A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain

Efficacy of intranasal fentanyl spray versus other opioids for breakthrough pain in cancer

OBJECTIVE

To compare the efficacy of intranasal fentanyl spray (INFS), oral transmucosal fentanyl citrate (OTFC), fentanyl buccal tablet (FBT) and oral morphine (OM) for the treatment of breakthrough cancer pain (BTCP).

METHODS

A systematic literature review (Medline, EMBASE, BIOSIS; 1996-2007) identified six randomised controlled trials (RCTs) investigating the effects of INFS, OTFC, FBT and OM for the treatment of BTCP. The endpoint of interest was pain intensity difference (PID, reported on a 0-10 numeric rating scale [NRS]) up to 60 minutes after intake. Results of all trials were analysed simultaneously with a mixed treatment comparison (extended meta-analysis). MTC can be considered a valid method when included studies are comparable regarding effect modifying baseline patient and study characteristics.

RESULTS

INFS provided the greatest reduction in pain relative to placebo: PID 1.7 points (95% CrI: 1.4; 1.9) at 15 minutes, 2.0 (1.6; 2.3) at 30 minutes, 2.0 (1.5; 2.4) at 45 minutes and 1.9 (1.5; 2.4) at 60 minutes. PID for OTFC and FBT relative to placebo were 0.4 (0.0; 0.8) and 0.5 (0.3; 0.7) at 15 minutes. Both treatments provided a reduction in pain superior to placebo at other time points. INFS displayed a more than 99% probability of providing the greatest pain reduction out of all interventions compared at 15 minutes after intake. This was maintained for any measured time point before 45 minutes when compared to FBT and for any measured time point before 60 minutes when compared to OTFC. Only from 45 minutes onwards did OM show a greater pain reduction than placebo.

CONCLUSION

Based on currently available evidence, INFS is expected to provide the greatest improvement in the treatment of BTCP. Due to its slow onset to effect OM cannot be considered an efficacious treatment for BTCP.

A comparison of intranasal fentanyl spray with oral transmucosal fentanyl citrate for the treatment of breakthrough cancer pain: an open-label, randomised, crossover trial

OBJECTIVE

The efficacy of intranasal fentanyl spray (INFS) was compared with that of oral transmucosal fentanyl citrate (OTFC) for the relief of cancer-related breakthrough pain (BTP) in an open-label, crossover trial.

METHODS

Adult cancer patients receiving stable background opioid treatment and experiencing BTP episodes were recruited from 44 study centres in seven European countries (Austria, France, Germany, Italy, Poland, Spain and the United Kingdom); of the 196 patients enrolled, 139 were randomised to receive INFS followed by OTFC, or vice versa. Patients were titrated to an effective dose of one agent (50, 100 or 200 microg INFS; 200, 400, 600, 800, 1200 or 1600 microg OTFC) to treat six BTP episodes, then titration and treatment were repeated with the other agent. The primary outcome was patient-recorded time to onset of 'meaningful' pain relief. Secondary outcomes included pain intensity difference (PID) at 10 and 30 minutes (PID(10), PID(30)), sum of PID at 15 and 60 minutes (SPID(0-15), SPID(0-60)), ease of administration, treatment preference and relationship between background opioid dose and effective INFS dose. Additional outcome measures included proportions of episodes with > or =33% and > or =50% pain intensity (PI) reduction, and PID at additional time points.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00496392.

