Brief overview
- Description: Seizure-like episodes of extreme pain due to an existing disease associated with pain (e.g. cancer)
- Treatment: Fast-acting strong painkillers (“rescue drugs”); supplementary therapy with physiotherapy, for example
- Causes: Often unknown cause; pain peaks may be signs of a worsening of the underlying disease; end-of-dose pain when the maximum dosage of a painkiller is no longer sufficient
- When to see a doctor: When painkillers no longer work with existing pain therapy
- Diagnostics: Medical history; pain assessment using scalable questionnaires; physical examination
What is breakthrough pain?
Breakthrough pain is the term used by doctors to describe a temporary extreme worsening (exacerbation) of pain due to an existing illness, an episode of seizure-like and extremely intense pain.
It is often caused by a tumor disease. It occurs, for example, in patients whose cancer-related persistent pain is actually sufficiently or satisfactorily controlled with medication. However, breakthrough pain is also conceivable in other illnesses that are accompanied by persistent pain – for example chronic pain syndromes such as lumbalgia and others.
Acute, severe, short-lived
Breakthrough pain occurs on average two to six times a day. They usually begin acutely. In 40 to 60 percent of affected patients, the maximum pain intensity is reached three to five minutes after the onset of the attack. These pain peaks are often perceived as unbearable. In two thirds of all cases, the breakthrough pain lasts for up to half an hour.
Spontaneous or with a trigger
(Tumor-related) breakthrough pain can be divided into two groups, depending on whether it arises spontaneously or is triggered by an event:
- Spontaneous (tumor-related) breakthrough pain occurs unexpectedly and unpredictably for the person affected.
- Event-related (tumor-related) breakthrough pain occurs in connection with a specific trigger. These may be conscious or unconscious actions by the patient (walking, eating, coughing, urge to defecate or similar) or a therapeutic measure (wound treatment, positioning, puncture, dressing change and others).
Consequences of breakthrough pain
Regardless of the type of illness that is responsible for breakthrough pain, the pain often has serious consequences for the patient and severely restricts their quality of life. For example, many cancer patients with breakthrough pain develop physical and/or psychological problems.
Frequency of breakthrough pain
Breakthrough pain in cancer occurs frequently. Depending on the exact definition or examination method, between 19 and 95 percent of all tumor patients are affected. In tumor patients who are treated as outpatients or in the home environment in accordance with the guidelines, the figure is around 20 percent.
Breakthrough pain occurs more frequently in certain patient groups, including cancer patients in an advanced stage of the disease, those with spinal pain and patients with a poor general condition.
How is breakthrough pain treated?
Breakthrough pain is treated taking into account the individual needs of the patient. The following aspects are important:
- Treat the actual cause of the pain in the best possible way.
- Avoid or treat factors that trigger pain.
- To alleviate persistent pain, patients are given a suitable painkiller with individual adjustment of the treatment regimen and dosage (“round-the-clock treatment”).
- If breakthrough pain occurs, the patient also receives suitable painkillers (on-demand medication).
- Non-drug therapy methods may also be used, such as acupuncture and talk therapy.
Medication for breakthrough pain
The painkillers of first choice for breakthrough pain are potent WHO level III opioids with a rapid onset of action and non-retarded, i.e. not time-delayed, effect (“rapid-onset opioids”). They are also referred to as “rescue drugs”.
The preparations currently available for breakthrough pain contain the active ingredient fentanyl, among others. They are prepared in such a way that the active ingredient is absorbed via the oral or nasal mucosa. These are, for example, lozenges, sublingual tablets (placed under the tongue) or nasal sprays. New drugs are those that are placed in the cheek (buccal application) and are quickly absorbed through the buccal mucosa.
Other active ingredients include morphine, oxycodone or hydromorphine.
Talk to your doctor about which painkiller is best for you. It is advisable that you or your family carers are well informed about the exact dosage, use and storage of these highly effective preparations.
Ideally, a doctor should also monitor the treatment. He or she will also regularly check whether the use of the painkillers is (still) necessary and appropriate.
Due to the risk of drowsiness following the use of strong painkillers, it is advisable that patients do not drive on the days in question.
In some cases, breakthrough pain is also treated with non-opioid painkillers (non-steroidal anti-inflammatory drugs, metamizole and others) and/or certain other painkillers (such as glucocorticoids).
Causes
There are many possible direct or indirect causes of breakthrough pain. In many cases, an acute worsening of the underlying disease leads to the pain peaks – but not always. Breakthrough pain is also possible in chronic pain syndromes without there being any particular change or worsening of the underlying disease. The cause is then usually unknown, “idiopathic” in medical terminology.
Possible known triggers of breakthrough pain, especially in malignant cancers, are
- A tumor disease itself
- secondary diseases or symptoms caused by a tumor disease, such as a weakening of the immune system (immunosuppression); this in turn may lead to another disease, which is ultimately responsible for the pain. One example is a new infection with the varicella zoster virus that is “dormant” in the body.
- Tumor therapy
When to see a doctor?
Talk to your doctor if the basic medication to alleviate persistent pain is no longer sufficiently effective and you are episodically plagued by severe pain peaks.
Diagnostics
The doctor will first have a detailed discussion with the patient (anamnesis). In addition to general aspects of the patient’s medical history, he is particularly interested in a precise description of the breakthrough pain. For example, it is important to know
- When and where does breakthrough pain occur?
- How does it progress and how long does it last?
- How severe is the breakthrough pain and how does it feel?
- Are there factors that trigger the breakthrough pain or make it worse?
- Are there factors that prevent the breakthrough pain or alleviate it if it is already present?
- Have attempts been made to alleviate the breakthrough pain in any way? If so, what treatments have been tried, have they worked and how have they been tolerated?
- Are there any accompanying physical and/or psychological symptoms?
- How much does the breakthrough pain affect the patient’s everyday life?
There are questionnaires for patients to clarify such questions, for example the German Pain Questionnaire, the German Pain Diary or the DGS Practice Questionnaire for Tumor-Related Breakthrough Pain.