Introduction to Management of Breakthrough Pain in Cancer Patients

In the first installment of the Management of Breakthrough Pain in Cancer Patients video series, moderator Jeffrey A. Gudin, MD, Director of the Pain Management Center at Englewood Hospital and Medical Center in Englewood, NJ, defines breakthrough cancer pain with the panel, which consists of Charles E. Argoff, MD, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center; Jeri Ashley, RN, MSN, AOCNS, CHPN, System Director for Life Planning and Palliative Medicine Services at Baptist Memorial Health Care Corporation in Memphis, TN; Vitaly Gordin, MD, Professor of Anesthesiology, Associate Vice-Chair of Chronic Pain, and Director of Pain Medicine Division at Penn State Hershey Pain Management; and Marc Rappaport, DO, Medical Oncologist at the Western Connecticut Medical Group in Danbury, CT.

According to Rappaport, the sole oncologist on the panel, there are 3 levels of cancer-related pain: short-onset pain, chronic pain, and fast-acting breakthrough pain “which comes in very short spurts and normally doesn’t have any good target to kind of hit it, except what we already have for the long- and short-acting meds.”

Expanding upon Rappaport’s definition of breakthrough cancer pain, Argoff notes that “a person who has breakthrough pain needs to have well-controlled baseline pain, and so this pain is above and beyond the pain that has been already controlled,” rather than poorly controlled chronic pain. To put it in simpler terms, Ashley adds “most of the time it’s a short spike that can be, in fact, a longer spike requiring short-acting (drugs), with the faster spikes requiring rapid-acting (drugs).”

For cancer patients who visit pain management physicians with an initial complaint of new-onset pain, Gordin says “we need to be very diligent as far as collecting history, doing physical exam, (and) ordering proper diagnostic studies because, by definition, any new cancer patient should be assumed (to have) a recurrence of their disease unless proven otherwise.”

Such diagnostic tools include the Functional Pain Scale, the Brief Pain Inventory, and the MD Anderson Symptom Inventory, all of which pain management physicians use “in order to determine the time relationship, activity relationship, (and) when (the pain) occurs,” Gordin says.