RESULTS

Among the intention-to-treat population (n = 139), median time to onset of 'meaningful' pain relief was 11 minutes with INFS versus 16 minutes with OTFC; 65.7% of patients attained faster time to 'meaningful' pain-relief onset with INFS (p < 0.001). PID was statistically significantly greater for INFS than OTFC from 5 minutes post-dosing. Significantly more INFS-treated breakthrough pain episodes achieved clinically important pain relief (> or =33% and > or =50% PI reduction) up to 30 minutes post-dosing. The proportions of episodes treated with INFS and OTFC achieving a PI reduction of > or =33% at 5 minutes were 25.3% versus 6.8% (p < 0.001), and at 10 minutes were 51.0% versus 23.6% (p < 0.001), respectively; the proportions of episodes treated with INFS and OTFC achieving a > or =50% PI reduction at 5 minutes were 12.8% versus 2.1% (p < 0.001), and at 10 minutes were 36.9% versus 9.7% (p < 0.001), respectively. Higher SPID(0-15) and SPID(0-60) scores were achieved with INFS (p < 0.001). More patients preferred INFS than OTFC (p < 0.001) and more patients found it very easy/easy to use. Both treatments were well tolerated. In the safety population (n = 139), 56.8% (n = 79) of patients experienced > or =1 AE during the trial. The only AE that occurred in > or =5% of patients in either treatment group was nausea. Among those patients who experienced serious AEs (13.7%, n = 19), none were considered to be related to either study medication. There was a weak correlation between effective INFS doses and background opioid doses.

CONCLUSION

In this open-label, randomised, crossover trial, significantly more patients attained faster 'meaningful' pain relief with INFS than OTFC, and more patients preferred INFS to OTFC.

A review of the role of emergency nurses in management of chemotherapy-related complications

AIMS AND OBJECTIVES

To examine the role of emergency nurses in caring for patients who receive chemotherapy in ambulatory oncology settings. Reasons for emergency department presentations are examined, specific sources of clinical risk for patients receiving chemotherapy who require emergency care are discussed and cost implications of emergency department presentations related to chemotherapy are analysed.

BACKGROUND

Given the increased administration of chemotherapy in ambulatory settings, emergency nurses play an important role in the management of patients undergoing adjuvant chemotherapy. Emergency departments are the major entry point for acute inpatient hospital care of complications arising from chemotherapy.

DESIGN

Systematic review.

RESULTS

Chemotherapy-related emergency department presentations have considerable clinical and cost implications for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications and reduction in preventable emergency department presentations has significant implications for improving cancer patients' quality of life and reducing the cost of cancer care.

CONCLUSIONS

Nurses are well placed to play a pivotal role in chemotherapy management and lead interventions such as a specialist oncology nursing roles that provide information and support to guide patients through their chemotherapy cycles. These interventions may prevent emergency department presentations for patients receiving chemotherapy in ambulatory settings.

RELEVANCE TO CLINICAL PRACTICE

Patients receiving chemotherapy require access to specialised care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach both within and across nursing specialities may improve care for patients receiving chemotherapy and increase effective use of healthcare resources.

Classification of pain in cancer patients--a systematic literature review

One of the aims of the European Palliative Care Research Collaborative (EPCRC) is to achieve consensus on a classification system for cancer pain. We performed a systematic literature review to identify existing classification systems and domains/items used to classify cancer patients with pain. In a systematic search in the databases Medline and Embase, covering 1986-2006, 692 hits were obtained. 92 papers were evaluated to address pain classification. Six standardised classification systems were identified; three of them systematically developed and partially validated. Both pain characteristics and patient characteristics relevant for cancer pain classification were included in the classification systems. All but one of the standardised systems aim at predicting treatment response or adequacy of treatment. Several domains and items used to describe cancer pain but not formally described as part of a classification system were also identified and systematized. The existing approaches to pain classification in cancer patients are different, mostly not thoroughly validated, and none is widely applied. An internationally accepted classification system for cancer pain could improve research and cancer pain management. This systematic review suggests a need for developing an international consensus on how to classify pain in cancer patients.

Management of breakthrough pain in patients with cancer

Breakthrough pain (BTP) in patients with cancer lacks a consensus definition and is subsequently inadequately diagnosed and assessed, therefore making it more challenging to manage. Cancer pain is generally moderate to severe in intensity and persistent in nature. Despite the problematic definition of BTP, it is generally described as having similar intensity, but may also be transitory and variable in predictability. Most breakthrough analgesia fails to be effective in the time required for BTP. No useful analgesia is therefore provided but drug adverse effects escalate. Cancer pain management relies on the WHO analgesic ladder. The frequency of BTP and its inadequate management means that it has significant adverse effects on patients, their families and those involved in their care. This article outlines a systematic, clinical and evidence-based approach to managing BTP in patients with cancer that emphasizes a holistic approach and an understanding of multidimensional 'total pain'. Guidelines for managing BTP are presented and areas of developing research are identified.

