Introduction

Chronic pain affects almost half of the general population, about a third of whom experience severe pain.¹ Chronic pain often has 2 components: persistent pain that lasts at least 12 hours and breakthrough pain (BTP), transitory, rapid-onset flares of often excruciating pain occurring in the context of stable persistent pain. Pain that goes either untreated or is incorrectly managed can exacerbate other medical conditions and lead to decreased quality of life, increased utilization of healthcare resources, and substantial economic consequences.²

BTP was first characterized in a study of cancer patients who were treated with opioids for pain. Transient flares of severe or excruciating pain, often occurring several times a day, were reported by 64% of the patients.³ This study established BTP as distinct from persistent pain and common in patients with cancer-related pain. BTP has since been characterized in opioid-treated patients with chronic pain of noncancer origins. In one study, 74% of opioid-treated patients with nociceptive and neuropathic chronic pain experienced BTP.⁴

One of the most substantial public health concerns associated with pain is undertreatment. Despite a growing understanding of BTP, evidence suggests that the management of cancer-related BTP does not always follow recommended guidelines and undertreatment is common.^3,5 BTP has both physical and psychosocial consequences6 and can diminish the sense of physical well-being and interfere with normal activities. Inadequate management of BTP is also associated with increased costs. In a survey of more than 1000 patients, those experiencing BTP required more physician visits and hospitalizations. The total yearly costs of pain-related care were $2400 for patients who did not experience BTP and $12,000 for those who did.⁷ Therefore, use of a comprehensive pain management strategy should result in increased patient well-being and reduced financial burden.

Management strategies for opioid-treated patients with BTP have historically included self-administered, short-acting, immediate-release preparations of opioid analgesics. The desirable pharmacologic profile of agents employed to manage BTP using this “rescue dose” approach are oral formulations of μ-opioid agonists with rapid onset, early peak effects, and a short half-life. Newer opioids developed specifically for BTP in patients treated with opioids for their baseline pain are solid formulations placed between the cheek and gum for buccal absorption, minimizing the time needed for maximum exposure.⁸ Two such agents are oral transmucosal fentanyl citrate and fentanyl effervescent buccal tablets.^9,10 Many clinicians are hesitant to prescribe opioids,¹¹ despite their efficacy, and many patients are not sufficiently treated due to fear of aberrant opioid use behaviors.¹² However, tools are available to monitor the safe use of opioid-based pharmacotherapies^13,14 and to mitigate risk.^15,16

Managed care professionals play a vital role in optimizing access to primary and preventive care while considering how medical services and pharmacotherapies can be used in the most cost-effective manner. This educational activity will update the managed care community on BTP and the opportunities that exist to maximize therapeutic strategies for treating patients with this condition.

1. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet. 1999;354:1248-1252.2. National Pharmaceutical Council. Pain: current understanding of assessment, management, and treatments. 2001. http://www.npcnow.org/resources/PDFs/painmonograph.pdf. Accessed November 20, 2007.

4. Portenoy RK, Bennett DS, Rauck R, et al. Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. J Pain. 2006;7:583-591.

6. Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81:129-134.

8. Portenoy RK, Taylor D, Messina J, Tremmel L. A randomized, placebocontrolled study of fentanyl buccal tablet for breakthrough pain in opioid-treated patients with cancer. Clin J Pain. 2006;22:805-811.

10. Fentora (fentanyl buccal tablet) [package insert]. Salt Lake City, UT: Cephalon, Inc; 2006.

12. Kirsch KL, Whitcomb LA, Donaghy K, Passik SD. Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms with empirical study. Clin J Pain. 2002;18:S52-S60.

14. Akbik H, Butler SF, Budman SH, Fernandez K, Katz NP, Jamison RN. Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP). J Pain Symptom Manage. 2006;32:287-293.

16. Katz NP, Sherburne S, Beach M, et al. Behavioral monitoring and urine toxicology testing in patients receiving long-term opioid therapy. Anesth Analg. 2003;97:1097-1102.

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