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Rozman de Moraes A, Erdogan E, Azhar A, Reddy SK, Lu Z, Geller JA, Graves DM, Kubiak MJ, Williams JL, Wu J, Bruera E, Yennurajalingam S. Scheduled and Breakthrough Opioid Use for Cancer Pain in an Inpatient Setting at a Tertiary Cancer Hospital. Curr Oncol 2024; 31:1335-1347. [PMID: 38534934 PMCID: PMC10969060 DOI: 10.3390/curroncol31030101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Our aim was to examine the frequency and prescription pattern of breakthrough (BTO) and scheduled (SCH) opioids and their ratio (BTO/SCH ratio) of use, prior to and after referral to an inpatient supportive care consult (SCC) for cancer pain management (CPM). Methods and Materials: Patients admitted at the MD Anderson Cancer Center and referred to a SCC were retrospectively reviewed. Cancer patients receiving SCH and BTO opioids for ≥24 h were eligible for inclusion. Patient demographics and clinical characteristics, including the type and route of SCH and BTO opioids, daily opioid doses (MEDDs) of SCH and BTO, and BTO/SCH ratios were reviewed in patients seen prior to a SCC (pre-SCC) and during a SCC. A normal BTO ratio was defined as 0.5-0.2. Results: A total of 665/728 (91%) patients were evaluable. Median pain scores (p < 0.001), BTO MEDDs (p < 0.001), scheduled opioid MEDDs (p < 0.0001), and total MEDDs (p < 0.0001) were higher, but the median number of BTO doses was fewer (2 vs. 4, p < 0.001), among patients seen at SCC compared to pre-SCC. A BTO/SCH ratio over the recommended ratio (>0.2) was seen in 37.5% of patients. The BTO/SCH ratios in the pre-SCC and SCC groups were 0.10 (0.04, 0.21) and 0.17 (0.10, 0.30), respectively, p < 0.001. Hydromorphone and Morphine were the most common BTO and SCH opioids prescribed, respectively. Patients in the early supportive care group had higher pain scores and MEDDs. Conclusions: BTO/SCH ratios are frequently prescribed higher than the recommended dose. Daily pain scores, BTO MEDDs, scheduled opioid MEDDs, and total MEDDs were higher among the SCC group than the pre-SCC group, but the number of BTO doses/day was lower.
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Affiliation(s)
- Aline Rozman de Moraes
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Elif Erdogan
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Suresh K. Reddy
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Joshua A. Geller
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - David Mill Graves
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Michal J. Kubiak
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Janet L. Williams
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Jimin Wu
- Department of Biostatistics, UT MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
| | - Sriram Yennurajalingam
- Department of Palliative Care, Rehabilitation Medicine, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX 77030, USA; (A.R.d.M.); (E.E.)
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Tekie Y, Nigatu YA, Mekonnen W, Berhe YW. Breakthrough pain among cancer patients at oncology units in Northern Ethiopia; a multi-center study. Front Oncol 2024; 13:1248921. [PMID: 38264754 PMCID: PMC10805268 DOI: 10.3389/fonc.2023.1248921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024] Open
Abstract
Background Breakthrough cancer pain (BTCP) is a transient exacerbation of pain that affects the length of hospitalization and quality of life of patients. The objective of this study was to determine the prevalence and factors associated with BTCP among cancer patients at oncology units in Northern Ethiopia in 2022. Methods A multi-center cross-sectional study was conducted from April to June 2022. After obtaining ethical approval, data were collected prospectively from 424 adult cancer patients admitted to oncology units. Breakthrough cancer pain was assessed by the numeric rating scale. Descriptive and binary logistic regression analyses were performed to determine the factors associated with BTCP. The strength of association was described in adjusted odds ratio (AOR) with 95% confidence intervals and variables with a P-value < 0.05 were considered to have a statistically significant association with BTCP. Result The prevalence of BTCP among cancer patients was 41.5%. The factors that were found to be associated with BTCP were colorectal cancer (AOR: 7.7, 95% CI: 1.8, 32.3), lung cancer (AOR: 6.9, 95% CI: 1.9, 26.0), metastasis (AOR: 9.3, 95% CI: 3.0, 29.1), mild background pain (AOR: 7.5, 95% CI: 2.5, 22.6), moderate background pain (AOR: 7.0, 95% CI: 2.2, 23.1), severe background pain (AOR: 7.1, 95% CI: 2.2, 22.8), no analgesics taken for background pain (AOR: 5.1, 95% CI: 2.8, 9.3) and uncontrolled background pain (AOR: 3.3, 95% CI: 1.8, 6.1). Conclusion The prevalence of BTCP was high. Colorectal cancer, lung cancer, the presence of metastasis, the presence of background pain, not taking analgesics for background pain, and uncontrolled background pain were significantly associated with BTCP.
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Affiliation(s)
- Yohanes Tekie
- Department of Anesthesia, Aksum University, Aksum, Ethiopia
| | | | - Wudie Mekonnen
- Department of Anesthesia, University of Gondar, Gondar, Ethiopia
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Løhre ET, Jakobsen G, Solheim TS, Klepstad P, Thronæs M. Breakthrough and Episodic Cancer Pain from a Palliative Care Perspective. Curr Oncol 2023; 30:10249-10259. [PMID: 38132380 PMCID: PMC10742182 DOI: 10.3390/curroncol30120746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/23/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
Cancer pain intensity (PI) fluctuates, but the relationship between pain flares and background pain with respect to pain management is not settled. We studied how flare and background PIs corresponded with treatment results for background cancer pain. Patients admitted to an acute palliative care unit with average and/or worst PI ≥ 1 on the 11-point numeric rating scale were included. Average and worst PI at admission and average PI at discharge were collected. We examined how the difference and ratio between worst and average PI and average PI at admission, were associated with average PI development during hospitalization. Positive differences between worst and average PI at admission were defined as pain flares. Ninety out of 131 patients had pain flares. The reduction in average PI for patients with flares was 0.9 and for those without, 1.9 (p = 0.02). Patients with large worst minus average PI differences reported the least improvement, as did those with large worst/average PI ratios. Patients with pain flares and average PI ≤ 4 at admission had unchanged average PI during hospitalization, while those with pain flares and average PI > 4 experienced pain reduction (2.1, p < 0.001). Large pain flares, in absolute values and compared to background PI, were associated with inferior pain relief.
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Affiliation(s)
- Erik Torbjørn Løhre
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Tora Skeidsvoll Solheim
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
| | - Morten Thronæs
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, 7030 Trondheim, Norway; (E.T.L.)
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU–Norwegian University of Science and Technology, 7030 Trondheim, Norway
- Centre for Crisis Psychology, Faculty of Psychology, University of Bergen, 5007 Bergen, Norway
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Mercadante S. Once again... breakthrough cancer pain: an updated overview. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:23. [PMID: 37480136 PMCID: PMC10360268 DOI: 10.1186/s44158-023-00101-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/26/2023] [Indexed: 07/23/2023]
Abstract
Breakthrough cancer pain (BTcP) is a complex and variegate phenomenon that may change its presentation during the course of patients' disease in the same individual. An appropriate assessment is fundamental for depicting the pattern of BTcP. This information is determinant for a personalized management of BTcP. The use of opioids as needed is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective. The most controversial point regards the opioid dose to be used. The presence of opioid tolerance suggests to use a dose proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested to use the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never ended question.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthetics, Main Regional Center for Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, Acute Supportive/Palliative Care Unit & Hospice, 90146, Palermo, Italy.
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Pergolizzi J, LeQuang JAK, Coluzzi F, Magnusson P, Lara-Solares A, Varrassi G. Considerations for Pain Assessments in Cancer Patients: A Narrative Review of the Latin American Perspective. Cureus 2023; 15:e40804. [PMID: 37489190 PMCID: PMC10363018 DOI: 10.7759/cureus.40804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/21/2023] [Indexed: 07/26/2023] Open
Abstract
Cancer incidence in Latin America is lower than in Europe or the United States but morbidity and mortality rates are disproportionately high. A barrier to adequate pain control is inadequate pain assessment, which is a relatively easy and inexpensive metric. The objective of this narrative review is to describe pain assessment for cancer patients in Latin America. Cultural factors may influence pain perception, including contextualizing pain as noble or natural suffering and aspects of what is now called "spiritual pain." Unlike other painful conditions, cancer pain may be strongly associated with existential fear, psychosocial distress, anxiety, and spiritual concerns. Pain assessment allows not just quantification of pain intensity but may elucidate pain mechanisms involved or psychosocial aspects that may color the pain. Many current pain assessment instruments capture only pain intensity, which is but one aspect of the pain experience; some have expanded to include functional assessments, mental health status evaluations, and quality of life metrics. A quality-of-life assessment may be appropriate for cancer patients since chronic pain can severely impact function, which can in turn create a vicious cycle by exacerbating pain. The incidence of cancer in Latin America is expected to increase in the ensuing years. Better pain assessment and clinician education are needed to help manage pain in this large and growing patient population.
