• Journal of Yeungnam Medical Science
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• v.41 no.1
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• pp.22-29
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• 2024

Breakthrough pain is transitory pain that occurs despite the use of opioids for background pain control. Breakthrough pain occurs in 40% to 80% of patients with cancer pain. Despite effective analgesic therapy, patients and their caregivers often feel that their pain is not sufficiently controlled. Therefore, an improved understanding of breakthrough pain and its management is essential for all physicians caring for patients with cancer. This article reviews the definition, clinical manifestations, accurate diagnostic strategies, and optimal treatment options for breakthrough pain in patients with cancer. This review focuses on the efficacy and safety of rapid-onset opioids, which are the primary rescue drugs for breakthrough pain.

• The Korean Journal of Pain
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• v.26 no.3
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• pp.223-241
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• 2013

Boney metastasis may lead to terrible suffering from debilitating pain. The most likely malignancies that spread to bone are prostate, breast, and lung. Painful osseous metastases are typically associated with multiple episodes of breakthrough pain which may occur with activities of daily living, weight bearing, lifting, coughing, and sneezing. Almost half of these breakthrough pain episodes are rapid in onset and short in duration and 44% of episodes are unpredictable. Treatment strategies include: analgesic approaches with "triple opioid therapy", bisphosphonates, chemotherapeutic agents, hormonal therapy, interventional and surgical approaches, steroids, radiation (external beam radiation, radiopharmaceuticals), ablative techniques (radiofrequency ablation, cryoablation), and intrathecal analgesics.

• Journal of Hospice and Palliative Care
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• v.18 no.1
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• pp.1-8
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• 2015

Breakthrough cancer pain is a transient exacerbation of pain that occurs despite relatively well controlled background pain with around-the-clock analgesia. It is highly prevalent in patients with cancer pain, with an overall prevalence of 70~90%. Breakthrough cancer pain has several negative effects on quality of life, including a decrease in functional status and social relationship, and higher incidence of anxiety/depression. It also places a detrimental burden on their families, society, and the healthcare system. According to the pathogenic mechanism, breakthrough cancer pain is classified into two categories: idiopathic (or spontaneous) pain and incident pain. Episodes of breakthrough cancer pain have typical characteristics, including rapid onset (5~10 min), severe intensity, and short duration (30~60 min). However, there are some variations in timing and severity of pain among patients and episodes. Therefore, a thorough assessment of pain episodes is needed and management plan must be individualized to provide optimal treatment. Several immediate-release formulations such as oxycodone, morphine, and hydromorphone are widely used despite relatively slow onset of action. Recent studies have shown that transmucosal fentanyl preparations were effective for faster control of breakthrough pain. We hope to improve management of breakthrough cancer pain with more efficient analgesics in line with currently available evidence.

• Journal of Hospice and Palliative Care
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• v.20 no.1
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• pp.18-25
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• 2017

Purpose: Adequate control of breakthrough pain is essential for patients with cancer. Managing breakthrough pain mainly depends on understanding the concept of breakthrough pain and the proper usage of rescue medication by physicians. This study aims to assess the attitudes and practice patterns of palliative physicians in managing breakthrough pain for patients in Korea. Methods: This study was based on data from the 2014 breakthrough cancer pain survey conducted by the Korean Society for Hospice and Palliative Care. One hundred physicians participated in the online survey. Among total 33 self-reported questionnaires, twelve items were selected in this analysis. Results: Rapid onset of action is the main influencing factor in selecting rescue opioids. Oral oxycodone (65%) and parenteral morphine (27%) are commonly used. A few physicians (3%) prefer to use transmucosal fentanyl. The percentage of physicians prescribing oral oxycodone due to its rapid onset of action is just 21.5%, whereas the percentage of physicians using parenteral morphine is 81.5%. Two thirds of respondents (66%) answered that breakthrough pain is not well controlled with rescue medications. Conclusion: There is a gap between the needs of physicians in terms of the perceived difficulties of managing breakthrough cancer pain and their practice patterns selecting rescue medications.

