Breakthrough Pain Overview

What happens when your usual pain therapy doesn't keep the pain away?

Back Pain
Back Pain.

What Is Breakthrough Pain?

Breakthrough pain, also called episodic pain, is the name given to pain (both cancer and non-cancer, although much more is known about the cancer type of breakthrough pain) that comes on very quickly and severely, when you are already being treated with long-acting pain medications.  (The pain "breaks through the usual medication.)  Another name for breakthrough pain is "flare up."  

Flare ups and/or breakthrough pain may become severe enough to disable or immobilize you. They occur in cases of back pain, cancer pain, neuropathic pain, and more.  It is commonly associated with cancer pain. In order for pain to be identified as breakthrough pain, persistent pain must first be present.

Almost all people with persistent back pain experience breakthrough pain.

Breakthrough Pain Symptoms

In their study entitled "Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain," which was published in the October 2009 issue of the British Journal of Anaesthia, Devulder and associates say that breakthrough pain generally takes about 10 minutes to ramp up to full intensity, and that an episode may last up to (a median of) 60 minutes.

If you have nerve-related breakthrough pain, you may experience shorter, more frequent episodes.

This pattern contributes to altered responses to pain and other stimuli in people with nerve pain. Examples of these altered responses include:

Breakthrough pain can confound doctors; one reason for this is that symptoms tend to be subjective.  Sadly, this can lead to missed diagnosis and under treatment.

Breakthrough Pain Medications

Experts on breakthrough pain generally recommend to doctors that they tailor treatments to each individual patient. Breakthrough pain is most often treated with short-acting opioids (narcotics). Medication given for breakthrough pain is referred to as "rescue medication."

There are several types of breakthrough pain, so determining exactly which medication will address yours should be done in partnership with your doctor. Your doctor will need to know about you, your medical history, your back condition, and your recent pain. Keeping a pain chart or diary will likely help you here because it is a form of self-reporting that doctors tend to rely on in their assessments. Your doctor uses the information you give her about pattern, cause (if you have that information), intensity, and onset of the episode(s) to determine which type you have and to match a particular quick-acting opioid medication to it.

Sometimes, breakthrough pain can be predicted. In this case, your doctor may anticipate it in advance and give you short-acting opioids preemptively.

An entirely different type of medication may be given when breakthrough pain cannot be predicted.  This is one of the (many) reasons why it's good to thoroughly communicate your symptoms and medical history to your prescribing physician.

According to Manchikanti, et. al, in a review published in the journal Pain Physician in 2011, not only is there no scientific evidence for the phenomenon of breakthrough pain, but the use of opioids to treat it is suspect.  

The authors report that treatment of (chronic non-cancer) pain with opioid narcotics has escalated in the past decade or so, and assert that the rise in prescribing has led to explosive use by physicians, as well as misuse of the drug, and many complications (called adverse drug events.)

The review found no significant evidence for any type of breakthrough pain in the chronic non-cancer pain medical literature.  The authors comment that increased prescribing of opioids for non-cancer chronic pain can be traced back to the late 1990s when state medical boards began to liberalize the laws around the use of this substance.  Since then, advocacy for opioid prescribing has grown tremendously, with both individual physicians and powerful inpatient and outpatient organizations standing behind this practice.

Non-Drug and At-Home Treatments for Breakthrough Pain

Non-drug treatments may be integrated with opioids for breakthough pain. Your doctor may counsel you to limit your activity, to use ice or heat, or other at-home therapies. She may refer you to physical or massage therapy, or to a specialist for a nerve block.

For integrating lifestyle and alternative therapies into your breakthrough pain management efforts, it is important to speak with your doctor directly.

Sources:

Bennett D, Burton AW, Fishman S, et al. Consensus panel recommendations for the assessment and management of breakthrough pain. Part 1: Assessment. Pharm Ther. 2005.

Bennett D, Burton AW, Fishman S, et al. Consensus panel recommendations for the assessment and management of breakthrough pain. Part 2: Management. Accessed: Dec 2010. P.T. Community

Devulder J, et. al. Impact of opioid rescue medication for breakthrough pain on the efficacy and tolerability of long-acting opioids in patients with chronic non-malignant pain. Br J Anaesth. 2009 Oct;103(4):576-85. Epub 2009 Sep 6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742451/?tool=pubmed

Manchikanti L. Breakthrough pain in chronic non-cancer pain: fact, fiction, or abuse. Pain Physician. March-April 2011. Accessed: June 2016. http://www.ncbi.nlm.nih.gov/pubmed/21412376

McCarberg BH., The treatment of breakthrough pain. Pain Med. 2007 Jan-Feb;8 Suppl 1:S8-13.http://www.ncbi.nlm.nih.gov/pubmed/17280601

Payne, R., MD, Colliflower, E., Recognition and Diagnosis of Breakthrough Pain. Pain Medicine. Vol. 8. Number S1. American Academy of Pain Medicine. Blackwell Publishing Inc. 2007. Accessed Dec 2010. 

Continue Reading