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Affiliation(s)
| | | | - Flaminia Coluzzi
- Medical and Surgical Sciences, Sapienza University of Rome, Rome, ITA
| | | | - Argelia Lara-Solares
- Pain and Palliative Care, National Institute of Medical and Nutritional Sciences, Mexico City, MEX
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Liossi C, Greenfield K, Schoth DE, Mott C, Jassal S, Fraser LK, Rajapakse D, Howard RF, Johnson M, Anderson AK, Harrop E. A Systematic Review of Measures of Breakthrough Pain and Their Psychometric Properties. J Pain Symptom Manage 2021; 62:1041-1064. [PMID: 33933619 DOI: 10.1016/j.jpainsymman.2021.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 12/20/2022]
Abstract
CONTEXT Breakthrough pain (BTP) is common in cancer and other conditions yet there is a lack of validated BTP measurement tools. OBJECTIVES We aimed to identify all tools assessing or characterising BTP in patients of any age with any condition, and to critically appraise their psychometric properties. METHODS The Cochrane Library, PROSPERO, Embase, CINAHL, Medline, PsycINFO, Web of Science, Google Scholar, ProQuest, Evidence Search and OpenGrey were searched to identify all available tools used to assess BTP. A second search identified studies that had evaluated psychometric properties of tools identified in Search 1. Databases were searched from inception to November 2020. Studies were assessed using COSMIN criteria and GRADE guidelines. RESULTS Search 1 found 51 tools used to assess BTP. Search 2 found six tools that had a development study and/or a study evaluating a tool psychometric property. No tool had more than one study evaluating psychometric properties so a meta-analysis could not be conducted. Studies were of inadequate to very good quality. Only the Breakthrough Pain Assessment Tool (BAT) had sufficient content validity and at least low-quality evidence for sufficient internal consistency. CONCLUSION The BAT is recommended to characterise BTP in adults with cancer; its applicability to other conditions is unknown. The remaining tools need further evaluation. Only the Breakthrough Pain Questionnaire for Children was designed for children with cancer, but no psychometric properties were evaluated. There is a need for a tool to assess and characterise BTP in children with non-cancer diagnoses and those who cannot self-report.
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Affiliation(s)
- Christina Liossi
- School of Psychology, University of Southampton, Highfield, UK; Great Ormond Street Hospital for Children NHS Foundation Trust, Psychological Medicine, London , UK.
| | | | - Daniel E Schoth
- School of Psychology, University of Southampton, Highfield, UK
| | - Christine Mott
- Hummingbird House Hospice and the Paediatric Palliative Care Service at Queensland Children's Hospital, Australia
| | | | - Lorna K Fraser
- Martin House Research Centre, University of York, York , UK
| | - Dilini Rajapakse
- Great Ormond Street Hospital for Children NHS Foundation Trust, The Louis Dundas Centre, London, UK
| | - Richard F Howard
- Great Ormond Street Hospital for Children NHS Foundation Trust, Department of Anaesthesia and Pain Medicine Level 4, London, UK
| | | | | | - Emily Harrop
- Helen & Douglas House Hospices, Oxford, Oxfordshire, UK; Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headington, Oxford, UK
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A Longitudinal Study of Breakthrough Cancer Pain: An Extension of IOPS-MS Study. J Clin Med 2021; 10:jcm10112273. [PMID: 34073907 PMCID: PMC8197313 DOI: 10.3390/jcm10112273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to longitudinally assess the characteristics of background pain and breakthrough pain (BTcP), analgesic treatment, and satisfaction with treatment four weeks after the first assessment. METHODS Adult cancer patients with a diagnosis of BTcP were included. At T0, age, gender, visit setting, cancer diagnosis, the extent of the disease, ongoing anticancer treatments, and Karnofsky level were recorded. The background pain intensity in the last 24 h (on a numerical scale 0-10), opioids used for background pain, and their doses, expressed as oral morphine equivalents (OME), as well as other analgesic drugs, were recorded. The number of BTcP episodes, their intensity, predictability and precipitating factors, onset duration of untreated episodes, and interference with daily activities were collected. Analgesics and doses used for BTcP, and the mean time to meaningful pain relief after taking medication, were assessed. The level of satisfaction with BTcP medication was also assessed. Adverse effects to be attributed to these medications were also recorded. At T4, the same data were evaluated. RESULTS After one-month follow-up, patients had a lower number of BTcP episodes and peak intensity, possibly due to the optimization of background analgesia. The principal characteristics of BTcP did not change significantly. CONCLUSION A careful and continuous assessment should be guaranteed to all patients to limit the burden induced by BTcP, other than treating BTcP episodes with short-onset opioids.
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Mercadante S, Maltoni M, Russo D, Adile C, Ferrera P, Rossi R, Rosati M, Casuccio A. The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain. Cancers (Basel) 2021; 13:cancers13051058. [PMID: 33801478 PMCID: PMC7958843 DOI: 10.3390/cancers13051058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. This prospective study showed that in this population, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes. Abstract The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
- Correspondence:
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Domenico Russo
- Hospice and the Palliative Care Service, Clinica San Marco, 04100 Latina, Italy;
| | - Claudio Adile
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Patrizia Ferrera
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, 90146 Palermo, Italy; (C.A.); (P.F.)
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Marta Rosati
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, 47014 Meldola, Italy; (M.M.); (R.R.); (M.R.)
| | - Alessandra Casuccio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy;
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Mercadante S, Portenoy RK. Understanding the Chameleonic Breakthrough Cancer Pain. Drugs 2021; 81:411-418. [PMID: 33515376 DOI: 10.1007/s40265-021-01466-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Abstract
Breakthrough cancer pain (BTcP) is a variegated phenomenon, that often presents in different ways in each individual, and may change its presentation in the same individual during the course of disease. An appropriate assessment is fundamental for depicting the pattern of BTcP in individuals. This information is determinant for a personalised management of BTcP. The use of opioids as needed, is recommended for the management of BTcP. There are several options which should be chosen according to the individual pattern of BTcP. In general, a drug with a short onset and offset should be preferred. Although oral opioids may still have specific indications, fentanyl products have been found to be more rapid and effective, providing analgesia in 5-15 min. The most controversial point regards the opioid dose to be used. The presence of tolerance suggests using a dose that is proportional to the dose used for background analgesia. In contrast, regulatory studies have suggested using the minimal available dose to be titrated until the effective dose. Further large studies should definitely settle this never-ending question.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Centre for Pain Relief and Palliative Care Unit, La Maddalena Cancer Centre, Via San Lorenzo 312, 90146, Palermo, Italy. .,Regional Home Care Programme, SAMOT, Palermo, Italia.
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY, 10006, USA. .,Neurology and Family and Social Medicine, Albert Einstein College of Medicine, New York, USA.
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Episodic Cancer Pain: Patient Reporting, Prevalence, and Clinicodemographic Associations at Initial Cancer Pain Clinic Assessment. Pain Res Manag 2020; 2020:6190862. [PMID: 32566062 PMCID: PMC7261329 DOI: 10.1155/2020/6190862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/02/2020] [Indexed: 01/11/2023]
Abstract
Background Better understanding of the episodic cancer pain (CP) spectrum, including pains that occur in addition to its conventionally defined breakthrough CP (BTcP) and incident CP (IcP) components, may inform CP assessment and management. This study aimed to determine the prevalence of episodic patient-reported CP and the prevalence and associations of study-defined BTcP (S-BTcP) and IcP (S-IcP) in patients with CP. Methods In a cross-sectional study at their first CP clinic attendance, participants with CP had the following assessments: Brief Pain Inventory (BPI); Pain Management Index (PMI), with PMI-negative status indicating undertreatment; standardized neuropathic pain component (NPC) status; S-BTcP (no trigger identified) and S-IcP (trigger identified) status, based on a preceding 7-day history of transitory pain flares distinct from background pain, and BPI-Worst or BPI-Now pain intensity ≥ 4. Clinicodemographic variables' association with S-BTcP and S-IcP was examined in logistic regression analyses. Results Of 371 participants, 308 (83%) had episodic CP by history alone; 140 (37.7%) and 181 (48.8%) had S-BTcP and S-IcP, respectively. Multivariable analyses demonstrated significant (p < 0.05) associations (odds ratios: 95% CIs) for 6 variables with S-BTcP: head and neck pain location (2.53; 1.20–5.37), NPC (2.39; 1.34–4.26), BPI average pain (1.64; 1.36–1.99), abdominal pain (0.324; 0.120–0.873), S-IcP (0.207; 0.116–0.369), and PMI-negative status (0.443; 0.213–0.918). Similar independent associations (p < 0.05) occurred for S-IcP with NPC, BPI average pain, and PMI-negative status, in addition to radiotherapy, S-BTcP, soft tissue pain, and sleep interference. Conclusions Episodic or transient patient-reported CP flares often do not meet the more conventional criteria that define BTcP and IcP, the principal episodic CP types. Both BTcP and IcP occur frequently and both are associated with a NPC, higher pain intensity, and less opioid underuse in the management of CP. Further studies are warranted to both better understand the complex presentations of episodic CP and inform its classification.
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Prevalence and characterization of breakthrough pain in patients with cancer in Spain: the CARPE-DIO study. Sci Rep 2019; 9:17701. [PMID: 31776408 PMCID: PMC6881364 DOI: 10.1038/s41598-019-54195-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/04/2019] [Indexed: 01/22/2023] Open
Abstract
We aimed to evaluate the prevalence, characteristics and impact of breakthrough pain (BTP) in patients with cancer attending the main specialties involved in the diagnosis and management of BTP in Spain using a multicenter, observational, cross-sectional, multidisciplinary study. Investigators had to record all patients seen at the clinic during 1 month, determine whether the patients had cancer pain, and apply the Davies algorithm to ascertain whether the patients were suffering from BTP. Of the 3,765 patients with cancer, 1,117 (30%) had cancer-related pain, and of these patients, 539 had BTP (48%, 95%CI:45–51). The highest prevalence was found in patients from palliative care (61%, 95%CI:54–68), and the lowest was found in those from hematology (25%, 95%CI:20–31). Prevalence varied also according to sex and type of tumor. According to the Alberta Breakthrough Pain Assessment Tool duration, timing, frequency, location, severity, quality, causes, and predictability of the BTP varied greatly among these patients. BTP was moderate (Brief Pain Inventory [BPI]-severity median score = 5.3), and pain interference was moderate (BPI-interference median score = 6.1) with a greater interference with normal work, general activity, and enjoyment of life. Patients with BTP showed a mean ± standard deviation score of 28.5 ± 8.0 and 36.9 ± 9.5 in the physical and mental component, respectively, of the SF-12 questionnaire. In conclusion, prevalence of BTP among patients exhibiting cancer-related pain is high. Clinical presentation is heterogeneous, and therefore, BTP cannot be considered as a single entity. However, uniformly BTP has an important impact on a patient’s functionality, which supports the need for early detection and treatment.
