30 Apr

ECONOMIC AND QUALITY-OF-LIFEBTP is a common cause of hospital admissions and accounts for 4.4% to 7.6% of readmissions. Patients with BTP have higher direct pain-related costs than patients without BTP ($1,080 vs. $750, respectively) and are approximately 2.5 times more likely to seek care in an emergency department than patients with chronic pain but without BTP.

To reduce the economic and the health-related quality-of-life burden of BTP and pain in general, various strategies have been employed with mixed results. Bookbinder et al. observed improvement in pain-related knowledge and attitudes in nurses but a reduction in patient satisfaction related to pain relief following the implementation of accepted standards. Two other groups of investigators noted a reduction in the hospi-talization rate for uncontrolled pain following staff education and other interventions, although the readmission rate for BTP actually increased in one group. Patient education ini­tiatives have provided favorable results and have been associated with reductions in pain severity, anxiety, and fear of addiction and improved pain-coping skills.

The selection of a management approach to BTP often includes cost as a factor. For BTP, the acquisition costs vary widely with oral IR morphine and other generic formulations that are several-fold less expensive than oral transmucosal fentanyl. Although this is an important consideration, this narrow focus on acquisition cost ignores the impact of a specific therapy on the total cost of care. The importance of total cost of care is underscored by a recent retrospective review that demonstrated that the outpatient use of oral trans-mucosal fentanyl citrate was associated with a reduced need for emergency-department visits, parenteral opioids, and hospitalization. Because the acquisition cost of a specific drug often varies widely among health care organizations and purchasing groups and there are few data describing the effect on the total cost of care for specific therapies for BTP, it is not possible to make ironclad recommendations regarding the preferred therapy for all situations involving BTP.

In general, however, the Consensus Panel believes that the use of an oral IR opioid may be cost-effective in many patients, such as those with slow-onset or prolonged BTP, and may be appropriate for patients with predictable incident BTP who have sufficient warning of anticipated pain. However, oral transmucosal fentanyl citrate may be more cost-effective in patients with rapid-onset idiopathic or unpredictable incident pain, especially if the BTP causes significant impairment of activities of daily living or if it prompts the patient to seek emergency medical care.
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Referral to a Pain Specialist

A primary care clinician can effectively manage most patients with BTP, but referral to a pain specialist might be considered under certain conditions, such as:

  • dose-limiting opioid toxicity in a patient
  • pain that is poorly controlled with IR opioids (oral or oral transmucosal)
  • past or present aberrant drug behavior of the patient
  • patients needing assessment for interventional pain techniques

Medical-Legal Issues

Although the relief of pain and suffering is a core commitment shared by all health care professionals, legal and regulatory issues related primarily to opioids are often cited as barriers to fulfilling this commitment. Because opioids are an important management option and pain relief has become an important societal concern (a fact that has been underscored by the Federation of State Medical Boards [FSMB] in its adoption of the 2004 Model Policy), various organizations and U.S. governmental agencies have established standards and provided guidelines to assist health care professionals in treating patients with a pain syndrome. Although the FSMB makes it clear that inappropriate treatment of pain, including undertreat-ment, is a departure from an acceptable standard of practice, the FSMB also describes appropriate steps that clinicians can take when treating patients with a pain syndrome. These steps are similar to those recommended by the American Academy of Pain Management.
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In general, clinicians can minimize their personal risk of legal and regulatory scrutiny by:

  • using sound assessment and monitoring techniques.
  • adhering to accepted principles of medication prescribing.
  • thoroughly documenting the patient’s medical record.
  • following the regulations of their state and the U.S. Drug Enforcement Administration (DEA).

In August 2004, the DEA issued a statement regarding the prescribing of pain medications, to answer questions frequently asked by health care professionals and law enforcement personnel. Citing misstatements, the DEA subsequently withdrew this announcement and indicated its intent to clarify appropriate principles related to the dispensing of controlled substances for the treatment of pain in a future issue of the Federal Register.


BTP is an important clinical problem commonly experienced by patients with chronic pain. Several subtypes of BTP exist, including incident, idiopathic, and end-of-dose pain. BTP is commonly characterized by severe or excruciating pain that typically peaks within minutes of its onset and remits within 15 to 30 minutes, but the spectrum of clinical presentations may vary. BTP must be assessed separately from baseline persistent pain. A thorough history and physical examination are essential to assess BTP, and the evaluation should take into consideration the pain diary or one or more unidimensional assessment tools.
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The management of BTP involves pharmacological and non-pharmacological measures, coupled with patient education. The initial management of BTP involves addressing readily correctable causes when present. Nonpharmacological measures (pacing, limiting activities, and applying physical medicine techniques) are often effective and prevent many of the complications associated with pharmacological therapy.

Opioids are the mainstay of pharmacological therapy for BTP. The opioid, dose, and route of administration must be tailored for all patients. Oral IR opioids are commonly used for BTP, as their actions are well established and they are relatively inexpensive. Their comparatively slow onset makes them less suitable for most cases of idiopathic or unpredictable incident pain.

The rapid onset of oral transmucosal fentanyl citrate makes it appropriate for most types of BTP, although its acquisition cost is greater than that for oral IR opioids. In addition to efficacy, safety, and acquisition cost, the impact on function and health-related quality of life are important considerations in selecting an opioid for BTP.