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Drugs & Aging

, Volume 31, Issue 6, pp 405–411 | Cite as

Breakthrough Pain in Elderly Patients with Cancer: Treatment Options

  • Sophie Pautex
  • Nicole Vogt-Ferrier
  • Gilbert B. Zulian
Therapy in Practice

Abstract

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.

Keywords

Pregabalin Cancer Pain Rescue Medication Breakthrough Pain Oral Transmucosal Fentanyl Citrate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgments

No sources of funding were used to assist in the preparation of this article. Sophie Pautex, Nicole Vogt-Ferrier and Gilbert B. Zulian have no conflict of interests to report.

References

  1. 1.
    Davis MP, Srivastava M. Demographics, assessment and management of pain in the elderly. Drugs Aging. 2003;20:23–57.PubMedCrossRefGoogle Scholar
  2. 2.
    Balducci L, Beghe C. Cancer and age in the USA. Crit Rev Oncol Hematol. 2001;37:137–45.PubMedCrossRefGoogle Scholar
  3. 3.
    Bruera E, Kim HN. Cancer pain. JAMA. 2003;290:2476–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Portenoy RK, Lesage P. Management of cancer pain. Lancet. 1999;353:1695–700.PubMedCrossRefGoogle Scholar
  5. 5.
    Mercadante S, Arcuri E. Pharmacological management of cancer pain in the elderly. Drugs Aging. 2007;24:761–76.PubMedCrossRefGoogle Scholar
  6. 6.
    AGS Panel. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205–24.CrossRefGoogle Scholar
  7. 7.
    Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81:129–34.PubMedCrossRefGoogle Scholar
  8. 8.
    Caraceni A, Martini C, Zecca E, Portenoy RK, Ashby MA, et al. Breakthrough pain characteristics and syndromes in patients with cancer pain: an international survey. Palliat Med. 2004;18:77–83.CrossRefGoogle Scholar
  9. 9.
    Zeppetella G. Impact and management of breakthrough pain in cancer. Curr Opin Support Palliat Care. 2009;3:1–6.PubMedCrossRefGoogle Scholar
  10. 10.
    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. Eur J Pain. 2009;13:331–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Davies AN. The management of breakthrough cancer pain. Br J Nurs. 2011;20(803–4):806–7.Google Scholar
  12. 12.
    Davies A, Zeppetella G, Andersen S, Damkier A, Vejlgaard T, et al. Multi-centre European study of breakthrough cancer pain: pain characteristics and patient perceptions of current and potential management strategies. Eur J Pain. 2011;15:756–63.PubMedCrossRefGoogle Scholar
  13. 13.
    American Pain Foundation. Breakthrough cancer pain: mending the break in the continuum of care. J Pain Palliat Care Pharmacother. 2011;25:252–64.PubMedCrossRefGoogle Scholar
  14. 14.
    Deandrea S, Corli O, Consonni D, Villani W, Greco MT, et al. Prevalence of breakthrough cancer pain: a systematic review and a pooled analysis of published literature. J Pain Symptom Manag. 2014;47:57–76.CrossRefGoogle Scholar
  15. 15.
    Davies A, Buchanan A, Zeppetella G, Porta-Sales J, Likar R, et al. Breakthrough cancer pain: an observational study of 1000 European oncology patients. J Pain Symptom Manag. 2013;46:619–28.CrossRefGoogle Scholar
  16. 16.
    Herr K. Pain assessment strategies in older patients. J Pain. 2011;12:S3–13.PubMedCrossRefGoogle Scholar
  17. 17.
    Davies A. Introduction. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 1–11.CrossRefGoogle Scholar
  18. 18.
    Laverty D. Assessment. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 23–30.Google Scholar
  19. 19.
    Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13:e58–68.PubMedCrossRefGoogle Scholar
  20. 20.
    Soares LG, Chan VW. The rationale for a multimodal approach in the management of breakthrough cancer pain: a review. Am J Hosp Palliat Care. 2007;24:430–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Portenoy RK. Treatment of temporal variations in chronic cancer pain. Semin Oncol. 1997;24:S16-7-12.PubMedGoogle Scholar
  22. 22.
    Tracy B, Morrison S. Pain management in older adults. Clin Ther. 2013;35:1659–68.PubMedCrossRefGoogle Scholar
  23. 23.
    Hwang SS, Chang VT, Kasimis B. Cancer breakthrough pain characteristics and responses to treatment at a VA medical center. Pain. 2003;101:55–64.PubMedCrossRefGoogle Scholar
