The management of breakthrough pain should be individualised [1]. The optimal management of breakthrough pain depends on a variety of pain-related factors, including the aetiology of the pain (cancer-related, treatment-related, concomitant illness), the pathophysiology of the pain (nociceptive, neuropathic, mixed), and the clinical features of the pain [2]. Furthermore, the management of breakthrough pain depends on a variety of patient-related factors, including the stage of the disease (early, advanced), the performance status of the patient (good, poor), and the personal preferences of the patient [2].

The successful management of breakthrough pain depends on adequate assessment of the patient [3]. Patients with pain should be assessed for the presence of breakthrough pain, and patients with breakthrough pain should have this pain specifically assessed [1]. The objectives of assessment are to determine the aetiology of the pain, the pathophysiology of the pain, and any factors that would indicate or contra-indicate specific interventions.
The assessment of breakthrough pain is similar in nature to that of the background pain [3].

The management of breakthrough pain includes treatment of the underlying cause of the pain, avoidance / treatment of the precipitating factors of the pain, modification of the background analgesic regimen (“around the clock medication”), use of rescue medication (“breakthrough medication”), use of non-pharmacological methods, and use of interventional techniques [1]. Opioids are the rescue medication of choice in the management of breakthrough pain, although it is important to use an appropriate formulation (and an appropriate dosage) [1].

The successful management of breakthrough pain also depends on adequate re-assessment of the patient [3]. Patients with breakthrough pain should have this pain specifically re-assessed [1]. The objectives of re-assessment are to determine the efficacy of the treatment, the tolerability of the treatment, and any change in the nature of the breakthrough pain. The re-assessment of breakthrough pain is similar in nature to that of the background pain [3].

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For further information see

• 'Breakthrough Pain should be distinguished from Background Pain' by Dr G Zeppetella.
• 'Impact and management of breakthrough pain in cancer' by Dr G Zeppetella.
• 'BTCP Clinical Assessment and Tools' a video presentation by by Dr A Davies.

References

[1]. Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G. The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. European Journal of Pain 2009; 13(4): 331-8.

[2]. Davies A. General principles of management. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 31-42.

[3]. Laverty DM Davies A. Assessment. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 23-30.