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What is Breakthrough Cancer Pain?

Program: Controlling Cancer Pain & When it Breaks Through
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Andrew Schorr:        

Yeah.  We’re going to talk about the management of that as people take pain medicines. And also, Dr. Passik, besides the pain that someone may have a level – a certain level all the time, it’s not uncommon, maybe more common, that people who are experience pain have what you call breakthrough pain.  Is this sort of a pain flare, if you will?

Dr. Steven Passik:        

Yeah. And again, Rick did a good job of describing that.  I mean, you can have pain that is relatively well controlled on say an opioid regimen like the medicines that Brian was mentioning.

But one movement or even spontaneously or because they’re coughing or because their medicine is not lasting the entire dosing period, all though some people dispute whether that’s truly breakthrough pain. We have arguments about this amongst the academicians, you know, about whether or not that’s truly breakthrough pain or you just need to adjust the background medicine. But a lot of times, patients will have their pain pretty well controlled. But they’ll have these often short lived, often, but not always, very excruciating spikes of pain on top of that.

And they are – they’re tricky because if we raised up, for example, the background dose to cover like the peaks of those – of those excruciating episodes at a time when the patient was not in that much pain, they’re likely to accrue a lot more side effects and be very sedated.  And so there are actually a new class of medicines, of opioid medicines, that are meant to deliver the drugs into the blood really quickly.  And better map on the time course of a breakthrough episode.  So one of the problems we’ve had, I think traditionally, is that we often give people something like a Percocet or a Vicodin or a Lortab or hydrocodone containing drug, pill, and these take 20 to 30 to 40 minutes to work.

And then they hang around for six hours. And if the pain episode really comes on in minutes and goes away within the hour, the drug is too slow to come on and too slow to go off.  And so, there definitely was this kind of pain that needed to be addressed more specifically.  And the drug companies really have jumped in there, and there are two or three or four approved rapid onset opioids, as they’re called, that are out there now.

Andrew Schorr:        

Right.  I know there are some versus taking a pill, which has to go through your digestive system. You have ones now where you can put a little film in your mouth, in your cheek…I think it’s called Onsolis.  Different approaches in your mouth that are absorbed right away, so hopefully that excruciating pain you’re feeling will be treated.  Now, I can imagine that, and I know for me, I don’t have cancer pain, but I know I have a certain movement where oh, my God, if I move it that way by mistake, I’m in big pain. And I’m working on that. But that must be – help people just – it’s a fear I guess you can develop that this is going to come out of nowhere, Dr. Passik.

And – and so that inhibits your quality of life, too.  The fear of a breakthrough pain.

Dr. Steven Passik:        

Absolutely.  And it can be almost paralyzing in a way psychologically. And it’s funny because at – at one time, the only breakthrough pain medicine in this class that we had was the sucker – they used to hate it when we called it a lollipop.  It’s an oralette was the term that the drug company used, but it was a way of delivering a very powerful opioid sentinel through your cheek by rubbing a lollipop like thing on the inside of your cheek. And it’s funny.  I would have patients who would walk around with one in their pockets, sometimes for weeks on end and not use it. But because they knew they had it, that was liberating enough. 

Like they could go to the mall and whatever, and they knew that if they, you know, got a severe episode of pain that they’d be able to treat it and treat it effectively and quickly.  And – and even – you know, and in those days, you know, this lozenge thing had a stick on it and everything.  It wasn’t the most discrete way of doing it.  Now there are, as you say, films that go in the mouth and tablets that dissolve between the gum and the cheek.  All of them are fentanyl-containing products because fentanyl is an ideal drug for delivering through the cheek and through membranes like that. 

But it’s – but to your point, people could walk around with one in their – in their – in their pocket knowing that they had that relief available if they needed it and never have to call on it. And that in itself was liberating because the anxiety was less.

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