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Yan XB. Breakthrough Cancer Pain. FROM CONVENTIONAL TO INNOVATIVE APPROACHES FOR PAIN TREATMENT 2019. [DOI: 10.5772/intechopen.84581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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13
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Early access to rapid onset opioids therapy in advanced cancer patients can affect their death place? Curr Probl Cancer 2019; 43:75-76. [DOI: 10.1016/j.currproblcancer.2018.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 05/18/2018] [Indexed: 11/21/2022]
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Løhre ET, Hjermstad MJ, Brunelli C, Knudsen AK, Kaasa S, Klepstad P. Pain Intensity Factors Changing Breakthrough Pain Prevalence in Patients with Advanced Cancer: A Secondary Analysis of a Cross-Sectional Observational International Study. Pain Ther 2018; 7:193-203. [PMID: 30415462 PMCID: PMC6251829 DOI: 10.1007/s40122-018-0107-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Different definitions of breakthrough pain (BTP) influence the observed BTP prevalence. This study examined BTP prevalence variability due to use of different cutoffs for controlled background pain, different assessment periods for background pain, and difference between worst and average pain intensity (PI). METHODS Cancer patients from the EPCRC-CSA study who reported flare-ups of pain past 24 h were potential BTP cases. BTP prevalence was calculated for different cutoffs for background PI on numeric rating scales (NRS 0-10) for the past week, past 48 and past 24 h period. Furthermore, BTP cases were categorized based on the difference between maximum and average PI past 24 h (range, 0 to > 2 points, NRS 0-10). RESULTS Of 696 respondents, 302 patients (43.4%) reported pain flares the past 24 h. The BTP prevalence when using a defined background PI ≤ 4 for the past week was 19.8%. This number varied for different defined cutoffs for background PI. Actual background PI and BTP prevalence also varied between the assessment periods "past week", "past 48 h", and "past 24 h" (PI 4.0, 3.6, and 3.4; BTP prevalence 19.8, 22.7, and 24.9% for background PI ≤ 4). For patients with background PI ≤ 4 past week, 105 had a difference between maximum and average PI ≥ one point and 48 had a difference > two points. CONCLUSIONS The reported BTP prevalence is dependent on the cutoff for background PI in the BTP definition, population background PI during the assessment period, and defined cutoff for the difference between worst and average PI. FUNDING NTNU, Norwegian University of Science and Technology.
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Affiliation(s)
- Erik Torbjørn Løhre
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway. .,Cancer Clinic, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cinzia Brunelli
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stein Kaasa
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Tagami K, Okizaki A, Miura T, Watanabe YS, Matsumoto Y, Morita T, Fujimori M, Kinoshita H. Breakthrough Cancer Pain Influences General Activities and Pain Management: A Comparison of Patients with and without Breakthrough Cancer Pain. J Palliat Med 2018; 21:1636-1640. [PMID: 29975582 DOI: 10.1089/jpm.2017.0675] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Breakthrough cancer pain (BTcP) is a predictor of interference with general activities and poor pain management. The extent of this influence has not yet been determined. OBJECTIVE This study aimed to investigate the influence of BTcP on general activities, and pain management in patients with controlled background pain. DESIGN Single-center prospective observational study. SETTING/SUBJECTS The study cohort comprised 258 consecutive patients (female, 40.0%; mean age, 64.5 years) who had received opioid medication for cancer pain for over 2 weeks. MEASUREMENTS A recommended diagnostic algorithm was used to quantitate and compare interference with general activities, average background pain intensity over the previous 24 hours (24h-PI), and achievement of personalized pain goals (PPGs) (24h-PI≤PPG) of 119 patients with and 139 patients without BTcP. RESULTS Interference with general activities, 24h-PI, and PPG scores [mean (standard deviation)] in patients with BTcP were 2.8 (2.2), 3.0 (1.7), and 1.8 (1.4), respectively, which are all significantly higher than for those without BTcP [1.3 (2.0), p < 0.01; 1.7 (1.6), p < 0.01; 1.5 (1.3), p = 0.03], respectively. A significantly smaller percentage of patients with BTcP than without BTcP achieved their PPGs (36.1% vs. 67.6%, p < 0.01). CONCLUSIONS BTcP has a negative impact on general activities and pain management. Healthcare providers should recognize that management of BTcP is important in improving general activities and management of cancer pain.
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Affiliation(s)
- Keita Tagami
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan .,2 Department of Palliative Medicine, Tohoku University School of Medicine , Sendai, Japan
| | - Ayumi Okizaki
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan
| | - Tomofumi Miura
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan .,3 Division of Biomarker Discovery, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center Hospital East , Kashiwa, Japan
| | - Yuki Sumazaki Watanabe
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan
| | - Yoshihisa Matsumoto
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan
| | - Tatsuya Morita
- 4 Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital , Hamamatsu, Japan
| | - Maiko Fujimori
- 5 Division of Cohort Consortium Research, Center for Public Health Sciences, National Cancer Center , Tokyo, Japan .,6 Division of Health Care Research, Center for Public Health Sciences, National Cancer Center , Tokyo, Japan
| | - Hiroya Kinoshita
- 1 Department of Palliative Medicine, National Cancer Center Hospital East , Kashiwa, Japan .,7 Department of Palliative Care, Tokatsu Hospital , Nagareyama, Japan
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Lux EA, Schwittay A, Kleeberg UR, Papke J. [Fentanyl buccal tablets in the treatment of breakthrough cancer pain. German cohort of a pan-European multicentre study]. MMW Fortschr Med 2018; 160:18-23. [PMID: 29974433 DOI: 10.1007/s15006-018-0728-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/21/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients with breakthrough cancer pain (BtCP) experience significant limitations in their physical, mental and social functions. Fentanyl buccal tablets (FBT), a rapid onset opioid, are specifically indicated for the treatment of BtCP. METHOD The results of the German cohort of a pan-European study are presented. This included cancer pain patients from 32 German centers. Patients were on continuous opioid medication and had at least 4 BtCP episodes per day. After randomization to 2 groups, 66 patients started the titration of FBT with 100 μg (group A) and 200 μg (group B), respectively. All patients were titrated to their individual EAD, which could be a maximum of 800 μg FBT per episode, regardless of the initial dose. Subsequently, up to 8 BtCP episodes were treated with this EAD. At baseline and after treatment, patients assessed the effects of BtCP on their functional status using the modified BPI-7S and answered questions about the efficacy, simplicity, and ease-of-use of the treatment. RESULTS AND CONCLUSIONS Successful titration was achieved by 49 patients (74.2%). There was no statistically significant difference between group A and group B. The global score of the modified BPI-7S increased by 8.5 (± 12.8) points (from 34.7 ± 13.6 at the beginning to 26.2 ± 15.8 at the end of treatment), from which a statistically significant improvement in the quality of life of patients can be derived. Global patient contentment improved, most notably the rapid onset of 2.4 points to 3.4 points at the end of the study. 76.9% of patients found taking FBT simple or very simple.
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Factors Influencing the Clinical Presentation of Breakthrough Pain in Cancer Patients. Cancers (Basel) 2018; 10:cancers10060175. [PMID: 29865170 PMCID: PMC6025469 DOI: 10.3390/cancers10060175] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of this study was to identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP). Methods: Cancer patients with a diagnosis of BTP were enrolled. Demographic and clinical characteristics, as well as background pain and BTP characteristics were collected. Multivariate analyses were conducted to assess the correlation between BTP characteristics and the variables examined. Results: Data of 4016 patients were analysed. Average daily number of BTP episodes was 2.4, mean intensity was 7.5, and a mean duration was 43.3 min. A short onset BTP was observed in 68.9% of patients. In 30.5% of patients BTP was predictable. There were 86.0% of participants who reported a marked interference of BTP with their daily activities. Furthermore, 86.8% of patients were receiving opioids for the management of BTP. The average time to meaningful pain relief was 16.5 min and 70.9% of patients were satisfied with their BTP medications. Age, head and neck cancer, Karnofsky, background pain intensity, predictable and fast onset BTP were independently associated with the number of BTP episodes. BTP pain intensity was independently associated with background pain intensity, fast onset BTP, and Karnofsky. Neuropathic pain mechanism was independently associated with unpredictable BTP. Variables independently associated with a longer duration of BTP were age, place of visit, cancer diagnosis, disease-oriented therapy, background pain intensity and mechanism, and unpredictable BTP. Age, Karnofsky, background pain intensity, fast onset, and long duration of BTP were independently associated with interference with daily activity. Conclusions: BTP has a variable presentation depending on interdependent relationships among its different characteristics.