Patients' perceptions of the effectiveness of guided imagery and progressive muscle relaxation interventions used for cancer pain

Relaxation and guided imagery are useful strategies for cancer pain; however, their effects vary from patient to patient. Patients' perceptions of these treatments and factors that contribute to their effectiveness have not previously been described. Data from interviews conducted after a trial of guided imagery and progressive muscle relaxation (PMR) interventions were analyzed to compare patients' perceptions of treatment effects with observed changes in pain scores, and to explore patients' ideas about factors that contributed to the effectiveness of each intervention. Post-study interviews were conducted with 26 hospitalized patients with cancer pain who had completed trials of guided imagery and PMR. In most cases, participants' perceptions of treatment effects matched observed changes in pain scores. Participants described treatment and patient characteristics that influenced effectiveness of the interventions such as active involvement in the intervention, guided instructions, providing a source of distraction, stimulating relaxation, individual abilities and preferences, and pain qualities.

The MERITO Study: a multicentre trial of the analgesic effect and tolerability of normal-release oral morphine during 'titration phase' in patients with cancer pain

Adequate and rapid pain control is one of the main goals of cancer pain treatment. The objective of this study was to assess the effect and tolerability of oral normal-release morphine during the initial phase of treatment in patients with moderate-to-severe cancer pain. Consecutive patients naïve to strong opioids received normal-release morphine 5 or 10 mg every 4 h during the titration phase (first 5 days), depending on previous analgesic therapy. Pain intensity was assessed using an 11-point Numerical Rating Scale (0-10), and data were recorded in a patient-compiled diary. The primary endpoint was the proportion of time with pain control (a reduction of at least 50% with respect to the baseline pain score) during the titration phase. A total of 159 consecutive patients (102 men; mean age 65 years) with cancer-related pain were enrolled. Pain control was observed for 75% (95% CI 70-80) of the follow-up period in the intent-to-treat population. Overall, 50% and 75% of patients achieved pain control within 8 and 24 h after starting normal-release morphine therapy respectively. The mean pain score was 7.63 points at baseline, and decreased to 2.43 and 1.67 points (both P<0.001) at days 3 and 5 respectively. The most commonly reported adverse events were somnolence (24% of patients), constipation (22%), vomiting (13%), nausea (10%) and confusion (7%). Normal-release morphine results in rapid and satisfactory pain control, and is well tolerated, during the strong-opioid titration phase in patients with moderate-to-severe cancer pain.

The efficacy of oxycodone for management of acute pain episodes in chronic neck pain patients

OBJECTIVE

Most treatments of acute pain associated with non-malignant chronic pains are not satisfactory. The aim of this study is to evaluate the efficacy and side effects of oxycondone controlled release (Oxy-CR) in managing chronic neck pain with acute pain episodes.

DESIGN

Randomised, double-blind, stand controlled study. A total of 116 patients were evenly divided into an oxycodone group (Oxy-CR, 5-10 mg and q12 h/day) and a placebo group (placebo, q12 h/day). Patients were assessed for the frequency of pain flares, visual analgesia score (VAS), quality of life (QOL), quality of sleep (QOS) and adverse effects before the treatment and on days 1, 3, 7, 14, 21 and 28 after the treatment. Withdrawal symptoms were monitored during the study, also on the completion of the entire study. The SF-36 was administered at the beginning and the end of the study for each patient.

RESULTS

Compared with the baselines of Oxy-CR and the placebo groups, the frequency of pain episodes and VAS were decreased significantly starting on day 3 of administration of Oxy-CR (p<0.05). Improvements in QOL and QOS were significant on day 3 after treatment with Oxy-CR (p<0.05). The patients who were treated with Oxy-CR reported significantly higher side effects than the patients in the placebo group (p<0.05). However, these side effects started to diminish after day 7 of the treatment. Withdrawal symptoms did not emerge in this study. Most domains of SF-36 were improved in the treated patients at the end of study (p<0.05).

