Here are some examples of patients with cancer and the approaches taken to their breakthrough pain treatment.

John* was a 76 year old gentleman with cancer of the prostate gland. He consulted his oncology team about a new pain in the groin, which was found to be due to spread of the cancer to the bones of the pelvis The constant groin pain (“background pain”) was controlled by taking regular doses of oral morphine, but he continued to complain of intermittent exacerbations of groin pain (“breakthrough pain”). John received some local radiotherapy, but this did not significantly improve the breakthrough pain.    

The breakthrough pain was brought on standing, and more so on walking: the pain came on as soon as he stood up, and although it got a little better as soon as he sat down, it would generally last for 20-30 min at a time; the pain was “agonizing” in nature, and there was nothing he could do to relieve the pain; oral morphine did not help these intermittent exacerbations of the pain.

The breakthrough pain was having a significant impact on his life. He was avoiding standing and walking. As a result he had become increasingly dependent on other people, which in turn affected his self esteem and mood. The increased dependency on his family had also affected the normal family relationships. In addition, he had had to curtail his social activities, which resulted in significant boredom and loneliness.

John was prescribed one of the new generation treatments, which he found to be very effective in treating his breakthrough pain episodes: he was advised to take the medication when he experienced the pain, and before prolonged periods of standing and walking (which precipitated the pain). The availability of a dependable treatment resulted in increased activity, increased independence, an improved mood, and (indirectly) an improved relationship with his family.

Julie* is a 46yr old woman with cancer of the left breast. She developed a recurrence in the root of her neck, which caused pressure on the nerves going to the left arm, and which resulted in progressive pain, altered sensation and reduced function in the left arm. She was treated with chemotherapy, and although the recurrence got considerably smaller, the pain in the arm did not getter significantly better.

She was treated with a number of different painkillers, including paracetamol, morphine and an antidepressant (that is used to treat pain secondary to nerve damage). Most of the time, the pain was well controlled, and Julie was able to lead an essentially normal life.
However, once or twice a day, she would experience distressing episodes of breakthrough pain.

The breakthrough pain could come on at any time, and she could not identify any factors that brought on the pain, or indeed factors that relieved the pain. The pain would only last for 5-10 min, but was so severe that she had to stop whatever she was doing. The pain would shoot down the arm, which felt like it was “on fire” at the peak of the attack. The pain was making her feel depressed, and was an ongoing reminder of the breast cancer.

Julie had tried unsuccessfully several drug treatments, and many non-drug treatments (e.g. massage, cold pack), for the breakthrough pain. She was reviewed by a pain specialist, and started on an antiepileptic drug (that is also used to treat pain secondary to nerve damage). The new drug was very effective, and resulted in much fewer episodes of pain (once a week), and also much less severe episodes of pain.

* Name changed