Davies, A.N., Dickman, A., Reid, C., Stevens, A.M., Zeppetella, G., & Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. (2009). The management of cancer-related breakthrough pain: Recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. European Journal of Pain, 13(4), 331–338.

The Science Committee of the Association for Palliative Medicine of Great Britain and Ireland convened a task group to produce up-to-date, evidence-based clinical guidelines regarding the management of cancer-related breakthrough pain in adult patients. Literature review provided limited evidence, only case series and expert opinion, and the task group could make no recommendations about any particular intervention.

Face-to-face group meetings initiated the review process and determined the scope of work. A draft set of recommendations was circulated to group members, and all members were in agreement regarding content. Authors did not describe the process of evidence grading or how the recommendations were drafted. A final meeting was held to finalize results. The MEDLINE keywords searched to retrieve reviews were breakthrough pain, incident pain, and episodic pain. The search was for the years 1950–2007. In addition to the MEDLINE search, investigators manually searched reference lists of retrieved papers and major texts. Authors did not specify inclusion or exclusion criteria. Evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) system.

• Authors noted these points regarding breakthrough pain:
  • The definition the authors adopted of the term breakthrough pain was “a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain.” (p. 332)
  • Authors noted that no definition of breakthrough pain is common to much of the work in this area.
  • Breakthrough pain was categorized as either idiopathic (unrelated to a precipitant) and unpredictable or incident (related to an identifiable precipitant).
• Authors noted that the guidelines they provided were based on consensus, not levels of evidence.
• Authors provided a simple algorithm of a dose-titration scheme for opioid rescue medications.

The guidelines make the recommendations that follow.

• Patients with pain should be assessed for the presence of breakthrough pain. Differentiating between uncontrolled background pain and controlled background pain with breakthrough pain is important.
• Patients with breakthrough pain should be assessed specifically for breakthrough pain. Authors note that no assessment tool for breakthrough pain exists, so guidelines recommend assessing breakthrough pain by using standard means of pain assessment.
• Management of breakthrough pain should be individualized—that is, reflect patient-related factors and preferences. In many cases, however, options are limited by availability and affordability of interventions. Guidelines recommend balancing the cost of the intervention with the cost of uncontrolled breakthrough pain.
• Those who determine treatment should consider the underlying cause of pain. Evidence supports the efficacy of cancer treatment in the management of background pain, but no evidence relates to breakthrough pain specifically.
• Caregivers should consider the benefits of avoiding precipitating factors versus treatment of precipitating factors. For example, practical support with activities of daily living and simple adaptation of surroundings could mitigate movement-related pain.
• Those who determine treatment should consider modifying the background analgesic regimen. Modification strategies could include
  • Titration of opioid analgesics.
  • Switching opioid analgesics.
  • Addition of adjuvant analgesics (such as antieleptics for neuropathic pain or antispasmodics for visceral pain).
  • Addition of other adjuvant drugs for relief from the side effects of pain medication.
  • Other strategies (e.g., use of nonanalgesic drugs, anti-inflammatories).
• Opioids are the rescue medication of choice in the management of breakthrough pain. Decisions regarding specific preparations and routes should be based on pain characteristics and the patient’s previous response to opioids. Oral opioids may have a role in breakthrough pain but are not typically the optimal approach.
• Individual titration should determine the dose of opioid rescue medication. Guidelines suggest that the traditional approach—that the dose of opioid rescue medication should be a fixed proportion of the background medication—is not the most effective.
• Nonpharmacologic methods may be useful in the management of breakthrough pain episodes. Guidelines mention rubbing or massage, application of heat or cold, distraction techniques, and relaxation techniques, though authors note that little evidence shows that these methods are effective.
• Nonopioid analgesics may be useful in the management of breakthrough pain episodes. Interventions that have been used include nonsteroidal anti-inflammatory drugs, ketamine, midazolam, and nitrous oxide.
• Intervention techniques may be useful in the management of breakthrough pain. Interventions include neuraxial drug infusion, neural blockade, neuromodulation (e.g., transcutaneous electrical nerve stimulation, or TENS), and interventional radiologic techniques.
• Breakthrough pain, specifically, should be reassessed.
• Patients with pain that is difficult to manage should be referred in a timely manner to a pain specialist or palliative care specialist.

Three members of the task force consult for pharmaceutical companies.

Breakthrough pain is heterogeneous and highly individual; clinicians and caregivers should approach it with these facts in mind. Little evidence guides the management of breakthrough pain. Current teaching is not in concert with recommendations related to the usual practice of prescribing a fixed proportional dose of background opioids as rescue medications. Guidelines point to the need to consider breakthrough pain as an issue separate from background pain. The use of rescue medications is only one aspect of managing breakthrough pain; clinicians should remember other approaches, such as treatment of the underlying causes of the pain. The field of oncology needs research aimed specifically at the management of breakthrough pain.