CONCLUSION

Oxycondone controlled release could be an important optional drug for the management of refractory and frequent acute episodes of chronic neck pain in patients who failed to respond to non-opioid conservative treatment.

The Alberta Breakthrough Pain Assessment Tool for cancer patients: a validation study using a delphi process and patient think-aloud interviews

Breakthrough pain is a prevalent cancer pain syndrome, and research is needed to identify more effective interventions to manage it. A validated tool to assess breakthrough pain in a standard and reliable manner is urgently needed to support the conduct of clinical trials in breakthrough pain. To address this need, we developed a breakthrough pain assessment tool for research purposes. The current study was undertaken to gather validity evidence for this breakthrough pain assessment tool, using a Delphi process involving an expert panel review, followed by a think-aloud process involving patients with cancer-related breakthrough pain. Two expert panels were formed: a national panel (within Canada; n=16) and an international panel (including experts from North America, UK, Europe, the Middle East, Australia, and New Zealand; n=22). Each panel participated in one anonymous survey round. Response rates were 56% (national panel) and 73% (international panel). The Delphi process revealed substantial consensus on the content of the tool, which increased between rounds of review. The overall level of agreement with the tool, averaged over the four evaluated aspects of all items, was 80% among national panelists and 88% among international panelists. Nine patients completed the think-aloud study. They were able to understand and complete the tool and provided specific direction on its improvement. The validity evidence gathered in this study suggests the Alberta Breakthrough Pain Assessment Tool is conceptually grounded and is understandable by patients and clinicians. Further validation of this tool as an assessment measure within clinical trials research is warranted.

[Cancer pain management. Basic therapy and treatment of breakthrough pain]

Cancer pain imposes a great burden on patients and results in considerable constraints limiting their quality of life. The basic treatment for chronic pain consists in oral administration of long-acting preparations of various analgesic agents according to a set schedule. In addition to chronic pain, however, about 60% of cancer patients also suffer from breakthrough pain. Rapid-onset and short-acting preparations of highly potent opioids are available for the management of these attacks. To choose the correct analgesic agent, it is essential to take a comprehensive medical history and be aware of the different forms of pain present.

The effects of analgesic prescription and patient adherence on pain in a dutch outpatient cancer population

Insufficient awareness of cancer pain, including breakthrough pain, inadequate analgesic prescriptions, and nonadherence contribute to inadequate cancer pain management. There are insufficient data about the contribution of each of these factors. In a cross-sectional survey among 915 adult cancer outpatients, pain was assessed by the Brief Pain Inventory. Breakthrough pain was defined as a worst pain intensity rated as "7 or more" and an average pain intensity rated as "6 or less" in patients on "around-the-clock" (ATC) analgesics. The Pain Management Index (PMI) was calculated to measure the quality of treatment. Adherence was considered inadequate when below 100% of the dose prescribed. Pain was present in 27% of patients. Worst pain was rated as moderate in 26%, and as severe in 54%. Breakthrough pain was present in 45% of patients with ATC medication. The PMI indicated inadequate treatment in 65% of patients. The proportions of patients adherent to ATC analgesics varied from 59% (tramadol) to 91% (Step 3 opioids). The management of cancer pain will benefit most from improving analgesic prescriptions and patient adherence.

Actiq: an effective oral treatment for cancer-related breakthrough pain

As a result of improved survival in cancer and the transfer of care from hospital to primary care, community nurses are taking increasing responsibility for the management of patients at all stages of the disease. Persistent or background pain is common, but between 40% and 80% of patients with advanced cancer also experience breakthrough pain (BTP), a sudden, rapidly escalating flare of pain occurring against a background of otherwise well-controlled persistent pain. While background pain can be successfully managed in most patients, BTP presents a particular challenge to community nurses, because short-acting, 'normal release' oral opioid drugs are absorbed too slowly to treat the typical episode. As this article explains, Actiq is an effective strong opioid with a rapid onset and short duration of action that closely matches the characteristics of an episode of BTP.