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Lawlor PG, Lawlor NA, Reis-Pina P. The Edmonton Classification System for Cancer Pain: a tool with potential for an evolving role in cancer pain assessment and management. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/23809000.2018.1467211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Peter G Lawlor
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Niamh A Lawlor
- Ottawa Hospital Cancer Program, The Ottawa Hospital (NAL), Ottawa, Canada
| | - Paulo Reis-Pina
- Palliative Care Unit, Casa de Saúde da Idanha, Sintra, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Koh SJ, Keam B, Hyun MK, Ju Seo J, Uk Park K, Oh SY, Ahn J, Lee JY, Kim J. Cancer Pain Management Education Rectifies Patients’ Misconceptions of Cancer Pain, Reduces Pain, and Improves Quality of Life. PAIN MEDICINE 2018; 19:2546-2555. [DOI: 10.1093/pm/pny039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Su-Jin Koh
- Department of Hematology and Oncology, Ulsan University College of Medicine and Ulsan University Hospital, Ulsan, Republic of Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Kyung Hyun
- Department of Preventive Medicine, College of Korean Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - Jeong Ju Seo
- Department of Quality & Patient Safety, Cheil Orthopedic Hospital Seoul, Republic of Korea
| | - Keon Uk Park
- Department of Hematology/Oncology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sung Yong Oh
- Department of Internal Medicine, Dong-A University Hospital, Busan, Republic of Korea
| | - Jinseok Ahn
- Department of Quality & Patient Safety, Cheil Orthopedic Hospital Seoul, Republic of Korea
| | - Ja Youn Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Republic of Korea
| | - JinShil Kim
- College of Nursing, Gachon University, Incheon, Korea
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Escobar Alvarez Y, Agamez Insignares C, Ahumada Olea M, Barajas O, Calderillo G, Calvache Guamán JC, Caponero R, Cavenago Salazar BA, Del Giglio A, Pupo Araya AR, Villalobos-Valencia R, Yepes Pérez A, Zumelzu Delgado N. Cancer pain management: recommendations from a Latin-American experts panel. Future Oncol 2017; 13:2455-2472. [DOI: 10.2217/fon-2017-0288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Generating a consensus in the Latin-American region on cancer pain management is a current need. Thus a panel of Latin-American experts met in Madrid in March 2017 in order to review the published literature, discuss the best approach for cancer pain classification and evaluation and also make recommendations of pharmacological and nonpharmacological therapies for cancer pain management improvement in Latin-American countries. The result of that meeting is presented in this document. The experts participating were from Costa Rica, Mexico, Chile, Colombia, Peru, Brazil and Ecuador, and the project coordinator was from Spain.
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Affiliation(s)
| | - Claudia Agamez Insignares
- Instituto Nacional de Cancerología/Universidad Militar Nueva Granada. Fondo Nacional de Estupefacientes en Políticas Públicas en medicamentos de control especial. Asociación Colombiana de Cuidados Paliativos, Colombia
| | - Monica Ahumada Olea
- Oncología Médica, Hospital Clínico Universidad de Chile, Clínica Dávila, Chile
| | - Olga Barajas
- Oncología Médica, Hospital Clínico Universidad de Chile, Fundación Arturo López Pérez, Santiago, Chile
| | - German Calderillo
- Instituto Nacional de Cancerología – Oncología Médica, Ciudad de México, México
| | | | - Ricardo Caponero
- Coordinator Supportive Therapy & Integrative Medicine, Hospital Alemão Oswaldo Cruz, Brazil
| | | | - Auro Del Giglio
- Faculdade de Medicina do ABC, Setor de Oncologia Clínica do IBCC e do HCOR, Brazil
| | - Ana Rocío Pupo Araya
- Unidad de Dolor del Hospital México/Unidad de Dolor Clínica Católica, Costa Rica
| | | | - Andrés Yepes Pérez
- Oncología Clínica, Fundación Colombiana de Cancerología Clínica Vida, Colombia
| | - Nilda Zumelzu Delgado
- Oncólogo Médico, Oncólogo Radioterapeuta, Hospital Base Valdivia, Clínica Alemana Valdivia, Chile
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21
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Katz NP, Gajria KL, Shillington AC, Stephenson JJ, Harshaw Q. Impact of breakthrough pain on community-dwelling cancer patients: results from the National Breakthrough Pain Study. Postgrad Med 2016; 129:32-39. [DOI: 10.1080/00325481.2017.1261606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nathaniel P. Katz
- Tufts University School of Medicine, Boston, MA, USA
- Analgesic Solutions, Natick, MA, USA
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Mercadante S, Adile C, Cuomo A, Aielli F, Marinangeli F, Casuccio A. The use of low doses of a sublingual fentanyl formulation for breakthrough pain in patients receiving low doses of opioids. Support Care Cancer 2016; 25:645-649. [PMID: 27744534 DOI: 10.1007/s00520-016-3457-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to prospectively assess the efficacy and safety of low doses of sublingual fentanyl (SLF) for the treatment of breakthrough pain (BTP) in cancer patients in patients who were receiving low opioid doses for background analgesia. METHODS A sample of cancer patients presenting BTP episodes and receiving stable low doses of opioids for background pain (less than 60 mg of oral morphine equivalents) was selected to assess the efficacy and safety of low doses of SLF (67 μg). For each patient, data from four consecutive episodes were collected. For each episode, changes in pain intensity and adverse effects when pain got severe (T0), and 5, 10, and 15 min after SLF administration (T5-T30) were recorded. The occurrence of serious effects occurring within 2 h of SLF administration were also considered. RESULTS Fifty-one patients were recruited for the study. The mean age was 66.8 (SD 12.9). A mean of 3.3 episodes/patient were recorded. Four patients did not have episodes of BTP. 147 episodes were evaluated. Six episodes (4.1 %) required a rescue medication at T30. Pain intensity significantly decreased at T5, T10, T15 and T30 (p < 0.0005 in all cases). A high percentage of patients had a pain reduction of more than 33 and 50 % at T5, T10, T15 and T30. Adverse effects were mild and generally already present, due to basal opioid treatment or disease. No serious adverse effects were observed for the subsequent 2 h. CONCLUSION This study suggests that SLF given in low doses in patients receiving lower doses of opioids for background analgesia is safe and effective in clinical practice.
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Affiliation(s)
- Sebastiano Mercadante
- Pain relief and Palliative/supportive care unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Claudio Adile
- Pain relief and Palliative/supportive care unit, La Maddalena Cancer Center, Palermo, Italy
| | - Arturo Cuomo
- Pain Therapy, National Cancer Institute "Pascale", Naples, Italy
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | | | - Alessandra Casuccio
- Department of Experimental Biomedicine and Clinical Neuroscience, University of Palermo, Palermo, Italy
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Hjermstad MJ, Kaasa S, Caraceni A, Loge JH, Pedersen T, Haugen DF, Aass N. Characteristics of breakthrough cancer pain and its influence on quality of life in an international cohort of patients with cancer. BMJ Support Palliat Care 2016; 6:344-52. [PMID: 27342412 DOI: 10.1136/bmjspcare-2015-000887] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/31/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Breakthrough cancer pain (BTP) represents a treatment challenge. Objectives were to examine the prevalence and characteristics of BTP in an international sample of patients with cancer, and to investigate the relationship between BTP and quality of life (QoL). METHODS This was an observational cross-sectional multicentre study. Participating patients completed self-report questionnaires on a touch-screen laptop computer, including the Brief Pain Inventory, Alberta Breakthrough Pain Assessment Tool (ABPAT) and European Organisation for Research and Treatment of Cancer 30-item Core Quality of Life Questionnaire (EORTC QLQ-C30). The study was performed in 17 centres in 8 countries and involved 4 languages (Norwegian, Italian, German and English). RESULTS Records from a convenience sample of 978 patients with advanced cancer were analysed; mean age was 62.2 years, 48.3% were women and 84.4% had metastatic disease. A total of 296 patients (30%) had no pain, defined as worst pain in the past 24 hours <1 on a 0-10 scale. Of the 682 patients with a pain score ≥1, 393 (58%) reported no BTP on the screening item, while 289 (30%) confirmed flare ups of BTP. Patients with BTP reported significantly higher pain intensity scores (<0.001) than patients without BTP; 57.1% of patients rated BTP at its worst as being severe: ≥7 on a 0-10 scale. Time from onset to peak intensity was <10 min for 42.9%, and average time to pain relief was 27.1 min. BTP was commonly triggered by medication wearing off (28%). Patients with BTP had significantly worse mean outcomes on 10 of 15 functional and symptom scales of the EORTC QLQ-C30 (<0.001). Severe pain intensity in the last week was a powerful predictor of BTP (OR 4.1) and poor QoL (OR 1.9). CONCLUSIONS BTP is highly prevalent with prolonged episodes despite analgaesics, and has a pervasive impact on QoL. Patients reporting high pain intensity should be carefully evaluated for BTP and efficacy of analgaesic treatment, to provide optimal pain management and improve QoL. TRIAL REGISTRATION NUMBER NCT00972634; Results.
