Breakthrough pain

Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.

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Breakthrough pain is a sudden, extremely severe aggravation (exacerbation) of existing pain in cancer patients. They can have an enormous impact on the quality of life and lead to physical, emotional and social complications. Read more about how cancer-related breakthrough pain develops and can be treated here.

Breakthrough pain: description

Cancer-related breakthrough pain is defined by doctors as a temporary extreme aggravation (exacerbation) of pain as a result of a tumor disease. It occurs in patients whose chronic cancer-related pain is actually sufficiently or satisfactorily controlled with medication. So far, however, there is no generally accepted definition of tumor-related breakthrough pain.

Acute, violent, short-lived

Breakthrough pain occurs an average of two to six times a day. Usually they start acutely. In 40 to 60 percent of affected patients, the maximum pain intensity is reached three to five minutes after the start of the attack. These peaks of pain are often felt to be unbearable. In two thirds of all cases, the breakthrough pain lasts for up to half an hour.

Spontaneously or with a trigger

Breakthrough pain caused by tumors can be divided into two groups, depending on whether they arise spontaneously or are triggered by an event:

Breakthrough pain caused by tumors that occurs spontaneously is unexpected and unpredictable for those affected.
Event-dependent tumor-related breakthrough pain is associated with a specific trigger. This can be a conscious or unconscious act of the patient (walking, eating, coughing, urge to defecate, etc.) or a therapeutic measure (wound treatment, positioning, puncture, etc.).

Consequences of breakthrough pain

Regardless of the type of cancer responsible for breakthrough cancer-related pain, the pain can have serious consequences for the patient and severely affect the quality of life. Many cancer patients with breakthrough pain develop physical and / or emotional problems.

These include, for example, restricted mobility, sleep disorders, an increased sense of fear or anxiety disorders as well as depressive moods. In addition, breakthrough pain can lead to social impairment because contact and maintenance of contacts in private and professional life are restricted.

Incidence of breakthrough pain

Breakthrough cancer pain is common. Depending on the exact definition or examination method, between 19 and 95 percent of all tumor patients are affected. In the case of tumor patients who are treated on an outpatient basis or in the home environment in accordance with the guidelines, the figure is around 20 percent.

Breakthrough pain is more common in certain patient populations, including those with advanced cancer, those with spinal pain, and those with poor general health.

Breakthrough pain: causes and possible diseases

Potential triggers for breakthrough pain in cancer patients include:

The tumor itself.
Consequential diseases or symptoms caused by the tumor disease such as a weakening of the immune system (immunosuppression); this in turn can lead to another disease which is ultimately responsible for the pain. One example is a renewed infection with the varicella-zoster virus that is “dormant” in the body).
The tumor therapy.
Other diseases that are not causally related to the cancer.

Breakthrough pain must be distinguished from other possible causes of aggravation of the pain. These include, for example, the progression of the tumor disease, the development or emergence of new clinical pictures (such as a cancer-related vertebral body fracture) and the failure of previously adequate pain therapy (e.g. because the body is becoming increasingly insensitive to the pain medication used).

Breakthrough pain: when should you see a doctor?

Talk to your doctor if the basic medication to relieve persistent pain is no longer effective and you are episodically plagued by severe pain peaks.

Breakthrough Pain: What Does the Doctor Do?

The doctor will first have a detailed discussion with the patient (anamnesis). In addition to general aspects of the medical history, he is particularly interested in a precise description of the breakthrough pain. For example, it is important:

When and where does tumor-related breakthrough pain occur?
How do they go and how long do they last?
How severe is the breakthrough pain and how does it feel?
Are there any factors that are triggering or making the breakthrough pain worse?
Are there any factors preventing or relieving the breakthrough pain when it is already there?
Has any attempt been made to alleviate the breakthrough pain in any way? If so, what treatment attempts have been made, have they worked and how have they been tolerated?
Are there any physical and / or emotional symptoms?
How much does breakthrough pain affect the patient's everyday life?

There are questionnaires for patients to clarify such questions, for example the German Pain Questionnaire, the German Pain Diary or the DGS Practice Questionnaire for tumor-related breakthrough pain.

This is followed by a physical examination, which may be supplemented by apparatus-based examination methods.

Breakthrough pain - the treatment

Breakthrough cancer-related pain is treated with a patient's individual needs in mind. The following aspects are important:

The actual cause of the pain should be treated optimally.
Pain-causing factors should be avoided or treated.
To relieve persistent pain, patients receive a suitable pain reliever with an individual adjustment of the application schedule and dosage ("around-the-clock treatment").
If breakthrough pain caused by tumors occurs, the patient is also given suitable pain relievers (reliever medication).
Non-drug therapy methods can also be used, such as acupuncture and talk therapy.

The treatment of breakthrough pain should be embedded in a multimodal and interdisciplinary overall concept. The cancer patient is treated by therapists from various disciplines (oncology, physiotherapy, etc.).

Painkillers for breakthrough pain

Painkillers of first choice for tumor-related breakthrough pain are highly effective opioids of WHO level III with a rapid onset of action and a non-retarded, i.e. non-delayed effect (“rapid-onset opioids”). The preparations currently available for breakthrough pain caused by tumors all contain the active ingredient fentanyl. They are prepared in such a way that the active ingredient is absorbed through the mucous membrane of the mouth or nose. These are, for example, lozenges, sublingual tablets (placed under the tongue) or nasal sprays.

Talk to your doctor about which pain reliever is best for you. You or your family caregivers should be well informed about the exact dosage, use and storage of the highly effective preparations. In addition, the treatment must be carefully monitored by a doctor. He also regularly checks whether the use of painkillers is (still) necessary and sensible.

It is also important that you are aware of the possible risks of opioid pain relievers. On the one hand, the drugs have a high potential for abuse. On the other hand, its use can cause side effects such as nausea, vomiting, tiredness and dizziness. Due to the risk of fatigue after using the strong pain relievers, patients should not drive on those days.

In individual cases, breakthrough pain caused by tumors is also treated with non-opioid pain relievers (non-steroidal anti-inflammatory drugs, metamizole, etc.) and / or certain other pain relievers (such as glucocorticoids).