Treating cancer-related breakthrough pain: the oral transmucosal route

Between 40 and 80% of patients with advanced cancer experience breakthrough pain (BTP), a sudden, rapidly escalating flare of pain occurring against a background of otherwise well-controlled persistent pain. Patients often have up to four episodes of BTP each day, with a typical episode reaching its peak intensity in three to five minutes and lasting about 30 minutes in total. It is essential to provide fast and effective relief since BTP reduces the quality of life of patients and their families, and increases health care costs. The usual approach is to treat BTP with a short-acting, 'normal release' oral opioid, but this is absorbed too slowly to treat the typical episode of BTP. As this article explains, oral transmucosal fentanyl citrate (Actiq) is an effective strong opioid that has a rapid onset and short duration of action that closely matches the characteristics of an episode of BTP.

Recognition and diagnosis of breakthrough pain

OBJECTIVE

To review major clinical issues related to recognition and diagnosis of breakthrough pain.

ISSUES

Persistent pain and breakthrough pain (BTP) are distinct clinical entities that should be recognized, diagnosed, and treated individually. BTP is common in patients with cancer and a variety of other chronic diseases. Reported incidence of BTP varies widely from 16% to 95% of those with persistent pain syndromes. Such variability is likely due to lack of a clear consensus on the definition of BTP. It is most commonly defined as an abrupt, short-lived, and intense pain that "breaks through" the around-the-clock analgesia that controls persistent pain. The three subtypes of BTP are incident, idiopathic, and end-of-dose failure. BTP also is categorized as somatic, visceral, neuropathic, or mixed. Appropriate assessment of the patient takes into consideration source, severity, pattern, subtype, and cause of pain. Successful treatment is important because BTP has a profound impact on the patient's quality of life, as well as cost of health care. BTP is likely to be underdiagnosed and undertreated because of the lack of consensus on its definition and unwarranted concerns among health care professionals and patients about overmedicating. Additionally, and for reasons not entirely clear, many physicians and other health care providers place a low priority on pain management and underrecognize the occurrence of BTP in patients with persistent pain.

CONCLUSION

Greater knowledge and awareness of BTP in cancer and nonmalignant conditions will lead to improved recognition and diagnosis of BTP and ultimately to more effective treatment and enhanced quality of life for these patients.

Impact of breakthrough pain on quality of life in patients with chronic, noncancer pain: patient perceptions and effect of treatment with oral transmucosal fentanyl citrate (OTFC, ACTIQ)

OBJECTIVE

To characterize breakthrough pain (BTP), its qualitative impact on quality of life (QoL), and the effects of BTP treatment on QoL.

DESIGN

Multicenter patient-reported survey.

SETTING

Five pain treatment centers.

PATIENTS

Fifty-six adults with chronic noncancer pain using oral transmucosal fentanyl citrate (OTFC, ACTIQ).

RESULTS

Forty-three patients qualified for in-depth analysis. BTP had a mean intensity of 9.0 (range 5-10) on an 11-point numerical scale (0 = no pain to 10 = worst possible pain), had a mean duration of 83 minutes, and had an adverse effect on multiple QoL domains. The largest negative QoL impacts were on "general activity level" and "ability to work." OTFC had a positive impact on both controlling BTP and improving QoL.

CONCLUSIONS

BTP appears to be a clinically important condition in this population and is associated with an adverse impact on QoL. Understanding those QoL domains most affected by BTP and those potentially improved with treatment should help in developing quantitative QoL assessment tools and other outcome measures for BTP management studies.

Sublingual Methadone for the Management of Cancer-Related Breakthrough Pain: A Pilot Study

BACKGROUND

Breakthrough pain is a highly prevalent and difficult to manage cancer pain problem. Current strategies are frequently ineffective, in part because of a mismatch between the sudden onset and brief duration of breakthrough pain and the slower onset and more prolonged duration of oral immediate-release opioids. Novel analgesic interventions are needed to provide a closer match between the temporal profile of the pain and the pharmacodynamics of the pain medication, and novel models of study of breakthrough pain are needed to evaluate them.

METHODS

This is an open-label feasibility study of a model to evaluate sublingual methadone for cancer-related breakthrough pain. The model has three phases: screening, upward titration, and optimal dose evaluation.

