How to Recognize and Treat Breakthrough Pain (BTP)

Why People Don't Have to Suffer Between Doses of Medication

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What is Breakthrough Pain?

Breakthrough pain (BTP) is the pain that occurs between regularly scheduled doses of pain medication. It is a distressing symptom requiring prompt treatment.

Most patients with chronic pain, including palliative care and hospice patients, are given medication to use as needed to treat breakthrough pain. Medication for BTP is typically fast acting with a relatively short duration of action (usually providing relief for two to four hours).

Unfortunately, studies have shown that although breakthrough pain is common in patients with advanced disease at home, medications to relieve it are not always prescribed, and patients in pain don't always use as much medication to treat their pain as is allowed.

When Does BTP Occur?

Patients experiencing chronic pain are most often prescribed around-the-clock (ATC) doses of an opioid pain medication. Breakthrough pain shows up between these doses of the medication and often causes the patient great distress. It is important to be able to recognize BTP and keep an accurate record of it so that your health care provider, or that of the loved one you're caring for, can treat it properly.

Breakthrough pain has three basic categories: incident pain, spontaneous pain, and end-of-dose medication failure. It's important for your health care provider to recognize which type of BTP you are experiencing, since the treatment for each can be quite different.

Treating Incident Pain

Incident pain is pain that can be predicted and that occurs with specific activities. An example of this is the patient who has pain every time he is turned from side to side for personal care.

Incident pain is often treated proactively. Because the pain is predictable, patients with incident pain can be pre-medicated with a quick-acting, short term-lasting pain medication before activities that cause pain.

The dose may be adjusted based on the level and duration of activity expected to cause pain.

Treating Spontaneous Pain

Spontaneous pain is unpredictable and not associated with any specific activity. Because of its unpredictability, it is often more difficult to treat.

Spontaneous pain is most often treated with a quick-acting, short term-lasting pain medication given as soon as the pain comes. Adjuvant medications may also be tried to offer better pain control. Adjuvant medications include anti-depressants, anti-seizure, and other medications that enhance the pain management of some patients.

Treating End-of-Dose Medication Failure

This is just what it sounds like: pain that occurs toward the end of the time frame in which a medication dose is intended to be effective. For example, in a patient who takes extended release morphine every 12 hours, pain that occurs between the eighth and 10th hour is considered end-of-dose failure.

Treatment of end-of-dose failure may include shortening the interval between doses or increasing the dose of medication.

For example, a patient experiencing pain after eight hours while on a drug intended to offer relief for 12 hours may have the interval between doses decreased to every eight hours, or her dose may be increased by 25 percent to 50 percent.

In all cases, a common medication often used in the hospice setting to treat BTP is oral morphine solution (OMS). OMS is a concentrated liquid form of morphine that begins working quickly and generally provides relief for two to four hours.

Keeping a Record of Breakthrough Pain

The best way to make sure breakthrough pain is being adequately treated is to keep a thorough and accurate medication log. Keeping an accurate record of pain levels, medications used to treat it, and response to the medication will help a health care provider determine the best treatment. Your medication log may look similar to the one below.

Example Breakthrough Pain Medication Log

Date/Time/Pain LevelDec. 8th, 9:00a, pain 5/10Dec. 8th, 5:00p, pain 6/10Dec. 11th, 11:00a, pain 4/10Dec. 12th, 2:00a, pain 6/10
Medication/Dose/Responsemorphine 5mg, pain unrelieved, another 5mg given with reliefmorphine 10mg, pain relievedmorphine 10mg, pain relievedmorphine 10mg, pain relieved

Sources:

Ferrell, BR and Coyle, N; Textbook of Palliative Nursing, Oxford University Press, 2006.

Ferrell BR, McGuire DB, and Yarbro CH; Cancer Pain Management, Jones and Bartlett Publishers, 1995.

Mercadante, C, et. al.; Breakthrough Pain in Advanced Cancer Patients Followed at Home: A Longitudinal Study, Journal of Pain and Symptom Management, Volume 38, Issue 4, Pages 554-560 (October 2009).

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