Breakthrough pain
Breakthrough pain is defined as a sudden and severe flare of pain that occurs despite ongoing analgesic treatment. This type of pain can be particularly common in individuals with chronic pain conditions, especially those with advanced cancer, where studies suggest that between 40 and 80 percent of patients experience it. Breakthrough pain episodes are often unpredictable, can be triggered by movement or other activities, and typically last around 30 minutes, although they can range from seconds to hours. The pain may be sharp and localized or present as an intensified dull sensation. It is often seen just before the next scheduled dose of pain medication, a situation referred to as end-of-dose failure.
Management of breakthrough pain generally involves the use of short-acting medications that can be administered in various forms, including oral, sublingual, or intravenous methods. Rescue medications are recommended to be taken at the first signs of an episode to effectively manage the pain. Beyond pharmacologic options, complementary therapies such as music therapy and relaxation techniques may also provide relief. Understanding breakthrough pain is crucial for patients and caregivers, as it can significantly impact quality of life and treatment outcomes.
On this Page
Subject Terms
Breakthrough pain
ALSO KNOWN AS: Episodic or incident pain
RELATED CONDITIONS: Breakthrough pain may be related to tumor progression or nerve compression as a result of cancer. It may also be a result of a treatment, including surgery, or a variety of painful disorders, such as arthritis.
DEFINITION: Breakthrough pain is a transient and intermittent flare of severe pain that “breaks through” analgesic medications.
Risk factors: Anyone undergoing treatment for trauma, illness, or other painful conditions is at risk for breakthrough pain. Cancer patients, particularly those with advanced disease, are at high risk for breakthrough pain.
Etiology and the disease process: Breakthrough pain generally is the result of whatever is causing a patient’s baseline persistent pain.
Incidence: In the mid-2020s, it was reported that up to 86 percent of people receiving treatment for chronic pain experience breakthrough pain. This includes between 40 and 80 percent of cancer patients, depending on the setting. The frequency of breakthrough pain varies among individuals; most patients with cancer-related pain have several episodes daily. Often, breakthrough pain flares up just before the patient is to take the next dose of pain medication, a phenomenon known as end-of-dose failure.
Symptoms: The severity, duration, and cause of breakthrough cancer pain vary among patients. Typically, breakthrough pain happens fast, with an average duration of approximately thirty minutes, but it may last anywhere from seconds to hours. Breakthrough pain is often unpredictable; it may occur spontaneously or be triggered by an activity, such as coughing or moving. It may manifest as an intensified or all-over dull sensation, or it may be a sharp, localized pain.
Screening and diagnosis: There is no independently validated measurement available for the evaluation of breakthrough pain. Often, doctors still rely on a numerical pain scale to assess breakthrough pain.
Treatment and therapy: Breakthrough pain medications are generally short-acting and work rapidly to control sudden flares of pain. Breakthrough pain medications may be administered in several ways: orally, by injection, intravenously, under the tongue (sublingually), rectally, or transmucosally. Traditionally, intravenously administered opioid derivatives, such as morphine, have been one of the fastest ways to alleviate breakthrough pain. A patient-controlled analgesia device (PCA) allows for convenient intravenous administration of pain medication. One drug that specifically treats breakthrough pain is oral transmucosal fentanyl citrate, which dissolves rapidly (within five to ten minutes) via the mucous membranes. Music therapy and cognitive techniques such as relaxation training, hypnosis, imagery, and distraction may also help relieve breakthrough pain.
Prognosis, prevention, and outcomes: Breakthrough pain medications are often called rescue medicines and are taken only at the time of an episode. It is important to take rescue medications at the earliest signs of breakthrough pain, as pain is harder to control when it is allowed to build up.
Bibliography
Buchanan, Alison, and Andrew Davies. "Breakthrough Cancer Pain: The Current Situation." International Journal of Palliative Nursing, vol. 20.1, 2014, pp. 6–8.
Davies, Andrew N. "Breakthrough Cancer Pain." Anaesthesia, Intensive Care, and Pain Management for the Cancer Patient. Ed. Paul Farquhar-Smith and Tim Wigmore. New York: Oxford UP, 2011, pp. 197–205.
Davies, Andrew N. Cancer-Related Breakthrough Pain. 2nd ed. Oxford: Oxford UP, 2012.
Fine, Perry G. The Diagnosis and Treatment of Breakthrough Pain. New York: Oxford UP, 2008.
Fine, Perry G., and Michael A. Busch. "Characterization of Breakthrough Pain by Hospice Patients and Their Caregivers." Journal of Pain and Symptom Management, vol. 16.3, 1998, pp. 179–83.
Hagen, Neil A., Patricia Biondo, and Carla Stiles. "Assessment and Management of Breakthrough Pain in Cancer Patients: Current Approaches and Emerging Research." Current Pain and Headache Reports, vol. 12.4, 2008, pp. 241–48.
Mercadante, Sebastiano. "Once Again... Breakthrough Cancer Pain: An Updated Overview." Journal of Anesthesia, Analgesia and Critical Care, vol. 3, 2023, doi.org/10.1186/s44158-023-00101-x. Accessed 11 Jun. 2024.
Mercadante, Sebastiano, et al. "Episodic (Breakthrough) Pain: Consensus Conference of an Expert Working Group of the European Association for Palliative Care." Cancer, vol. 94.3, 2002, pp. 832–39.
Taylor, Donald R. Managing Cancer Breakthrough Pain. London: Springer, 2013.
Weatherspoon, Deborah, and Stephanie Watson. “Breakthrough Pain: Medication, Dosing, and Management.” Healthline, 14 Aug. 2018, www.healthline.com/health/breakthrough-pain. Accessed 11 June 2024.
Yeo, Jinseok. "Breakthrough Pain and Rapid-onset Opioids in Patients with Cancer Pain: A Narrative Review." Journal of Yeungnam Medical Science, vol. 41.1, 2024, pp. 22-29.