RESULTS

Seven patients with breakthrough pain because of cancer entered the upward titration phase of the trial, and 61 episodes of breakthrough pain were evaluated with sublingual methadone at escalating doses ranging from 2-18 mg. Toxicity was generally mild and similar to patients' prior breakthrough medication. Four patients entered the optimal dose evaluation phase, and 39 discrete episodes of breakthrough pain were available for evaluation. Significant relief of pain occurred with a median onset of 5 minutes, and no serious adverse events were encountered.

CONCLUSIONS

This model of assessment of breakthrough pain, whereby each episode of pain is treated as a separate data set and multiple discrete episodes of breakthrough pain are assessed every 5 minutes in each patient, appears to be feasible within the cancer pain population. Preliminary results suggest a very rapid onset of relief of breakthrough pain with sublingual methadone when administered at the optimal dose, consistent with a highly favorable early pharmacodynamic profile of methadone administered via this route. Further study is warranted.

Oral transmucosal fentanyl citrate for cancer breakthrough pain: a review

PURPOSE/OBJECTIVES

To review the dose titration, efficacy, and safety of oral transmucosal fentanyl citrate (OTFC).

DATA SOURCES

Phase I and II clinical trial abstracts and evidence-based review articles.

DATA SYNTHESIS

OTFC has an onset, peak, and duration of action similar to that of an IV dose of an opioid and has been demonstrated to be effective and well tolerated for the management of breakthrough pain in patients with cancer.

CONCLUSIONS

Studies of OTFC demonstrate that it is easy to use,noninvasive, effective, safe, and acceptable to patients, caregivers, and healthcare providers. However, OTFC is expensive and approved for use only in opioid-tolerant patients with cancer.

IMPLICATIONS FOR NURSING

Breakthrough pain in patients with cancer is a common problem with characteristics that make it difficult to treat. Oncology nurses should familiarize themselves with OTFC's unique characteristics to be able to best help patients manage their therapy.

A Randomized, Placebo-controlled Study of Fentanyl Buccal Tablet for Breakthrough Pain in Opioid-treated Patients With Cancer

OBJECTIVES

Cancer-related breakthrough pain (BTP) is typically managed with a short-acting oral opioid, taken as needed during a fixed-schedule opioid regimen. The conventional approach may not provide the onset of analgesia required for BTP for many patients, because the onset of analgesia with short-acting opioids lags behind the time course of the majority of episodes of BTP. The fentanyl buccal tablet (FBT) employs a novel delivery system that enhances the rate and extent of absorption of fentanyl through the buccal mucosa. This double-blind, randomized, placebo-controlled study evaluated the efficacy, safety, and tolerability of FBT in opioid-treated patients with cancer-related BTP.

METHODS

After an open-label titration (N=123) to identify an effective FBT dose to treat BTP episodes, 77 patients were randomly assigned to 1 of 18 prespecified dose sequences of 10 tablets (7 FBT and 3 placebo). Pain intensity, pain relief (PR), and global performance of the medication were recorded at regular time intervals between 15 and 60 minutes. Pain intensity differences (PID), the summed PID (SPID), and summed total PR were calculated. The SPID at 30 minutes (SPID30) was the primary efficacy variable. Adverse events were reported.

RESULTS

Sixty-five percent (80/123) of patients were titrated to an effective dose. The mean (SE) SPID30 for FBT was 3.0+/-0.12 versus 1.8+/-0.18 for placebo (P<0.0001). Measures of PR, PID, SPID, summed total PR, and patient ratings of global performance of medication significantly favored FBT over placebo at all time points. Adverse events were typical of opioid drugs. Poor oral tolerability was noted in 2 patients.

CONCLUSIONS

FBT is efficacious and safe in the treatment of cancer-related BTP.

Cancer-related breakthrough pain

Breakthrough pain is a common problem in patients with cancer, and is associated with significant morbidity among this group of patients. This review examines the different types of breakthrough pain, and the various options for the management of breakthrough pain.