  24. 24.
    Hanks GW, de Conno F, Cherny N, Hanna M, Kalso E, et al. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer. 2001;84:587–93.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Mercadante S, Villari P, Ferrera P, Casuccio A. Optimization of opioid therapy for preventing incident pain associated with bone metastases. J Pain Symptom Manag. 2004;28:505–10.CrossRefGoogle Scholar
  26. 26.
    Kalso E, Heiskanen T, Rantio M, Rosenberg PH, Vainio A. Epidural and subcutaneous morphine in the management of cancer pain: a double-blind cross-over study. Pain. 1996;67:443–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Enting RH, Oldenmenger WH, van der Rijt CC, Wilms EB, Elfrink EJ, et al. A prospective study evaluating the response of patients with unrelieved cancer pain to parenteral opioids. Cancer. 2002;94:3049–56.PubMedCrossRefGoogle Scholar
  28. 28.
    Gannon C, Davies A. Non-opioid drugs. In: Davies A, editor. Cancer-related breakthrough pain. Oxford: Oxford University Press; 2006. p. 83–96.Google Scholar
  29. 29.
    Cleeland CS. Undertreatment of cancer pain in elderly patients. JAMA. 1998;279:1914–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Denny DL, Guido GW. Undertreatment of pain in older adults: an application of beneficence. Nurs Ethics. 2012;19:800–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Ruiz-Garcia V, Lopez-Briz E. Morphine remains gold standard in breakthrough cancer pain. BMJ. 2008;337:a3104.PubMedCrossRefGoogle Scholar
  32. 32.
    Kuo KL, Saokaew S, Stenehjem DD. The pharmacoeconomics of breakthrough cancer pain. J Pain Palliat Care Pharmacother. 2013;27:167–75.PubMedCrossRefGoogle Scholar
  33. 33.
    Jandhyala R, Fullarton JR, Bennett MI. Efficacy of rapid-onset oral fentanyl formulations vs. oral morphine for cancer-related breakthrough pain: a meta-analysis of comparative trials. J Pain Symptom Manag. 2013;46:573–80.CrossRefGoogle Scholar
  34. 34.
    Zeppetella G, Ribeiro MD. Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database Syst Rev. 2006;(1):CD004311.Google Scholar
  35. 35.
    Zeppetella G. Opioids for the management of breakthrough cancer pain in adults: a systematic review undertaken as part of an EPCRC opioid guidelines project. Palliat Med. 2011;25:516–24.PubMedCrossRefGoogle Scholar
  36. 36.
    Coluzzi PH, Schwartzberg L, Conroy JD, Charapata S, Gay M, et al. Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR). Pain. 2001;91:123–30.PubMedCrossRefGoogle Scholar
  37. 37.
    Kharasch ED, Hoffer C, Whittington D. Influence of age on the pharmacokinetics and pharmacodynamics of oral transmucosal fentanyl citrate. Anesthesiology. 2004;101:738–43.PubMedCrossRefGoogle Scholar
  38. 38.
    Likar R, Wittels M, Molnar M, Kager I, Ziervogel G, et al. Pharmacokinetic and pharmacodynamic properties of tramadol IR and SR in elderly patients: a prospective, age-group-controlled study. Clin Ther. 2006;28:2022–39.PubMedCrossRefGoogle Scholar
  39. 39.
    Skaer TL. Practice guidelines for transdermal opioids in malignant pain. Drugs. 2004;64:2629–38.PubMedCrossRefGoogle Scholar
  40. 40.
    Davis MP, Walsh D, Lagman R, LeGrand SB. Controversies in pharmacotherapy of pain management. Lancet Oncol. 2005;6:696–704.PubMedCrossRefGoogle Scholar
  41. 41.
    Vigano A, Bruera E, Suarez-Almazor ME. Age, pain intensity, and opioid dose in patients with advanced cancer. Cancer. 1998;83:1244–50.PubMedCrossRefGoogle Scholar
  42. 42.
    Lennernas B, Hedner T, Holmberg M, Bredenberg S, Nystrom C, et al. Pharmacokinetics and tolerability of different doses of fentanyl following sublingual administration of a rapidly dissolving tablet to cancer patients: a new approach to treatment of incident pain. Br J Clin Pharmacol. 2005;59:249–53.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Mercadante S, Prestia G, Casuccio S. The use of sublingual fentanyl for breakthrough pain by using doses proportional to opioid basal regimen. Curr Med Res Opin. 2013;29:1527–32.PubMedCrossRefGoogle Scholar
  44. 44.
