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Understanding Breakthrough Pain and Flares

(ĐTĐ) – Breakthrough pain (BTP) is a fact of life for many cancer patients. But pain experts are now finding that these sudden, temporary flares of severe pain can affect people with noncancerous conditions as well.


“We are much better now at identifying breakthrough pain, partly because the government requires that we ask if a patient is in pain,” says Naum Shaparin, MD. Shaparin is a pain management specialist at New Jersey Medical School. “Before this ‘fifth vital sign’ became the norm, patients with pain were often missed because the question wasn’t asked.”

And new research confirms that breakthrough pain is common among noncancer patients. A recent study published in the Journal of Opioid Management found that breakthrough pain was more common in patients without cancer than among those with the disease. And the noncancer patients were more impaired than those with cancer.

Breakthrough pain — often called “flares” by doctors or “flare-ups” by patients — is serious enough to upset the lives of people who are already trying to control chronic pain with one or more drugs. BTP is not new pain. It is a more severe episode of the background pain that already exists.

Understanding Breakthrough Pain and Flares

Breakthrough pain is common in patients without cancer

By the Numbers

Findings taken from an American Pain Foundation (APF) survey of cancer-pain patients regarding breakthrough cancer pain confirm that numbers tell the story:

  • More than 80% say that BTP affects the quality of their lives, including their desire to participate in certain activities.
  • More than 70% say that BTP affects their relationships with family members and their ability to perform everyday chores.
  • More than 50% say that BTP has increased their daily medical expenses.

While there aren’t as many hard statistics on noncancer BTP, an increasing body of evidence links it with rheumatoid arthritis, osteoarthritis, migraine headaches, nerve pain, low back pain, shingles, fibromyalgia, and diabetic neuropathy. The list continues to grow.

Why, When, How Often, and How Long

Different things trigger BTP for different people. Sometimes, it just happens for no particular reason. At other times, individuals get flares during certain activities like exercising, coughing, moving after surgery, going to the bathroom, or even during a simple act like dressing.

“Another problem is called end-of-dose failure,” Shaparin tells WebMD. “This happens when a patient is started on a long-acting opioid. Although the medication is supposed to last 12 hours, in some people it lasts less; at times, only eight hours. The person experiences BTP when the long-acting drug is not effective for the intended length of time.”

Whatever the cause, breakthrough pain comes on suddenly, often without warning, and it can happen even if a person is taking medication for chronic pain. It reaches peak intensity within three minutes and normally lasts 30 to 60 minutes.

People with chronic pain who take opioid drugs experience breakthrough pain or severe flares an average of twice a day, or 14 times each week, according to an American Pain Foundation report.

Another study showed that the average noncancer patient had BTP over a period of three-and-a-half years. According to the National Pain Foundation, researchers estimate that more than 80% of people taking long-acting medications for chronic pain experience breakthrough pain.

Drugs Designed for Breakthrough Pain

For a drug to be effective in treating breakthrough pain, it should be:

  • Fast-acting.
  • Flexible enough to get you through the flare, but not much longer.
  • Easy to take.

Short-acting and ultra short-acting drugs to relieve breakthrough pain are available in a variety of forms:

  • Tablets taken by mouth.
  • A lozenge on a handle. This medication dissolves through mucus membranes in the mouth to provide rapid pain relief.
  • A film that dissolves when placed on the inside of the cheek.
  • Injection.
  • Sublingual (under the tongue).
  • Nasal spray.

Over-the-Counter Pain Relief Options

Ibuprofen and naproxen sodium, known as nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen are over-the-counter medications used to treat mild breakthrough pain. Some might argue that breakthrough pain is never mild, but OTC medications shouldn’t be totally dismissed. They might work for some people. Doctors occasionally recommend their use in combination with prescription pain drugs to:

  • Provide a synergistic (combination) effect.
  • Stagger the timing of pain relief drugs.
  • Reduce the amount of narcotics being taken during a relatively short time period.

Side effects of NSAIDs may include upset stomach, nausea, vomiting, heartburn, headache, diarrhea, and/or constipation.

Prescription Medications for Breakthrough Pain

If pain is moderate and not responding to nonsteroidal anti-inflammatory drugs, opioid medications may be used. Opioid medication can be combined with NSAIDs or acetaminophen. Drug options may include oxycodone, hydrocodone, codeine, and others.

For moderate to severe pain, opioid medications are prescribed at higher doses. Medication options may include morphine, fentanyl, oxycodone, and hydromorphone.

Side effects of opioid medications may include drowsiness, nausea, vomiting, dry mouth, and/or constipation. Be sure to talk with your doctor about any side effects you may experience from any medication.

Getting Through a Flare

You can take action to get through a flare that does not necessarily involve hospitals or drugs. Here are some suggestions:

  • Talk with your doctor about the difference between a flare and pain that might need a closer look. Most chronic pain patients know (too well) the difference.
  • Make a list of things that appear to cause flares and when they occur. A pain diary will allow you to discuss the problem in detail with your doctor.
  • Keep an action plan close by in case BTP occurs. The plan might include a change in activities, relaxation or distraction techniques, reminders to use heat or cold applications, or guidelines for short-term changes in medications.
  • Remind yourself that flares are going to happen and rarely call for more tests or visits to the doctor.

Know Your Options

There is a lot about breakthrough pain that we don’t know, but advances in breakthrough pain management are encouraging.

“People who experience breakthrough pain should know that there are good treatment options available,” Shaparin says. “They should get regular evaluations and treatment from their primary care doctor first and then, if needed, from a board-certified pain medicine physician.”


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