Oxcarbazepine in painful diabetic neuropathy: results of a dose-ranging study

OBJECTIVES

To evaluate the efficacy and safety of oxcarbazepine in patients with diabetic neuropathy in a multicenter, double-blind, placebo-controlled, dose-ranging 16-week study.

METHODS

A total of 347 patients were randomized to oxcarbazepine 600 mg/day (n = 83), 1,200 mg/day (n = 87), 1,800 mg/day (n = 88), or placebo (n = 89). The primary efficacy variable was change in mean visual analog scale (VAS) score from baseline to the last week of the study.

RESULTS

No difference between any oxcarbazepine group and the placebo group was noted for the primary efficacy variable. Both the 1,200- and 1,800-mg/day groups showed a trend toward statistical significance (P = 0.101, P = 0.096, respectively). Statistically significant differences were found between the oxcarbazepine 1,200-mg/day (P = 0.038) and 1,800-mg/day (P = 0.005) groups and placebo in the overall mean weekly VAS scores for the entire double-blind treatment phase.

CONCLUSIONS

Although the primary efficacy variable did not reach statistical significance, patients taking oxcarbazepine 1,200 and 1,800 mg/day showed improvements in VAS scores compared with placebo. Oxcarbazepine may provide clinically meaningful pain relief in patients with painful diabetic neuropathy.

Opioids for the management of breakthrough (episodic) pain in cancer patients

BACKGROUND

Breakthrough pain is a transient increase in pain intensity over background pain. It is a common and distinct component of cancer pain that can have a negative impact for both the patient and carers' quality of life. Breakthrough pain is usually related to background pain and is typically of rapid onset, severe in intensity, and generally self-limiting with an average duration of 30 minutes. At present the current approach to managing breakthrough pain is using supplemental analgesia (also known as rescue medication) at a dose proportional to the total around-the-clock (ATC) opioid dose.

OBJECTIVES

This review explores and assesses the evidence for the use of opioids in the management of breakthrough pain in patients with cancer.

SEARCH STRATEGY

MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CancerLit (1993 to 2005), CINAHL (1982 to 2005) and Cochrane databases were searched. Handsearching of medical journals and reference from key textbooks was undertaken and drug companies contacted for unpublished data. There was no language restriction. Date of most recent search: January 2005.

SELECTION CRITERIA

Randomized controlled trials of opioids used as rescue medication against active or placebo comparator in patients with cancer pain were included. Outcome measures sought were reduction in pain intensity measured by an appropriate scale, adverse effects, attrition, patient satisfaction and quality of life. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Eligible studies were selected and examined independently by the two reviewers. Full text was retrieved if any uncertainty about eligibility remained. Non-English texts were screened. Quality assessment and data extraction were conducted using standardised data forms. Drug and placebo dose, titration, route and formulation were compared and detail of all outcome measures (if available) recorded.

MAIN RESULTS

Four studies (393 participants) met the inclusion criteria, all were concerned with the use of oral transmucosal fentanyl citrate (OTFC) in the management of breakthrough pain. Two studies examined the titration of OTFC, one study compared OTFC to normal release morphine and one study compared OTFC to placebo.OTFC was shown to be an effective treatment for breakthrough pain. When compared to placebo and morphine, participants gave lower pain intensity scores and higher pain relief scores for OTFC at all time points. Global assessment scores also favoured OTFC.

AUTHORS' CONCLUSIONS

There is evidence that OTFC is an effective treatment in the management of breakthrough pain. The randomised trial literature for the management of breakthrough pain is small and no trials were found for other opioids. Given the importance of this subject, more trials need to be undertaken.

[Safety and efficacy of oral trans-mucosal fentanyl citrate in the long-term treatment of breakthrough pain in oncology patients: the ECODIR study]

INTRODUCTION

Oral trans-mucosal fentanyl citrate (OTFC) is the one drug specifically developed for the management of breakthrough pain. This study assesses the long-term safety and efficacy of OTFC standard clinical conditions. Patients and methods. Six-month observational study performed on cancer patients with episodes of breakthrough pain. Safety was assessed by recording the advent of adverse events and efficacy by the evaluating the intensity of breakthrough pain.

