Quick help for a troublesome side effect

Hardly any patients report it, but many suffer from it: Tumor breakthrough pain. The sudden attacks of pain are a psychological and physical burden for those affected, which severely restricts their quality of life. In addition, tumor breakthrough pain causes considerable costs due to increased use of medical services. Quick help is needed here.

(red) Almost none of the oncology patients are spared tumor-related breakthrough pain during the course of their disease. Depending on how advanced the disease is, the prevalence is 23-89%. Around one in three oncology patients undergoing outpatient treatment report breakthrough pain. Among inpatient cancer patients, it is one in two and among hospice patients, 9 out of 10 report experiencing breakthrough pain (Fig. 1). Nevertheless, too little focus is often placed on this phenomenon – perhaps also because there is no generally accepted definition of breakthrough pain in tumor patients. According to the German Society for Pain Medicine, it is a temporary pain exacerbation that occurs despite adequate control of the permanent pain. Typical for tumor breakthrough pain is the sudden onset of pain, a short duration of pain, as well as the high intensity of pain, which is described as devastating or unbearable. In addition, the pain increases rapidly, reaches its maximum after 3-5 minutes and rarely lasts longer than half an hour. The frequency of breakthrough pain attacks varies significantly between patients, with episodes occurring a median of 2-6 times per day.

A distinction is made between idiopathic and incidental pain. This distinction is important because different medication may be used for exercise-induced breakthrough pain than for spontaneous/idiopathic breakthrough pain. Predictable or incidental breakthrough pain can be triggered by voluntary (e.g. lifting or walking), involuntary (e.g. coughing or urinating) or procedure-dependent events (e.g. medical or nursing interventions). Preparations that reach their maximum effect after a delay, such as liquid morphine sulphate in a single-dose container, can be used here. In the case of spontaneous pain, on the other hand, it is essential to use medication that acts quickly.

Recognizing and treating breakthrough pain

Many patients do not report the extent of their pain in detail. It would therefore be ideal if the pain were recorded in a pain diary. In addition to the frequency and intensity of the pain, the accompanying circumstances and potential triggers can also be recorded. Otherwise, standardized questionnaires such as the “Brief Pain Inventory” or the “Breakthrough Pain Assessment Tool” (BAT) are available.

In terms of differential diagnosis, attention must be paid to inadequate analgesic dosing of the basic medication, individually incompatible opiates and an excessively long dosing or administration interval (Table 1). The latter is often the case with round-the-clock analgesia. This “end-of-dose” pain then always occurs shortly before the next planned dose.

The therapy depends on the underlying pain mechanisms. The type of pain should also be taken into account when choosing medication. In principle, opioids, non-opioids and co-analgesics can be considered for the treatment of tumor-related breakthrough pain. The form of administration – intravenous, oral, rectal, sublingual, transmucosal, subcutaneous or local – should be tailored to the needs and preferences of the individual patient and their care situation. An ideal preparation for the treatment of tumor breakthrough pain should have a rapid onset of action, high analgesic potency, short duration of action and ease of administration. Fast-acting fentanyl is therefore recommended as an on-demand medication. It can very quickly and over a sufficiently short period of time reduce the pain peaks in the event of unpredictable breakthrough pain.