• Korean Journal of Clinical Pharmacy
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• v.33 no.1
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• pp.43-50
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• 2023

Background and Objective: With the advancement of cancer treatments and increased life expectancy, managing breakthrough cancer pain (BTcP) is essential to improve the quality of life for cancer patients. This study aimed to compare the major rapid onset opioids in Korea based on their characteristics and costs to determine the best option for each patient. Methods: Based on sales information from IQVIA-MIDAS, sublingual fentanyl tablet (SLF), fentanyl buccal tablet (FBT), and oral transmucosal fentanyl citrate (OTFC) were selected as the top three drugs for the treatment of BTcP in Korea, considering them the most comparable drugs. The cost and cost-pain relief ratio of the drugs for short-term (1 month) and long-term (1 year) treatment were compared and the ease of administration based on various factors, including pharmacokinetics, onset of action, and administration procedures were evaluated. Results: SLF was evaluated as the best overall in terms of rapid onset of action, ease of administration, and drug cost and also had the highest market share. SLF had the lowest cost pain relief ratio for both the initial and supplemental treatment for the 1-month pain intensity difference 15 (PID15) ratio. However, for the 1-month PID30 ratio, SLF was not superior to OTFC or FBT. The longer the breakthrough cancer pain duration, the more cost-effective the other rapid onset opioids. Conclusion: The rapid onset opioids that fit the patient's breakthrough cancer pain pattern have the best cost-effectiveness.

• The Korean Journal of Pain
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• v.35 no.4
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• pp.475-487
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• 2022

Background: Use of opioids for chronic intractable pain is increasing globally, and their proper use can improve patients' quality of life. In contrast, opioid use disorders, such as abuse or addiction, caused by prescribing opioids, are a worldwide issue. This study aimed to understand current opioid prescribing patterns and pain physicians' experiences with opioid use in South Korea. Methods: Pain physicians in 42 university hospitals in South Korea were asked to complete anonymous questionnaires regarding opioid prescriptions. Results: A total of 69 surveys were completed. Most pain physicians started prescribing opioids at a pain score of 7/10 and aimed to reduce pain by 50%. Most physicians (73.1%) actively explained the prescribed medications and possible side effects, and 61.2% of physicians preferred the prescription interval of 4 weeks. Immediate-release opioids were the most popular treatment for breakthrough pain (92.6%). The most common side effect encountered by physicians was constipation (43.3%), followed by nausea/vomiting (34.3%). Of the physicians, 56.5% replied that addiction and misuse prevalences were less than 5%. However, the most concerning side effect was addiction (33.0%). Conclusions: The survey results showed that the prescribing patterns of pain physicians generally followed Korean guidelines. Physicians were most interested in the safety and effectiveness of opioid prescriptions. They were most concerned about respiratory depression and abuse or addiction. A significant number of physicians agreed that the NHIS regulations needed improvement for patient convenience and safe and effective treatment, though there were pros and cons of the NHIS restrictions on prescription conditions.

• Asian Oncology Nursing
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• v.2 no.1
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• pp.36-49
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• 2002

The purpose of this study was to evaluate the effects of the pain management education on pain of the terminal cancer patients at home. For evaluating the effectiveness of the intervention modified Patient Outcome Questionnaire (APS, 1995) including patients concerns with cancer pain management, pain intensity, and interference of daily activities related to pain were measured before and after the education in control group and experimental group and the differences were compared with each other. Satisfaction with pain management was measured after the intervention. Pain management education was delivered to 16 experimental group patients by home care nurses, who were provided with 3-hour education on cancer pain management by one of the researchers. Pain management education included common misconceptions about cancer pain control and pharmacological and non-pharmacological interventions and emphasis was put on the importance of pain reports and patients' active participation in pain management. The results of the study were as follows. Patients concerns with pain management were decreased more greatly in the experimental group than those of the control group. The worst, average, and present pain intensities during the last 24 hours were decreased more greatly in the experimental group, and total score and each subcategory of the interference of daily living, except walking, were decreased more greatly in the experimental group. And satisfaction score with total pain management and nurses response to the pain reports were higher in the experimental group. The results of this study suggest that pain management education given to the patients by home care nurses is a very useful intervention to improve pain of the cancer patients at home. This positive result is thought to derive from patients' active pain report and participation in pain control and the use of powder form sustained release morphine for breakthrough pain control in part. Further studies with increased sample size from more institutions are recommended and early introduction of short acting morphine is strongly suggested for effective cancer pain control.