RESULTS

174 cancer patients were recruited into the study. All adverse reactions reported were mild or moderate. OTFC was significantly faster (time to the commencement of pain relief: 12.7 +/- 11.4 vs 32.7 +/- 18.4 minutes; p < 0.001) and potent (post-treatment pain intensity: 3.4 +/- 1.5 vs 4.3 +/- 1.5; p < 0.001) than the previously-used drugs.

CONCLUSIONS

This observational study confirms the good safety profile of OTFC as well as its effectiveness over long-term period treatment of breakthrough pain.

Characterization of the early pharmacodynamic profile of oral methadone for cancer-related breakthrough pain: a pilot study

Methadone is effective for chronic cancer pain, but its early pharmacodynamic profile and effectiveness for breakthrough pain remain uncertain. This was an open-label, non-randomized, crossover study comparing the use of oral methadone for breakthrough pain with patients' usual opioid. Study variables included pain intensity (pretreatment and at 10-minute intervals post treatment), treatment-related side effects, and treatment satisfaction. In 37 discrete episodes of breakthrough pain, onset of analgesic effect of a titrated dose of oral methadone was rapid for all patients; 3 of 6 study patients experienced an onset of relief by 10 minutes post-ingestion. The adverse effect profile of oral methadone was not different from patients' usual 'rescue' opioid, and patients were moderately to completely satisfied with oral methadone as a breakthrough pain medication. These observations suggest that oral methadone can have a rapid onset of analgesic action and may have a legitimate role in the management of cancer-related breakthrough pain.

Oral transmucosal fentanyl citrate in the outpatient management of severe cancer pain crises: a retrospective case series

OBJECTIVE

This retrospective chart review evaluated the efficacy of oral transmucosal fentanyl citrate (OTFC) in an outpatient cancer pain center for patients experiencing severe exacerbations of pain that exceed usual breakthrough pain levels.

PATIENTS

Records were reviewed for all patients who received OTFC at M.D. Anderson's outpatient pain clinic over a three-month time period. OTFC was used in thirty-nine patients experiencing a recent onset of severe pain (> or =7 on a 0-10 scale). All patients had cancer, cancer-related pain syndromes, and were opioid tolerant with an oral morphine equivalent daily dosage (MEDD) of (> or =40 mg/day.

RESULTS

Prior to OTFC treatment, all patients reported a mean pain intensity of 9.0 (SD = 1.2). After OTFC treatment, patients reported a mean intensity of 3.0 (SD = 1.4), a significant reduction in pain intensity (P < 0.001). In most cases, OTFC averted the need for an emergency center visit, parenteral opioids, and hospital admission, which suggests that OTFC may be an effective alternative over intravenous opioids to rapidly titrate analgesia in selected opioid-tolerant cancer patients experiencing severe pain.

Improving cancer care in a Kentucky managed care plan: a case study of cancer disease management

CHA Health (CHA) is a provider-owned managed care plan serving a predominantly rural membership in Kentucky. Quality Oncology, Inc. is a national disease management company specializing in cancer care. This paper reports the results over the first 2 years of a cancer disease management program installed at CHA. The authors also review the evidence-based health services research that has guided the development and implementation of the program. The authors conclude that cancer is a disease state where specialized management can improve efficiency, treatment effectiveness, patient coordination, and outcomes reporting.

Pharmacotherapy of cancer-related episodic pain

Episodic pain is a transient increase in pain intensity over background pain. Episodic pain occurs commonly in cancer patients; it is a heterogeneous phenomenon that is incapacitating, debilitating and can have a significant impact on quality of life. Episodic pain can be difficult to manage; it is often unpredictable, typically of fast onset, of short duration and feels similar to background pain except that it may be more severe. The successful management of episodic pain can only be achieved following a thorough assessment. The subsequent management usually involves both pharmacological and non-pharmacological strategies integrated into the overall care and appropriate for the stage of the patient's disease. Pharmacological management includes the implementation of primary therapies (e.g., chemotherapy for the underlying aetiology of the pain, optimising the scheduled medication (e.g., analgesics and adjuvant analgesics) and specific pharmacological interventions for the episodic pain (e.g., rescue medication).