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Affiliation(s)
- Marianne Jensen Hjermstad
- Department of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital, Oslo, Norway Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Stein Kaasa
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Augusto Caraceni
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Department of Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS, Istituto Nazionale Dei Tumori, Milano, Italy
| | - Jon H Loge
- Department of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital, Oslo, Norway Department of Behavioural Sciences in Medicine, University of Oslo, Oslo, Norway
| | - Tore Pedersen
- Bjørknes University College, Oslo, Norway National Institute of Occupational Health, Oslo, Norway
| | - Dagny Faksvåg Haugen
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, European Palliative Care Research Centre, Norwegian University of Science and Technology (NTNU), Trondheim, Norway Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - Nina Aass
- Department of Oncology, Regional Advisory Unit for Palliative Care, Oslo University Hospital, Oslo, Norway Faculty of Medicine, University of Oslo, Oslo, Norway
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Mercadante S, Cuomo A. Breakthrough Cancer Pain: Ten Commandments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:531-536. [PMID: 27565269 DOI: 10.1016/j.jval.2016.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/03/2016] [Accepted: 03/05/2016] [Indexed: 06/06/2023]
Abstract
The term "breakthrough cancer pain" (BTcP) was introduced about 25 years ago. Peaks of pain intensity reported in patients with cancer had been invariably examined in the past years, providing relevant information for a better knowledge of this phenomenon and its treatment. The aim of this critical review was to provide the golden rules, namely, the 10 commandments, for a correct diagnostic pathway of BTcP and a consequent personalized pharmacological treatment. These are as follows: 1) assessment of background analgesia, 2) drugs used for background analgesia, 3) BTcP is a frequent phenomenon, 4) characteristics of BTcP, 5) diagnosis of BTcP, 6) continuous assessment, 7) tailored pharmacological treatment of BTcP, 8) selection of BTcP medication, 9) dosing BTcP medications, and 10) education. These steps may help clinicians to recognize and treat BTcP adequately.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
| | - Arturo Cuomo
- Anesthesia, Intensive care and Pain Therapy, National Cancer Institute, "Pascale", Naples, Italy
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Breakthrough pain in cancer patients: prevalence, mechanisms and treatment options. Curr Opin Anaesthesiol 2016; 28:559-64. [PMID: 26263120 DOI: 10.1097/aco.0000000000000224] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The aim of this article was to examine the definition, the characteristics, and the management of breakthrough cancer pain (BTP) in cancer patients by a critical review of recent literature. RECENT FINDINGS BTP should be more correctly defined as an episode of severe intensity in patients receiving an adequate treatment with opioids able to provide at least mild analgesia. BTP is a heterogeneous condition as episodes vary between individuals. BTP can be classified into two big distinct pictures: spontaneous-type and incident-type pain. The principal pharmacological treatment of BTP is represented by the administration of opioids as needed. Recent reviews revealed that transmucosal preparation of fentanyl provided superior and more rapid pain relief as compared with placebo in the first 30 min after dosing. Few comparison studies among fentanyl products have been performed.Finally, although dose titration was recommended for years, a meaningful dosing according to the level of opioid tolerance may enhance the advantages of such products. SUMMARY BTP represents a serious problem reported by many cancer patients despite receiving regular use of opioids. Subgroups of breakthrough pain have been identified. Different modalities of pharmacological interventions are available. Further studies are warranted to assess the net benefit of these drugs to assist decision-making by patients, clinicians, and payers according to individual clinical conditions.
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Løhre ET, Klepstad P, Bennett MI, Brunelli C, Caraceni A, Fainsinger RL, Knudsen AK, Mercadante S, Sjøgren P, Kaasa S. 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. J Pain Symptom Manage 2016; 51:1013-9. [PMID: 26921493 DOI: 10.1016/j.jpainsymman.2015.12.329] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/05/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Cancer pain can appear with spikes of higher intensity. Breakthrough cancer pain (BTCP) is the most common term for the transient exacerbations of pain, but the ability of the nomenclature to capture relevant pain variations and give treatment guidance is questionable. OBJECTIVES To reach consensus on definitions, terminology, and subclassification of transient cancer pain exacerbations. METHODS The most frequent authors on BTCP literature were identified using the same search strategy as in a systematic review and invited to participate in a two-round Delphi survey. Topics with a low degree of consensus on BTCP classification were refined into 20 statements. The participants rated their degree of agreement with the statements on a numeric rating scale (0-10). Consensus was defined as a median numeric rating scale score of ≥7 and an interquartile range of ≤3. RESULTS Fifty-two authors had published three or more articles on BTCP over the past 10 years. Twenty-seven responded in the first round and 24 in the second round. Consensus was reached for 13 of 20 statements. Transient cancer pain exacerbations can occur without background pain, when background pain is uncontrolled, and regardless of opioid treatment. There exist cancer pain exacerbations other than BTCP, and the phenomenon could be named "episodic pain." Patient-reported treatment satisfaction is important with respect to assessment. Subclassification according to pain pathophysiology can provide treatment guidance. CONCLUSION Significant transient cancer pain exacerbations include more than just BTCP. Patient input and pain classification are important factors for tailoring treatment.
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Affiliation(s)
- Erik Torbjørn Løhre
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Cinzia Brunelli
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Augusto Caraceni
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Robin L Fainsinger
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Anne Kari Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Italian Oncological Pain Survey (IOPS): a multicentre Italian study of breakthrough pain performed in different settings. Clin J Pain 2015; 31:214-21. [PMID: 25654429 DOI: 10.1097/ajp.0000000000000161] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A survey of breakthrough pain (BTP) was performed in five palliative care units (PCU), seven oncology departments (ONC), and nine pain clinics (OPC). METHODS A standard algorithm was used to confirm the diagnosis of BTP of patients refereed to different settings. RESULTS 1,412 evaluable cancer patients were enrolled. 53.9% were males and the mean age was 63.7±13.1 years. The mean intensity of background pain was 2.8±0.73. Patients reported 2.4±1.1 BTP episodes/day with a mean intensity of 7.37±1.28. 80.6% patients reported that the BTP had a significant negative impact in everyday life. The majority of patients reported a fast onset of BTP, which was predictable in 50.7% of cases, while BTP with a gradual onset (>10 min) was less predictable (29%) (P=0.001). PCU patients were older, had lower Karnofsky levels, a lower number of BTP episodes/day, a slow onset of BTP onset, and a less predictable BTP. Cancer diagnosis was performed a mean of 23.5 months (SD±32.8) before the assessment. The mean duration of background pain was 3.5 months (SD±3.5), and the mean duration of any analgesic treatment was 2.5 months (SD±3). BTP started a mean of 2.2 months (SD±1.9) before the assessment. Characteristics of BTP were influenced by the course of disease, as well as the duration of background pain and initiation of BTP. Most patients took rapid onset opioids and were satisfied with the treatment. BTP diagnosis was prevalently made by ONC and OPC physicians, and rarely by GPs. CONCLUSION This survey performed by an Italian observatory expert review group, has confirmed that the BTP represents a clinically relevant condition with a negative impact on the patient's quality of life. BTP was detected in all settings involved. A number of factors are associated with the BTP. Also factors regarding the course of disease and setting of care have been assessed. This information may help in stratifying patients or predicting the risk of development of BTP with specific characteristics.
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Torres LM, Trinidad JM, Calderón E, Benitez D, Perelman M. Fentanyl pectin nasal spray for breakthrough cancer pain. Int J Palliat Nurs 2015; 21:114-6. [PMID: 25815759 DOI: 10.12968/ijpn.2015.21.3.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Luis M Torres
- Head of Anesthesia, Critical Care and Pain Treatment Department
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Breakthrough pain and its treatment: critical review and recommendations of IOPS (Italian Oncologic Pain Survey) expert group. Support Care Cancer 2015; 24:961-968. [PMID: 26438145 DOI: 10.1007/s00520-015-2951-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
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.
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31
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Webber K, Davies AN, Cowie MR. Accuracy of a Diagnostic Algorithm to Diagnose Breakthrough Cancer Pain as Compared With Clinical Assessment. J Pain Symptom Manage 2015; 50:495-500. [PMID: 26025280 DOI: 10.1016/j.jpainsymman.2015.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/29/2015] [Accepted: 05/13/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Breakthrough cancer pain (BTCP) is a heterogeneous condition, and there are no internationally agreed standardized criteria to diagnose it. There are published algorithms to assist with diagnosis, but these differ in content. There are no comparative data to support use. OBJECTIVES To compare the diagnostic ability of a simple algorithm against a comprehensive clinical assessment to diagnose BTCP and to assess if verbal rating descriptors can adequately discriminate controlled background pain. METHODS Patients with cancer pain completed a three-step algorithm with a researcher to determine if they had controlled background pain and BTCP. This was followed by a detailed pain consultation with a clinical specialist who was blinded to the algorithm results and determined an independent pain diagnosis. The sensitivity, specificity, and positive and negative predictive values were calculated for the condition of BTCP. Further analysis determined which verbal pain severity descriptors corresponded with the condition of controlled background pain. RESULTS The algorithm had a sensitivity of 0.54 and a specificity of 0.76 in the identification of BTCP. The positive predictive value was 0.7, and the negative predictive value was 0.62. The sensitivity of a background pain severity rating of mild or less to accurately categorize controlled background pain was 0.69 compared with 0.97 for severity of moderate or less; however, this was balanced by a higher specificity rating for mild or less, 0.78 compared with 0.2. CONCLUSION The diagnostic breakthrough pain algorithm had a good positive predictive value but limited sensitivity using a cutoff score of "mild" to define controlled background pain. When the cutoff level was changed to moderate, the sensitivity increased, but specificity reduced. A comprehensive clinical assessment remains the preferred method to diagnose BTCP.
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Affiliation(s)
- Katherine Webber
- St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, United Kingdom.
| | - Andrew N Davies
- St. Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Martin R Cowie
- National Heart & Lung Institute, Imperial College, London, United Kingdom
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Baek SK, Kim DY, Kang SY, Sym SJ, Kim YS, Lee JY. A Korean Nationwide Survey for Breakthrough Cancer Pain in an Inpatient Setting. Cancer Res Treat 2015; 48:768-74. [PMID: 26511815 PMCID: PMC4843738 DOI: 10.4143/crt.2015.087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/21/2015] [Indexed: 11/27/2022] Open
Abstract
Purpose We evaluated the prevalence and characteristics of breakthrough cancer pain (BTcP) in Korean patients admitted with cancer pain. Materials and Methods In-hospital patients with cancer pain completed a questionnaire concerning severity of background cancer pain (BCP), prevalence and treatment for BTcP, sleep disorders, and satisfaction with cancer pain treatment. Medical records showing medications for BCP and BTcP were also evaluated. Results Total 609 patients with controlled BCP enrolled. Mean age of the patients was 59.5 years old, and 59% were male. Of all patients, 177 (29%) complained of BTcP. No clinical characteristic predicted BTcP. Of the 177 patients with BTcP, 56% did not receive treatment for BTcP. Patients with BTcP showed significant association with a sleep disorder and dissatisfaction with pain control, compared to those without BTcP (p < 0.0001 and p=0.0498, respectively). Oxycodone-immediate release was the most commonly used short-acting analgesic, followed by intravenous morphine. Conclusion The prevalence of BTcP was 29% in patients admitted with controlled BCP. Although the patients had well-controlled BCP, BTcP showed association with a lower quality of life in patients with cancer. More medical attention is needed for detection and management of BTcP.
