The management of breakthrough pain (BTP) should be handled as a separate and distinct aspect of each patient’s pain syndrome. This approach allows the clinician to consider BTP as a therapy challenge separate from the patient’s baseline persistent pain (Figure 1). The treatment of BTP must be based on the individual patient factors uncovered during the pain assessment.
An analogy would be the monitoring of blood glucose in patients with diabetes. Blood glucose monitoring is used to adjust therapy on the basis of the patient’s diet, exercise, and response to pharmacological therapy in the same way that ongoing pain assessments, including the use of a pain diary, are used to tailor the management of BTP. Whereas the short-term, day-to-day objective for diabetic patients is to control blood glucose, the longer-term goal is to slow disease progression with its complications and resultant patient morbidity. Applying the chronic disease-management model to the control of both baseline persistent pain and BTP decreases both the overall morbidity associated with chronic pain and the effect of poorly controlled pain on other medical conditions as well. canada drugs pharmacy
Figure 1 General approach to the management of breakthrough pain (BTP). ATC = around the clock; PRN = as needed; R/O = rule out. (See Part 1 of this series in the May 2005 issue of P&T.)
In Part 1 of this series (see P&T, May 2005), BTP was defined as a transient exacerbation of pain occurring in a patient with otherwise stable, baseline persistent pain. Several subtypes of BTP can produce a spectrum of symptoms. Despite the lack of a validated tool, the assessment of BTP was highlighted in Part 1, with emphasis placed on the role of a pain diary. Part 2 in this issue describes the nonpharmacological and pharmacological management of BTP, with an emphasis on the selection and use of opioids, including a discussion of their efficacy, safety, and cost considerations.
Readily reversible causes of BTP, when present, must be treated. Examples include vertebroplasty or kyphoplasty for a vertebral compression fracture, surgical debulking of a solid tumor, or radiation therapy for bone metastases. This topic is beyond the scope of this paper and is covered elsewhere.