Breakthrough Pain: Insights from a Global Working Group
- Credit Type
- CME
- Credit Amount
- 1
- Release Date
- 01/25/2010
- Expiration Date
- 01/24/2011
- Activity Type
- Monograph
Jointly sponsored by Albert Einstein College of Medicine, Montefiore Medical Center, and Asante Communications
This activity is supported by an educational grant from Cephalon, Inc.
Activity Goal
The goal of this activity is to discuss best practices in the assessment, diagnosis, and treatment of persistent and breakthrough pain (BTP).
Intended Audience
This activity is intended for pain specialists, neurologists, rheumatologists, physical medicine and rehabilitation specialists, family practitioners, oncologists, and internal medicine practitioners.
There are no prerequisites for this educational activity.
Statement of Need
Patients with chronic pain commonly experience functionally debilitating exacerbations of their pain levels. In some patients, intermittent pain episodes negatively affect treatment outcomes despite otherwise well-managed chronic pain.1 In an effort to define these severe supervening pain episodes in opioid-treated cancer patients, Portenoy and Hagen introduced the clinical construct of BTP in 1990.2 Since that time, more generalized definitions and various classification criteria have been proposed based on relationships to specific precipitating events or analgesic dosing.3,4 Yet despite general acceptance of BTP as a clinically important phenomenon in both cancer-related and noncancer chronic pain, fundamental definitional, diagnostic, and management issues remain.3,4 Nevertheless, evidence that BTP by itself contributes to adverse patient outcomes necessitates targeted assessment and treatment to reduce its deleterious effects on multiple functional dimensions, including affective, physical, and work-related.1,5 Concomitant evaluations of baseline and BTP are required to appropriately tailor treatment, including disease-modifying approaches, adjustments to baseline regimens, behavioral interventions, and rescue medications.5 Importantly, clinical experience and a growing evidence base suggest that opioids are an important analgesic option in appropriately selected patients with functionally impairing persistent and breakthrough pain.6 Selection of patients for opioid-based multimodal analgesic strategies necessitates careful consideration of pathophysiology, patient-specific treatment goals, risks related to opioid pharmacology, and the ability of the prescriber to structure therapy accordingly and monitor adherence to the pain management plan.7
Learner’s Gap
The clinical construct BTP comprises a heterogeneous spectrum of entities, varying among and at times within patients. Differential diagnosis requires an N-of-1 approach, including comprehensive assessment of transient pain flares and their relationship with background pain, evaluation of functional effects, and consideration of new or progressing pathologies. Clinicians will benefit from an improved understanding of BTP terminology, published evidence supporting assessment and treatment strategies, and expert opinion on how to close gaps in the evidence base.
Learning Objectives
At the completion of this initiative, participants should be better prepared to:
- Conduct multidimensional, semi-structured assessment of chronic pain based, in part, on the phenomenology and inferred pathophysiology, temporal fluctuations, patient function, and treatment goals.
- Differentially diagnose transient pain exacerbations in patients with chronic pain
- Discuss definitions, presentations, and clinical controversies for specific BTP subtypes.
- Develop multimodal opioid-based treatment strategies tailored to multidimensional persistent and BTP assessment as well as the potential for aberrant medication use
Accreditation Statement
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Albert Einstein College of Medicine and Montefiore Medical Center, and Asante Communications. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation
Albert Einstein College of Medicine designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Conflict of Interest Statement
The Conflict of Interest Disclosure Policy of Albert Einstein College of Medicine requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical, product, or device company. Presenters whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity will not be permitted to present.
Albert Einstein College of Medicine also requires that faculty participating in any CME activity disclose to the audience when discussing any unlabeled or investigational use of any commercial product or device not yet approved for use in the United States.
Faculty of this program have indicated the following disclosure information:
Roger Chou, MD
Dr Chou has no conflict of interest to report.
Andrew Davies, MMBS, MSc, MD
Archimedes Pharma Limited; Cephalon Europe; Meda Pharmaceuticals Inc.; Nycomed; ProStrakan Group plc (consultant); Cephalon Europe; Nycomed; ProStrakan Group plc (grant/research support)
Perry G. Fine, MD
Alkermes, Inc.; Ameritox, Ltd.; Cephalon, Inc.; Forest Laboratories, Inc.; King Pharmaceuticals, Inc.; NeuroAdjuvants, Inc.; PriCara [Ortho-McNeil-Janssen Pharmaceuticals]; Purdue Pharma L.P. (consultant); Wyeth (speaker bureau)
Sebastiano Mercadante, MD
Pfizer Inc (grant/research support); Nycomed (consultant); Cephalon, Inc. (consultant, speakers bureau); Grunenthal (consultant; speakers bureau); Janssen (speakers bureau); Mundipharma (consultant, grant/research support); GW Pharmaceuticals (consultant)
Christine Miaskowski, RN, PhD
Endo Pharmaceuticals, Purdue Pharma L.P. (consultant)
Russell K. Portenoy, MD
Adolor; Alpharma Inc.; Ameritox, Ltd.; Archimedes Pharmaceuticals; Baxter; Calloway Labs; Cephalon, Inc.; Endo Pharmaceuticals; Fralex; GW Pharmaceuticals; Grupo Ferrer; Insys Therapeutics; King Pharmaceuticals, Inc.; Neuromed Pharmaceuticals Ltd.; Pfizer Inc; Purdue Pharma L.P.; Shire Pharmaceuticals; Titan; Transcept Pharmaceuticals; United BioSource Corp. (grant/research support); WEX Pharmaceuticals, Inc.; Wyeth; Xenon (consultant)
Giovambattista Zeppetella, MD
Dr. Zeppetella has no conflict of interest to report.
David M. Kaufman, MD CCME Reviewer
Dr Kaufman has no conflict of interest to report.
Albert Einstein College of Medicine, CCME staff, and the staff of Asante Communications have no conflicts of interest with commercial interests related directly or indirectly to this educational activity.
James Kappler, PhD, of Asante Communications, has no conflicts of interest with commercial interests related directly or indirectly to this educational activity.
Steven Jay Feld, of Albert Einstein College of Medicine, or a member of his household own securities in Bioheart, Inc., Chelsea Therapeutics, Inc., and Pharmacopeia, Inc.
Copyright Information
Copyright © 2010 Albert Einstein College of Medicine and Montefiore Medical Center, and Asante Communications. All rights reserved. No part of this syllabus may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embedded in articles or reviews.
References
- Portenoy RK, Bennett DS, Rauck R, et al. Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. J Pain. 2006;7:583-591.
- Portenoy RK, Hagen NA. Breakthrough pain: definition, prevalence and characteristics. Pain. 1990;41:273-281.
- 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;13:331-338.
- Svendsen KB, Andersen S, Arnason S, et al. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain. 2009;9:195-206.
- Fine P. The Diagnosis and Treatment of Breakthrough Pain. 2008: New York, Oxford University Press
- Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
- Portenoy RK. Appropriate use of opioids for persistent non-cancer pain. Lancet. 2004;364:739-40.
Faculty
