This information has been reviewed and approved by the OncoLink Editorial Board
Chronic pain, a debilitating condition that lasts at least three months, consists of two components:5
Persistent pain - pain that lasts 12 or more hours each day1
Breakthrough pain (BTP) - pain flares that occur suddenly throughout the day1
Breakthrough pain (BTP) is a sudden flare of pain that "breaks through" the long-acting medication prescribed to treat moderate to severe persistent pain.1,2,3 Up to 86 percent of Americans suffering from cancer-related and other types of chronic pain experience BTP episodes, even when their persistent pain is well-managed.4
The good news is that with proper evaluation and treatment, breakthrough pain - like most pain - can be successfully managed.6
The Facts About Breakthrough Pain
Most people treated for moderate to severe persistent pain experience breakthrough pain, with an average of 4 episodes per day.1,4 Breakthrough pain flares may be caused by disease, treatment, or other unrelated factors.1
Breakthrough pain episodes are often unpredictable, brought on by something as simple as swallowing or coughing ("spontaneous" pain).1
Breakthrough pain flares may occur more regularly when carrying out a specific activity like walking ("incident" pain).1,7
People may also experience breakthrough pain flares as they reach the end of their dose of persistent pain medication.1,2,8
While breakthrough pain flares may vary in length, intensity, or cause, the typical episode reaches peak intensity in as little as 3 minutes and lasts an average of 30 minutes.1
Treating Breakthrough Pain
Breakthrough pain is different from persistent pain and requires different treatment.9 The ideal treatment for breakthrough pain is a strong, short-acting opioid medication that works quickly and lasts about as long as a breakthrough pain episode.10 Breakthrough pain medication is taken on an as-needed basis, as soon as symptoms are experienced.8 Breakthrough pain treatment is prescribed in addition to long-acting medication (usually an opioid) taken around-the-clock to maintain control over persistent pain.11,12
Prescription pain medication have been specifically studied, developed, and approved as breakthrough pain treatment.
Traditional short-acting oral opioid pain medicines (pills, tablets, and liquids) may not act fast enough to treat breakthrough pain flares because they can take 30 to 60 minutes to reach the central nervous system where they must be absorbed to effectively relieve pain.9,13
Treating breakthrough pain flares by simply raising the dose of a long-acting pain medicine can result in overmedication, which in turn may increase side effects such as constipation, sedation, and confusion.9
When evaluating treatment options for breakthrough pain, several factors must be considered: adequacy of persistent pain management; number of pain flares each day; location, predictability, and intensity of breakthrough pain episodes; and satisfaction with rapidity of pain relief from current treatment.
The Consequences of Breakthrough Pain
Untreated breakthrough pain has significant consequences for individual patients, their caregivers, and the healthcare system.
Without treatment, breakthrough pain flares can harm a person's sense of well-being, interfere with daily activities, interrupt disease-related treatment schedules, and even make it more difficult to treat persistent pain.9,14,15
Effective treatment of breakthrough pain is not only good medicine, but also cost-effective. Research has shown that cancer patients with breakthrough pain have medical costs that are five times higher than those without breakthrough pain.16 These findings suggest that the incremental costs associated with proper assessment and management of breakthrough pain may reduce the need for more expensive medical interventions such as hospitalizations and physician visits.
Portenoy RK, Hagen NA. Breakthrough pain: definition and manifestations. Primary Care & Cancer. April 1991: 27-33.
Portenoy RK et al. Oral transmucosal fentanyl citrate (OTFC) for the treatment of breakthrough pain in cancer patients: a dose controlled titration study. Pain. 1999;79:303-312.
Fine PG, Busch MA. Characterization of breakthrough pain by hospice patients and their caregivers. J Pain Symptom Manage. 1998;16(3): 179-83.
Lapcevic JS. Pain management: medical and legal issues of undertreatment. In Weiner RS (Ed.), Pain management: a practical guide for clinicians. Sixth edition. CRC Press LLC. 2002: 915-933.
Levy MH. Pharmacologic treatment of cancer pain. N Engl J Med. 1996;335:1124-1132.
McQuay HJ, Jadad AR. Incident Pain. Cancer Surv. 1994;21:17-24.
Patt RB, Ellison NM. Breakthrough pain in cancer patients: characteristics, prevalence, and treatment. Oncology. 1998; 12(7):1035-1046.
Simmonds MA. Management of breakthrough pain due to cancer. Oncology. 1999;13(8): 1103-1108.
Farrar J et al. Oral transmucosal fentanyl citrate: randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients. J Natl Cancer Inst. 1998;90:611-616.
Supernaw RB. Drug management of pain. In Weiner RS (Ed.), Pain management: a practical guide for clinicians. Sixth edition. CRC Press LLC. 2002:435-448.
Principles of analgesic use in the treatment of acute pain and cancer pain. Fourth edition. American Pain Society. 1999.
Coluzzi PH. Cancer pain management: newer perspectives on opioids and episodic pain. The Am J of Hospice & Palliat Care. 1998;15(1):13-22.
Mercadante S et al. Pain characteristics of advanced lung cancer patients referred to a palliative care service. Pain. 1994;59:141-145.
Bruera E et al. A prospective multicenter assessment of the Edmonton staging system for cancer pain. J Pain Symptom Manage. 1995;10: 348-355.
Fortner BV et al. A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. J Pain. 2002;3(1): 38-44.