Mr Smith* was a 76 year old gentleman with metastatic carcinoma of the prostate. He presented to the palliative care team with severe pain in the left groin / hip, which was related to progressive osseous metastases and associated pathological fractures (Figure 1a & b). The constant pain (background pain) was controlled using moderate doses of modified-release oral morphine, but he continued to complain of intermittent exacerbations of pain (breakthrough pain). Mr Smith also received a course of radiotherapy, and regular bisphosphonate therapy, although these interventions did not significantly improve the breakthrough pain.

The breakthrough pain was incident in nature, and brought on by weight bearing, i.e. on standing, walking: it came on as soon as he stood up, and would generally last for 20-30 min; the pain was located in the left groin / hip, and radiated to the left knee; it was “agonizing” in nature, and he scored it as 8/10 on a numerical rating scale (where 0/10 = no pain, and 10/10 = worse possible pain); the pain was partially relieved by rest, but not relieved by standard doses of immediate-release oral morphine.

The breakthrough pain was having a significant impact on his quality of life. The patient was avoiding weight bearing (and so walking). As a result he had become more dependent on other people, which in turn affected his self esteem and general mood. The increased dependency on his son had also negatively impacted on their normal relationship. In addition, he had had to curtail his social activities, which resulted in significant boredom and loneliness. Finally, the breakthrough pain was a regular reminder of the nature of the disease, or as he put it that his “body was crumbling beneath him”.

The patient was prescribed a transmucosal fentanyl formulation, which he found to be an effective treatment for the breakthrough pain episodes: he was advised to take the medication when he experienced the pain, and before extended periods of weight bearing (which precipitated the pain). The availability of a dependable intervention resulted in increased activity, increased independence, an improved mood, and (indirectly) an improved relationship with his son.

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* Name changed