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

Zeppetella G, Ribeiro MDC

Published Online:

January 21, 2009

Oral transmucosal fentanyl citrate (OTFC) is an opioid and is effective in the management of breakthrough pain. Breakthrough pain is a common and debilitating component of pain in patients with cancer. Clinical trial evidence was sought to determine the effectiveness of opioids in relieving breakthrough pain and the incidence of side effects in these cancer patients. Four trials were identified and included 393 participants; the studies identified examined the use of OTFC in breakthrough pain in cancer patients taking regularly scheduled opioids. All four studies used similar outcome measures. Available data suggest that OTFC is safe and effective (compared to both placebo and morphine) in relieving breakthrough pain. The side effect profile of OTFC is similar to other opioids. Recommendations are made about future clinical trials.

Abstract (click to read)

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 patient and carers' quality of life. Breakthrough pain's 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 current management to 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:

To explore and assess evidence for the use of opioids in the management of breakthrough pain in patients with cancer.

Search strategy:

MEDLINE, EMBASE, CancerLit, CINAHL and Cochrane databases were searched in January 2005. There was no language restriction.

Selection criteria:

Randomized controlled trials (RCTs) 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

This record should be cited as:

Zeppetella G, Ribeiro MDC. Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004311. DOI: 10.1002/14651858.CD004311.pub2

Assessed as up to date:

November 2, 2005

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Primary Review Group:

Pain, Palliative and Supportive Care Group

Health topics:

Cancer > Palliative and supportive care > Symptomatic relief

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

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

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