spray, fentanyl buccal tablet, and oral transmucosal fentanyl citrate showed greater PIDs relative to placebo than other BTCP medications 15 minutes after intake. All other medications showed greater PIDs relative to placebo at 30 minutes, except morphine sulfate immediate release, which did not show efficacy over placebo until 45 minutes. Only INFS produced clinically meaningful pain relief (absolute PID ≥2) at 15 minutes.

CONCLUSION

From current evidence, although all BTCP medications provided pain relief within the time frames assessed, transmucosal fentanyl medications achieved a greater level of pain relief in a shorter time frame than placebo or oral morphine.

Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms

Breakthrough pain or transient worsening of pain in patients with an ongoing steady pain is a well known feature in cancer pain patients, but it is also seen in non-malignant pain conditions with involvement of nerves, muscles, bones or viscera. Continuous and intermittent pain seems to be a general feature of these different pain conditions, and this raises the possibility of one or several common mechanisms underlying breakthrough pain in malignant and non-malignant disorders. Although the mechanisms of spontaneous ongoing pain and intermittent flares of pain (BTP) may be difficult to separate, we suggest that peripheral and/or central sensitization (hyperexcitability) may play a major role in many causes of BTP. Mechanical stimuli (e.g. micro-fractures) changes in chemical environments and release of tumour growth factors may initiate sensitization both peripherally and centrally. It is suggested that sensitization could be the common denominator of BTP in malignant and non-malignant pain.

[Differential therapeutic aspects of analgesia with oral sustained-release strong opioids: application intervals, metabolism and immunosuppression]

The oral "around-the clock" administration of sustained-release strong opioids has been recommended for the long-term treatment of patients suffering from chronic severe pain. At present a plethora of products are available in Germany. Modern galenics even allow for only once-daily oral application without clinically relevant negative chronobiological interference. This application scheme has been shown to improve compliance and sleep quality, factors that influence treatment outcome. Randomized controlled studies revealed no relevant differences between the different strong opioids with respect to efficacy and tolerability. However, hydromorphone and oxycodone appear to be advantageous over morphine due to a lack of immunosuppression. Hydromorphone has the additional benefit of a lower risk of intoxication by accumulation of active metabolites in patients with decreased renal function. As a result, although morphine has been regarded as the standard for the treatment of chronic severe pain, hydromorphone and oxycodone may be better and safer alternatives for certain patient groups (e.g. older age, multimorbidity, cancer).

Epidemiology of cancer pain and factors influencing poor pain control

Pain is one of the most commonly experienced and feared symptoms of advanced cancer. Most cancer patients experience pain, usually of moderate to severe intensity, and most also have a number of distinct pains. The most common type of pain is related to bone metastases. Neuropathic pain occurs in one-third of patients, alone, or as a mix of nociceptive and neuropathic pain. The failure to manage pain properly is due to several factors. In developing countries, it is likely to be related to geography and limited resources. Legal restrictions also present barriers. In developed countries, failure to manage pain properly is usually related to a "disease" rather than a "symptom" model of care, which minimizes symptom management. Other factors include lack of physician education and failure to follow existing guidelines. Patients fear addiction, drug tolerance, and side effects. Despite adequate resources, pain is still undertreated.

Postoperative pain management in obstetric anesthesia–new challenges and solutions

The current understanding of pain processing mechanisms, the different pharmacologic drugs, and other nonpharmacologic means that can be used to manage postobstetric operation pain are reviewed.

Cancer pain management and the JCAHO's pain standards: an institutional challenge

Unrelieved pain is a major medical problem. In response to this problem, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) launched new standards for pain management in 1999. A review was conducted in five hospitals of 117 charts of 80 inpatients and 37 outpatients with cancer who had pain documented in their medical records to determine whether application of these JCAHO standards was documented. Pain assessment and management were not documented for most patients. Pain intensity was noted for 57% of outpatients and 53% of inpatients. When pain was documented, treatment was noted in 86% of outpatients' charts and 89% of inpatients' charts. Of those patients with documented pain, reassessment after treatment was reported in 34% of the outpatient charts and 44% of the inpatient charts. Work to properly manage cancer pain needs to continue, and the JCAHO standards provide a mechanism to evaluate practice documentation in order to improve care.

Cancer Pain: Progress Since the WHO Guidelines

In has been 15 years since the WHO Guidelines for the management of cancer pain were developed. This article reviews the guideline development and its effectiveness. Current trends in cancer care utilizing aggressive chemotherapeutic and surgical protocols lead to many patients living longer with advanced cancer and an attendant increase in pain. Future trends in cancer pain care are outlined.