    Gomez-Batiste X, Madrid F, Moreno F, Gracia A, Trelis J, et al. Breakthrough cancer pain: prevalence and characteristics in patients in Catalonia, Spain. J Pain Symptom Manag. 2002;24:45–52.CrossRefGoogle Scholar
  45. 45.
    Davies AN, Vriens J, Kennett A, McTaggart M. An observational study of oncology patients’ utilization of breakthrough pain medication. J Pain Symptom Manag. 2008;35:406–11.CrossRefGoogle Scholar
  46. 46.
    Sophie Lussier D, Portenoy RK. Adjuvant analgesics in pain management. In: Doyle D, Hanks G, Cherny N, Calman K, editors. Oxford textbook of palliative medicine. 3rd ed. Oxford: Oxford University Press; 2004. p. 349–78.Google Scholar
  47. 47.
    Semel D, Murphy TK, Zlateva G, Cheung R, Emir B. Evaluation of the safety and efficacy of pregabalin in older patients with neuropathic pain: results from a pooled analysis of 11 clinical studies. BMC Fam Pract. 2010;11:85.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Bauer C, Lahjibi-Paulet H, Somme D, Onody P, Saint Jean O, et al. Tolerability of an equimolar mix of nitrous oxide and oxygen during painful procedures in very elderly patients. Drugs Aging. 2007;24:501–7.PubMedCrossRefGoogle Scholar
  49. 49.
    Paris A, Horvath R, Basset P, Thiery S, Couturier P, et al. Nitrous oxide-oxygen mixture during care of bedsores and painful ulcers in the elderly: a randomized, crossover, open-label pilot study. J Pain Symptom Manag. 2008;35:171–6.CrossRefGoogle Scholar
  50. 50.
    Mercadante S, Sapio M, Villari P. Suprascapular nerve block by catheter for breakthrough shoulder cancer pain. Reg Anesth. 1995;20:343–6.PubMedGoogle Scholar
  51. 51.
    Zeppetella G, Ribeiro MD. Pharmacotherapy of cancer-related episodic pain. Expert Opin Pharmacother. 2003;4:493–502.PubMedCrossRefGoogle Scholar
  52. 52.
    Mercadante S, Arcuri E. Breakthrough pain in cancer patients: pathophysiology and treatment. Cancer Treat Rev. 1998;24:425–32.PubMedCrossRefGoogle Scholar
  53. 53.
    Farquhar-Smith P. Cancer-related bone pain. In: Davies A, editor. Anaesthetic/interventional techniques. Oxford: Oxford Press; 2007. p. 85–97.Google Scholar
  54. 54.
    Burton AW, Reddy SK, Shah HN, Tremont-Lukats I, Mendel E. Percutaneous vertebroplasty—a technique to treat refractory spinal pain in the setting of advanced metastatic cancer: a case series. J Pain Symptom Manag. 2005;30:87–95.CrossRefGoogle Scholar
  55. 55.
    Swanwick M, Haworth M, Lennard RF. The prevalence of episodic pain in cancer: a survey of hospice patients on admission. Palliat Med. 2001;15:9–18.PubMedCrossRefGoogle Scholar
  56. 56.
    Fine PG, Busch MA. Characterization of breakthrough pain by hospice patients and their caregivers. J Pain Symptom Manag. 1998;16:179–83.CrossRefGoogle Scholar
  57. 57.
    Chi GC, Young A. Selection of music for inducing relaxation and alleviating pain: literature review. Holist Nurs Pract. 2011;25:127–35.PubMedCrossRefGoogle Scholar
  58. 58.
    Kwekkeboom KL, Gretarsdottir E. Systematic review of relaxation interventions for pain. J Nurs Scholarsh. 2006;38:269–77.PubMedCrossRefGoogle Scholar
  59. 59.
    Salamon E, Esch T, Stefano GB. Pain and relaxation. Int J Mol Med. 2006;18:465–70.PubMedGoogle Scholar
  60. 60.
    Ducloux D, Guisado H, Pautex S. Promoting sleep for hospitalized patients with advanced cancer with relaxation therapy: experience of a randomized study. Am J Hosp Palliat Care. 2013;30:536–40.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Sophie Pautex
    • 1
  • Nicole Vogt-Ferrier
    • 2
  • Gilbert B. Zulian
    • 3
    • 4
  1. 1.Community Palliative Care Unit, Division of Primary Care, Department of Community Medicine and Primary CareGeneva University HospitalsGenevaSwitzerland
  2. 2.Gerontopharmacology Unit, Division of Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive CareGeneva University HospitalsGenevaSwitzerland
  3. 3.Division of Palliative Medicine, Department of Readaptation and Palliative MedicineGeneva University HospitalsGenevaSwitzerland
  4. 4.Division of Palliative Medicine, Hôpital de Bellerive, DRMPHUGCollonge-BelleriveSwitzerland

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