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Affiliation(s)
- Sun Kyung Baek
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Do Yeun Kim
- Department of Internal Medicine, Dongguk Univerity Ilsan Hospital, Goyang, Korea
| | - Seok Yun Kang
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon, Korea
| | - Sun Jin Sym
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Young Sung Kim
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - June Young Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
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A new once-a-day fentanyl citrate patch (Fentos Tape) could be a new treatment option in patients with end-of-dose failure using a 72-h transdermal fentanyl matrix patch. Support Care Cancer 2015; 24:1053-9. [PMID: 26248654 DOI: 10.1007/s00520-015-2880-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The recommended dosing interval for transdermal fentanyl is every 72 h. However, some patients will have "end-of-dose failure," which may be seen as an increase of episodes of severe pain flares at the third day after application of the patch. A new once-a-day fentanyl patch was developed in Japan since 2010. This study aimed to assess the efficacy of the once-a-day fentanyl citrate patch for patients with cancer-related pain receiving the 72-h transdermal fentanyl not lasting 72 h. METHODS We performed a cross-sectional retrospective analysis of 445 inpatients with the 72-h transdermal fentanyl at Higashi Sapporo Hospital. We could switch to the once-a-day fentanyl citrate patch if patients reported inadequate pain relief beyond 48 h after application of the 72-h transdermal fentanyl. Patients recorded baseline scores for background pain intensity (PI) and the frequency of use of daily rescue medication for breakthrough cancer pain (BTcP). RESULTS Of all patients, 10.1% showed the increase in PI of 30% or more baseline PI on the third day after application of the 72-h transdermal fentanyl. Of patients, 84.4% were converted from equivalent dose of the 72-h transdermal fentanyl to the once-a-day fentanyl citrate patch. On the third day after switching, 60.5% of patients showed a reduction of more than 30% from baseline PI. Switching to the once-a-day fentanyl citrate patch significantly reduced the mean frequency of daily rescue dose for BTcP. CONCLUSIONS A once-a-day fentanyl citrate patch provided stable pain control. Its use may be considered as the dominant strategy for patients receiving a 72-h transdermal fentanyl not lasting 72 h.
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Fonoff ET, Lopez WOC, de Oliveira YSA, Teixeira MJ. Microendoscopy-guided percutaneous cordotomy for intractable pain: case series of 24 patients. J Neurosurg 2015; 124:389-96. [PMID: 26230468 DOI: 10.3171/2014.12.jns141616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to show that microendoscopic guidance using a double-channel technique could be safely applied during percutaneous cordotomy and provides clear real-time visualization of the spinal cord and surrounding structures during the entire procedure. METHODS Twenty-four adult patients with intractable cancer pain were treated by microendoscopic-guided percutaneous radiofrequency (RF) cordotomy using the double-channel technique under local anesthesia. A percutaneous lateral puncture was performed initially under fluoroscopy guidance to localize the target. When the subarachnoid space was reached by the guiding cannula, the endoscope was inserted for visualization of the spinal cord and surrounding structures. After target visualization, a second needle was inserted to guide the RF electrode. Cordotomy was performed by a standard RF method. RESULTS The microendoscopic double-channel approach provided real-time visualization of the target in 91% of the cases. The other 9% of procedures were performed by the single-channel technique. Significant analgesia was achieved in over 90% of the cases. Two patients had transient ataxia that lasted for a few weeks until total recovery. CONCLUSIONS The use of percutaneous microendoscopic cordotomy with the double-channel technique is useful for specific manipulations of the spinal cord. It provides real-time visualization of the RF probe, thereby adding a degree of safety to the procedure.
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Affiliation(s)
- Erich Talamoni Fonoff
- Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Brazil; and
| | - William Omar Contreras Lopez
- Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Brazil; and.,Department of Stereotactic and Functional Neurosurgery, University Medical Center, Freiburg, Germany
| | | | - Manoel Jacobsen Teixeira
- Pain Center and Division of Functional Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Brazil; and
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Davies A, Kleeberg UR, Jarosz J, Mercadante S, Poulain P, O'Brien T, Schneid H, Kress HG. Improved patient functioning after treatment of breakthrough cancer pain: an open-label study of fentanyl buccal tablet in patients with cancer pain. Support Care Cancer 2015; 23:2135-43. [PMID: 25556611 DOI: 10.1007/s00520-014-2590-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE This open-label study evaluated the effects of fentanyl buccal tablet (FBT) on functioning and mood in cancer patients with breakthrough cancer pain (BTcP). METHODS Opioid-tolerant patients in seven European countries with up to four BTcP episodes/day received FBT doses (100-800 μg) identified during open-label titration to treat up to eight BTcP episodes during an open-label treatment period. In countries where FBT was not commercially available, patients could enter an open-label continuation phase. Functionality and satisfaction assessments included change from baseline to the end of the treatment period in the modified Brief Pain Inventory (BPI-7S) seven-item interference subscale, patient's global assessment of satisfaction and ease of use, and Patient's Global Impression of Change (PGIC). Safety was also assessed. RESULTS Of 330 randomized patients, 218 completed the treatment period and 88 entered the continuation phase. Median background pain intensity was 4.0 (mild) throughout the study. After the treatment period, mean (SD) global modified BPI-7S score improved from 39.7 (15.9) at baseline to 31.6 (16.8) for a mean change of -8.6 (95% confidence interval CI -10.5, -6.7; P < 0.0001), and 74.5% of patients reported improvement in overall status (PGIC) compared with 25.5% who reported no change or worsening (P < 0.001). Treatment-related adverse events (≥2 patients) during the continuation phase were application site erythema (6.9%), application site swelling (4.6%), and vertigo (4.6%). CONCLUSIONS FBT may improve patient functioning, mood, and overall satisfaction in the management of BTcP. Long-term data did not indicate new safety concerns with FBT doses up to 800 μg.
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Affiliation(s)
- Andrew Davies
- Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, Surrey, UK,
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Sperlinga R, Campagna S, Berruti A, Laciura P, Ginosa I, Paoletti S, Giuliano P, Tucci M, Rosato R, Scagliotti G, Saini A. Alberta Breakthrough Pain Assessment Tool: A validation multicentre study in cancer patients with breakthrough pain. Eur J Pain 2014; 19:881-8. [DOI: 10.1002/ejp.612] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/09/2022]
Affiliation(s)
- R. Sperlinga
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - S. Campagna
- School of Nursing; ‘San Luigi Gonzaga’; University of Torino; Italy
| | - A. Berruti
- Medical Oncology; Department of Medical and Surgical Specialties; Radiological Sciences and Public Health; ‘Spedali Civili’ Hospital; University of Brescia; Italy
| | | | - I. Ginosa
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - S. Paoletti
- School of Nursing; Catholic University of the Sacred Heart - Little House of Divine Providence; Cottolego Hospital; Turin Italy
| | - P.L. Giuliano
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - M. Tucci
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - R. Rosato
- Cancer Epidemiology Unit; ‘Città della Salute e della Scienza’ Hospital; Turin Italy
| | - G.V. Scagliotti
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
| | - A. Saini
- Medical Oncology; Department of Oncology; ‘San Luigi Gonzaga’ Hospital; Orbassano Italy
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Torres LM, Revnic J, Knight AD, Perelman M. Relationship between onset of pain relief and patient satisfaction with fentanyl pectin nasal spray for breakthrough pain in cancer. J Palliat Med 2014; 17:1150-7. [PMID: 25211772 DOI: 10.1089/jpm.2014.0089] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Satisfaction with pain relief in patients with breakthrough pain in cancer (BTPc) has typically been assessed by overall efficacy without consideration of the rapidity of that response. OBJECTIVE To determine the relationship between speed of onset of pain relief and patient satisfaction for treated BTPc episodes overall and for individual treatments. DESIGN Pooled data from two randomized, double-blinded crossover studies. SETTING/SUBJECTS Patients having 1-4 BTPc episodes per day on ≥60 mg/day oral morphine or equivalent. Episodes treated with fentanyl pectin nasal spray (FPNS; 100-800 μg), immediate-release morphine sulfate (IRMS), or placebo. MEASUREMENTS Pain intensity was measured on an 11-point scale (5-60 minutes posttreatment); satisfaction was measured on a 4-point scale (30 and 60 minutes). The primary analysis assessed the overall relationship of time to onset of pain relief (pain intensity difference [PID]≥1) or time to clinically meaningfully reduction in pain (PID≥2) versus patient satisfaction and overall pain intensity (summed pain intensity difference at 30 [SPID30] and 60 minutes [SPID60]) assessed by analysis of variance (ANOVA). A secondary analysis assessed whether satisfaction was different between treatments using a within-patient comparison. RESULTS Eight hundred thirty-one FPNS-treated, 368 IRMS-treated, and 200 placebo-treated episodes were analyzed. Overall, within the pool there was a statistically significant relationship between time to onset of pain relief (PID≥1 and PID≥2) and patient satisfaction (both speed of relief and overall) at 30 and 60 minutes (p<0.001); this relationship was also true within individual treatment groups (p<0.01). Similar results were found for overall pain intensity reduction. When treatment groups were compared using within-patient data, FPNS provided earlier onset of pain relief than IRMS or placebo (p<0.05), which translated into better satisfaction at 60 minutes (p<0.01). CONCLUSIONS Earlier onset of pain relief resulted in greater patient satisfaction and overall relief of pain; between-treatment comparisons showed that FPNS provided earlier pain relief and greater satisfaction than IRMS or placebo.