• The Korean Journal of Pain
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• v.20 no.2
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• pp.190-194
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• 2007

Complex regional pain syndrome (CRPS), which is a syndrome that is defined by pain and sudomotor and/or vasomotor instability, is usually resistant to conventional treatment. Here, a case involving a 30-year-old male patient with CRPS type I who showed severe intractable right shoulder pain with allodynia and hyperalgesia despite being treated with oral medications, nerve blocks including thoracic sympathetic neurolysis, and spinal cord stimulation is described. The patient frequently visited the emergency room due to severe uncontrollable breakthrough pain. Although a favorable effect was observed in response to intermittent ketamine infusion therapies that were performed on an outpatient basis, acute exacerbation of pain occurred frequently during the night and could not be controlled. Therefore, subcutaneous ketamine infusion therapy using a patient-controlled analgesic system was attempted and found to effectively control acute exacerbation of pain during 6 weeks of infusion without serious complications.

• The Korean Journal of Pain
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• v.34 no.2
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• pp.210-216
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• 2021

Background: Postherpetic neuralgia (PHN) is the most common complication of acute herpes zoster. The treatment of PHN remains a challenge for clinical pain management. Despite the effectiveness of anticonvulsants, antidepressants, and lidocaine patches in reducing PHN, many patients still face intractable pain disorders. In this randomized controlled study, we evaluated whether hydromorphone through intravenous patient-controlled analgesia (IV PCA) was effective in relieving PHN. Methods: Patients with PHN were randomly divided into two groups, one group received oral pregabalin with IV normal saline, another group received oral pregabalin with additional IV PCA hydromorphone for two weeks. Efficacy was evaluated at 1, 4, and 12 weeks after the end of the treatments. Results: Two hundred and one patients were followed up for 12 weeks. After treatment, numerical rating scale (NRS) score of patients in the hydromorphone group was significantly lower than that of the control group, and the difference of NRS scores between the two groups was statistically significant at 4 and 12 weeks after treatment. The frequency of breakthrough pain in the hydromorphone group was significantly lower than that in the control group 1 and 4 weeks after treatment. After treatment, the quality of sleep in the hydromorphone group was significantly improved compared with the control group. The most common adverse reactions in the hydromorphone group were dizziness and nausea, with no significant respiratory depression. Conclusions: IV PCA hydromorphone combined with oral pregabalin provides superior pain relief in patients with PHN, which is worthy of clinical application and promotion.

• Journal of Hospice and Palliative Care
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• v.17 no.4
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• pp.270-277
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• 2014

Purpose: This is a retrospective study that investigated cancer patients' complaints of moderate or severe pain to analyze pain characteristics, pain relief interventions and their effects. Methods: The participants of this study were 363 patients who were hospitalized in the cancer ward for three to 30 days and scored 4 points or higher on the pain severity assessment. Results: The most frequent region of pain was the abdomen. The most frequent factor that exacerbated pain was movement. The most frequent pain alleviating factor was administration of analgesics. The most frequent pain type was breakthrough pain, and the most frequent non-pharmaceutical intervention for pain control was heat therapy. Among all, analgesics were routinely prescribed for 52.2% of the participants. Morphine sulfate was the most frequently used analgesic while Gabapentin was the most frequently used non-narcotic analgesic. At the time of discharge, 82.5% of the participants marked their pain intensity as 3 points or lower. Conclusion: For cancer patients complaining of moderate or severe pain, it is important to actively control pain from the beginning of admission. Thus, it is necessary to educate not only cancer patients using narcotic analgesic for pain control and their families but nurses about the effects and side-effects of drugs. Moreover, patients and their families need to learn how to assess and record pain at home to collect data that can be referred for future treatment.