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Affiliation(s)
- Luis M Torres
- 1 Hospital Universitario Puerta del Mar , Cádiz, Spain
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Breakthrough cancer pain (BTcP): a synthesis of taxonomy, pathogenesis, therapy, and good clinical practice in adult patients in Italy. Adv Ther 2014; 31:657-82. [PMID: 25005168 PMCID: PMC4115180 DOI: 10.1007/s12325-014-0130-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Indexed: 11/04/2022]
Abstract
Pain presents in 80% of patients with advanced cancer, and 30% have periods of increased pain due to fluctuating intensity, known as breakthrough cancer pain (BTcP). BTcP is high-intensity, short-duration pain occurring in several episodes per day and is non-responsive to treatment. The clinical approach to BTcP is variable. A review of the literature was performed to provide clinicians and practitioners with a rational synthesis of the ongoing scientific debate on BTcP and to provide a basis for optimal clinical approach to BTcP in adult Italian patients. Data show that circadian exacerbations of pain should be carefully monitored, differentiating, if possible, between fluctuations of background pain (BP), end-of-dose effect, and BTcP. BTcP should be monitored in all care contexts in clinical practice and each care facility must have all the medications and products approved for use in BTcP at their disposal. Data show that knowledge about medications for BTcP is lacking: medications for BTcP treatment are not interchangeable, although containing the same active substance; each physician must know the specific characteristics of each medication, its pharmacological properties, limitations in clinical practice, specifics relating to titration and repeatability of administration, and technical specifics relating to the accessibility and delivery. Importantly, before choosing a rapid-onset opioid (ROO), it is essential to deeply understand the status of patient and the characteristics of their family unit/caregivers, taking into account the patient’s progressive loss of autonomy and/or cognitive-relational functionality. When BTcP therapy is initiated or changed, special attention must be paid to training the patient and family members/caregivers, providing clear instructions regarding the timing of drug administration. The patient must already be treated effectively with opioids before introducing ROOs for control of BTcP.
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Breakthrough pain in patients with controlled or uncontrolled basal pain: an observational study. Pain Res Manag 2014; 19:e168-71. [PMID: 24945289 PMCID: PMC4273716 DOI: 10.1155/2014/646312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, there has been debate regarding the definition of ‘breakthrough pain’ and the patients to whom the term applies, with suggestions made to broaden the definition to include both patients with uncontrolled and controlled baseline pain, rather than only patients with controlled pain. To contribute to this discussion, the authors assessed the occurrence and characteristics of breakthrough pain among patients with controlled and uncontrolled baseline pain. BACKGROUND: Breakthrough pain (BTP) is traditionally defined as a pain exacerbation in patients with chronic controlled pain. However, this definition has recently been challenged. OBJECTIVES: To evaluate the prevalence of unsatisfactory control in patients with chronic cancer pain, and investigate the frequency and intensity of BTP episodes. METHODS: A total of 665 patients with chronic cancer pain attending 21 pain therapy units in Italy were evaluated for baseline pain intensity and number of BTP episodes over a 30-day period. All patients started, continued or modified treatment for BTP at enrollment, according to medical judgment. RESULTS: The number of BTP events was higher in patients with uncontrolled baseline pain, although the intensity and duration of episodes were similar. In patients with uncontrolled baseline pain, the number of events decreased with time and reached values comparable with those reported in patients with controlled pain. Both the intensity of the pain and the duration of the BTP events exhibited similar values in the two groups at all time points, following increased monitoring and the prescription of analgesic medication. CONCLUSION: Patients with uncontrolled baseline pain experienced BTP flares with higher frequency, but similar intensity and duration with respect to patients with controlled pain at baseline. Notably, a close follow-up and adequate management of the BTP episodes led to an improvement of BTP in the observed patients.
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Kongsgaard UE, Eeg M, Greisen H. The use of Instanyl® in the treatment of breakthrough pain in cancer patients: a 3-month observational, prospective, cohort study. Support Care Cancer 2014; 22:1655-62. [PMID: 24510192 PMCID: PMC4008783 DOI: 10.1007/s00520-014-2128-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/13/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Instanyl® (intranasal fentanyl spray) is a novel treatment for breakthrough pain (BTP) in cancer patients. It has shown a rapid onset of pain relief in clinical trials. This study examines the use of Instanyl® in real-life settings. METHODS A 3-month observational, prospective, cohort study of cancer patients with BTP receiving Instanyl® (50, 100, or 200 μg) under routine clinical practice. Data were collected at three time points corresponding with routine clinic visits - baseline, Week 4, and Week 13. PRIMARY OUTCOMES success of titration and maintenance dose after titration. SECONDARY OUTCOMES change in maintenance dose of Instanyl® and level of background pain medication; Brief Pain Inventory--Short Form (BPI-SF) and Patient Treatment Satisfaction Scale (PTSS) scores; adverse drug reactions (ADRs). RESULTS Titration with Instanyl® was successful in 84.5 % of 309 patients; most patients were titrated at the lowest dose (50 μg). The majority showed no change in maintenance dose, with little change in the level of background pain medication. BPI-SF and PTSS scores significantly improved from baseline to Week 4. The main reason for terminating Instanyl® was death, as expected due to the underlying disease; incidence of ADRs was low and no fatal ADRs were reported. CONCLUSIONS In a real-life group of cancer patients with disease progression, Instanyl® was titrated successfully at doses <200 μg in the majority of patients, requiring only one dose, with no further change in maintenance dose. Pain severity, impact of pain on daily life, and treatment satisfaction significantly improved with Instanyl® treatment. No unexpected ADRs occurred.
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Affiliation(s)
- Ulf E Kongsgaard
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Medical Faculty, University of Oslo, Oslo, Norway,
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Deandrea S, Corli O, Consonni D, Villani W, Greco MT, Apolone G. Prevalence of breakthrough cancer pain: a systematic review and a pooled analysis of published literature. J Pain Symptom Manage 2014; 47:57-76. [PMID: 23796584 DOI: 10.1016/j.jpainsymman.2013.02.015] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 02/18/2013] [Accepted: 02/22/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Despite the large body of literature on breakthrough cancer pain (BTcP), an accurate estimate of BTcP prevalence is still not available. OBJECTIVES To provide an estimate of BTcP prevalence and investigate the association between different prevalence rates and possible determinants. METHODS We conducted MEDLINE and EMBASE searches for studies published from 1990 to 2012 reporting data on BTcP prevalence in adult cancer populations. Pooled prevalence rates from observational studies with an acceptable methodological quality were computed. The association between BTcP prevalence and possible predictors was investigated using subgroup analyses and meta-regression. RESULTS Twenty-seven observational studies were identified. When quality criteria were applied, only 19 studies were included in the pooled analysis. The overall pooled prevalence was 59.2%, with high heterogeneity. The lowest prevalence rates were detected in studies conducted in outpatient clinics (39.9%), and the highest prevalence was reported in studies conducted in hospice (80.5%). The association between BTcP prevalence and other determinants such as publication year, age, gender, metastatic disease prevalence, or baseline pain intensity did not reach statistical significance. CONCLUSION In the context of a large between-studies heterogeneity, more than one in two patients with cancer pain also experiences BTcP, with some variability according to clinical and organizational variables.
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Affiliation(s)
- Silvia Deandrea
- Center for the Evaluation and Research on Pain (CERP), IRCCS Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy; Istituto di Statistica Medica e Biometria "G. A. Maccacaro,", Università degli Studi di Milano, Milan, Italy.
| | - Oscar Corli
- Center for the Evaluation and Research on Pain (CERP), IRCCS Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy
| | - Dario Consonni
- Unit of Epidemiology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Walter Villani
- Center for the Evaluation and Research on Pain (CERP), IRCCS Istituto di Ricerche Farmacologiche "Mario Negri," Milan, Italy
| | - Maria Teresa Greco
- Istituto di Statistica Medica e Biometria "G. A. Maccacaro,", Università degli Studi di Milano, Milan, Italy
| | - Giovanni Apolone
- Direzione Scientifica, IRCCS Arcispedale Santa Maria Nuova, Reggio-Emilia, Italy
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Nalamachu S. An evaluation of total disintegration time for three different doses of sublingual fentanyl tablets in patients with breakthrough pain. Pain Ther 2013; 2:121-8. [PMID: 25135150 PMCID: PMC4107913 DOI: 10.1007/s40122-013-0019-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Indexed: 11/06/2022] Open
Abstract
Introduction Breakthrough pain is common among patients with cancer and presents challenges to effective pain management. Breakthrough pain is characterized by rapid onset, severe intensity, and duration typically lasting <1 h. Thus, optimal relief from breakthrough pain is best attained by administering analgesics with dissolution times and bioavailabilities that closely match the onset and duration of breakthrough pain. The objective of this study was to assess complete disintegration time of three different doses of sublingual fentanyl tablets in opioid-tolerant patients. Methods This was a single-center, non-randomized, open-label study. Opioid-tolerant adult patients (N = 30) with chronic pain were assigned to one of three dose groups and self-administered a single 100, 200, or 300 μg sublingual fentanyl tablet (Abstral®, Galena Biopharma, Portland, OR, USA). Time to complete disintegration was measured by each patient with a stopwatch and independently verified by study personnel. Results Disintegration time (mean ± SD) for sublingual fentanyl tablets (all doses) was 88.2 ± 55.1 s. Mean disintegration times tended to be slightly longer for the 200 μg (96.7 ± 57.9 s) and 300 μg doses (98.6 ± 64.8 s) compared to the 100 μg dose (69.5 ± 40.5 s). Differences were not statistically significant. Disintegration time was not significantly different between men and women and was not affected by age. Conclusion Sublingual fentanyl tablets dissolved rapidly (average time <2 min) in all patients, with the higher doses taking slightly more time to dissolve. Electronic supplementary material The online version of this article (doi:10.1007/s40122-013-0019-6) contains supplementary material, which is available to authorized users.
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Soden K, Ali S, Alloway L, Barclay D, Barker S, Bird L, Hall L, Perkins P. How do nurses in specialist palliative care assess and manage breakthrough cancer pain? A multicentre study. Int J Palliat Nurs 2013; 19:528-34. [DOI: 10.12968/ijpn.2013.19.11.528] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Katie Soden
- The Priscilla Bacon Centre for Specialist Palliative Care Services, Colman Hospital, Unthank Road, Norwich, NR2 2PJ, England
| | | | - Lara Alloway
- North Hampshire Palliative Care Service, England
| | | | - Stephanie Barker
- The Priscilla Bacon Centre for Specialist Palliative Care Services
| | - Lydia Bird
- Division of Primary Care, University of Nottingham, England
| | - Lesley Hall
- The Priscilla Bacon Centre for Specialist Palliative Care Services
| | - Paul Perkins
- Sue Ryder Leckhampton Court Hospice and Gloucestershire Hospitals NHS Foundation Trust, England
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Abstract
Breakthrough cancer pain can be treated effectively by rapid-onset opioids, such as sublingual fentanyl. However, it remained unclear how the optimal dose of sublingual fentanyl should be determined. Dosing proportional to basic opioid regimen is now proposed as an alternative to dose titration.
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Affiliation(s)
- Guy H Hans
- Department of Anesthesiology, Antwerp University Hospital (UZA) , Edegem , Belgium
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Mercadante S, Valle A, Porzio G, Aielli F, Adile C, Ficorella C, Raineri M, Giarratano A, Casuccio A. Relationship between background cancer pain, breakthrough pain, and analgesic treatment: a preliminary study for a better interpretation of epidemiological and clinical studies. Curr Med Res Opin 2013; 29:667-71. [PMID: 23551065 DOI: 10.1185/03007995.2013.792247] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The different operational definitions of breakthrough cancer pain (BTcP) has generated unclear epidemiological data. METHODS A consecutive sample of patients was categorized on the basis of their background pain intensity, background analgesic treatment, and the presence of BTcP. RESULTS A total of 265 patients were surveyed; 117 patients had background pain and 91 patients presented peaks of pain intensity distinguishable from background pain. Of 117 patients with background pain, 49 patients were re-assessed after optimization of background analgesia (T1) within a mean of 8.2 days. Pain intensity significantly decreased in comparison with values recorded at admission (p < 0.0005); 75.5% of these patients had BTcP episodes, with a significant decrease in the number BTcP episodes in comparison with T0 (p < 0.0005). The mean BTcP intensity was significantly lower in comparison with T0 (p < 0.0005). Finally, the mean duration of untreated BTcP episodes decreased significantly in comparison with T0 (p = 0.016). After optimization of analgesic therapy, most patients with moderate or severe background pain receiving opioids for moderate pain, patients with moderate or severe pain receiving strong opioids, and patients with moderate or severe pain receiving no opioids moved to the group of patients with mild pain receiving strong opioids. The difference was significant (p = 0.022). CONCLUSION Patients having good pain control after optimization of the analgesic regimen may have a decrease in number, intensity, and duration of BTcP, although the general prevalence of BTcP remains unchanged.
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Bornemann-Cimenti H, Wejbora M, Szilagyi IS, Sandner-Kiesling A. Fentanyl for the treatment of tumor-related breakthrough pain. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:271-7. [PMID: 23671467 DOI: 10.3238/arztebl.2013.0271] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 12/17/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Breakthrough cancer pain (BTCP) is common among cancer patients and markedly lowers their quality of life. The treatment for BTCP episodes that is recommended in current guidelines involves extended-release formulations in combination with rapid-onset and short-acting opioids. In the past few years, several new preparations of fentanyl, an opioid with a very rapid onset, have been approved for this indication. Treating physicians need to be aware of the clinical differences between the newer fentanyl preparations and immediate-release opioids. METHODS We searched the PubMed and Embase databases for randomized controlled trials (RCTs) of fentanyl for buccal, sublingual or intranasal administration in comparison with other opioids or a different fentanyl preparation for the treatment of BTCP. RESULTS In 6 trials of buccal, sublingual or intranasal fentanyl versus oral immediate-release opioids for the treatment of BTCP episodes, the use of fentanyl was associated with significantly less intense pain. In particular, fentanyl more often lowered the intensity of pain by at least 33% (range between studies: 13% to 57%) or by at least 50% (range between studies: 9% to 38%) within 15 minutes. Please change to "versus" if you agree.] Dose titration should begin at the lowest dose. When one fentanyl preparation is exchanged for another, the effective dose will probably differ. CONCLUSION The newer fentanyl preparations extend the treatment options for BTCP. They relieve pain within a short time better than conventional, immediate-release oral opioids do and may therefore be very helpful for patients with suddenly arising, intense, and short-lasting BTCP episodes. Further comparative trials are urgently needed.
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Gatti A, Gentili M, Iorno V, Mammucari M, Tufaro G, Lazzari M, Sabato AF. Beyond the traditional definition of breakthrough pain: an observational study. Adv Ther 2013; 30:298-305. [PMID: 23444055 DOI: 10.1007/s12325-013-0013-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Breakthrough pain (BTP) is traditionally defined as a transitory pain flare in opioid-treated patients with chronic background pain. This definition has, however, been challenged in recent years. This study aimed to analyze BTP prevalence in different pain conditions. METHODS This was a prospective, non-interventional, observational study conducted from June to September 2011 in two Italian pain treatment reference centres. Consecutive patients aged >18 years with oncological or non-oncological pain were eligible for this study; background pain was acute/ subacute (<3 months) or chronic (>3 months). The characteristics of pain were evaluated by means of a structured interview by physicians, and patients were asked to complete a dedicated clinical study form. The following outcomes were assessed: chronic pain duration (in patients with chronic pain), BTP prevalence, and number and severity of daily BTP episodes. All outcomes were assessed in four populations of patients with: (a) chronic oncological pain; (b) chronic non-oncological pain; (c) non-chronic oncological pain; (d) non-chronic non-oncological pain. The correlation between BTP and gender was also investigated. RESULTS Of 1,270 patients with chronic pain, 1,086 had non-oncological pain (85.5%). Most patients (68.6%) with non-oncological pain were female (P = 0.001). Pain duration was significantly longer in non-oncological pain versus oncological pain groups (P = 0.002). BTP prevalence was lower in non-oncological patients (P < 0.001). No differences were reported in terms of number and severity of daily BTP episodes. BTP was more frequent in females with non-oncological pain (P = 0.04). Females had a significantly higher pain severity (P = 0.02) than males. CONCLUSION BTP is frequently reported in patients who do not have BTP according to the traditional definition. BTP frequency and severity is similar in oncological and non-oncological pain.
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Affiliation(s)
- Antonio Gatti
- Emergency Care, Critical Care Medicine, Pain Medicine and Anesthesiology Department, Tor Vergata Polyclinic, University of Rome Tor Vergata, Rome, Italy
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Rustøen T, Geerling JI, Pappa T, Rundström C, Weisse I, Williams SC, Zavratnik B, Wengström Y. How nurses assess breakthrough cancer pain, and the impact of this pain on patients' daily lives--results of a European survey. Eur J Oncol Nurs 2012; 17:402-7. [PMID: 23276599 DOI: 10.1016/j.ejon.2012.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 10/16/2012] [Accepted: 12/01/2012] [Indexed: 02/01/2023]
Abstract
PURPOSE To increase our knowledge of how nurses assess breakthrough cancer pain (BTCP); and whether they find it difficult to distinguish BTCP from background pain; how they estimate the impact of BTCP on patients' daily lives, and the factors that nurses consider to induce BTCP. Variations in their use of assessment tools and their ability to distinguish between different types of pain were also examined in terms of the number of years of oncology nursing experience and the practice in different countries. METHODS In total, 1241 nurses (90% female) who care for patients with cancer, from 12 European countries, completed a survey questionnaire. KEY RESULTS Half the sample had >9 years of experience in oncology nursing. Although 39% had no pain assessment tool to help them distinguish between types of pain, 95% of those who used a tool found it useful. Furthermore, 37% reported that they had problems distinguishing background pain from BTCP. Movement was identified as the factor that most commonly exacerbated BTCP across all countries. The nurses reported that BTCP greatly interfered with patients' everyday activities, and they rated the patients' enjoyment of life as most strongly affected. The use of tools and the ability to distinguish between different pains varied between European countries and with years of experience in oncology nursing. CONCLUSIONS The nurses reported that BTCP greatly interfered with patients' lives, and many nurses had problems distinguishing between background pain and BTCP. Nurses require more knowledge about BTCP management, and guidelines should be developed for clinical use.
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Affiliation(s)
- Tone Rustøen
- Division of Emergencies and Critical Care, Department of Research and Development, Ullevål, Oslo University Hospital, Postbox 4956, Nydalen, 0424 Oslo, Norway.
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