• Successful management of breakthrough pain depends on adequate assessment and reassessment
• Inadequate assessment may lead to ineffective or even inappropriate treatment
• The objectives of assessment are to determine the aetiology and pathophysiology of the pain, and factors that indicate or contraindicate particular treatments
• Inadequate reassessment may lead to the continuance of ineffective or inappropriate treatment.
The successful management of breakthrough pain depends on adequate assessment, appropriate treatment, and adequate reassessment (i.e. assessment of the treatment) (Davies, 2002). Inadequate assessment may lead to utilization of ineffective treatment, or even inappropriate treatment. Similarly, inadequate reassessment may lead to continuance of ineffective/inappropriate treatment (and continuance of pain).
The objectives of assessment are to determine the aetiology of the pain (e.g. cancer-related, non-cancer-related), the pathophysiology of the pain (i.e. nociceptive, neuropathic, mixed), and factors that would indicate/contraindicate particular treatment strategies (e.g. performance status, co-morbidity). The assessment of breakthrough pain is essentially the same as the assessment of background pain.
3.2 Diagnosis of breakthrough pain
A task group of the Association for Palliative Medicine of Great Britain and Ireland defined breakthrough pain as ‘a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain’ (Davies et al., 2009). This definition has been endorsed by other national/international organizations (Davies et al., 2018).
It is important to differentiate patients with uncontrolled background pain experiencing transient exacerbations of that pain, from patients with controlled background pain experiencing episodes of breakthrough pain. Thus, the optimal management of the former scenario is likely to be completely different from the optimal management of the latter scenario.
The task group of the Association for Palliative Medicine of Great Britain and Ireland developed diagnostic criteria for breakthrough pain, based on their definition for breakthrough pain (Figure 3.1) (Davies, 2010). These diagnostic criteria have also been endorsed by other national/international organizations (Davies et al., 2018).
3.3 Assessment of breakthrough pain
The assessment of pain primarily depends on basic clinical skills, that is, taking a detailed history and performing a thorough examination (Davies, 2002). It is important to take a general history, as well as a pain history. In particular, patients should be screened for psychological, spiritual, and social factors that may be contributing to their experience of pain (the concept of ‘total pain’) (Twycross, 1994). Similarly, it is important to perform a general examination, as well as an examination of the painful area. Investigations can be extremely useful in the assessment of pain. Nevertheless, investigations should only be viewed as a part of the assessment process, rather than the main focus of the assessment process. Thus, investigations may produce both false negative results and false positive results.
All patients require a detailed pain history to be taken. The features of the pain that need to be determined include (Davies et al., 2009):
• Quality (character)
• Intensity (severity)
• Duration—this should guide the choice of rescue medication/other interventions
• Exacerbating factors
• Relieving factors
• Response to analgesics—it is essential to determine the response to previous analgesics and particularly the response to opioid analgesics
• Response to other interventions—it is essential to determine the response to previous anti-cancer treatment and to previous non-pharmacological interventions
• Associated symptoms—the presence of other symptoms may help to determine the aetiology of the pain
• Interference with activities of daily living—it is important to ascertain the global impact of the pain. (Activities of daily living can be used as a surrogate marker of the response to treatment.)
All patients require a thorough local examination to be performed. The examination should include a neurological examination, since the presence of neurological signs suggests an underlying neuropathic component to the pain (Bennett, 2001). It can be useful to reproduce the patient’s pain by using so-called provocative manoeuvres (e.g. palpation, passive movement) (Hagen, 1999). However, it is important that the benefits of such manoeuvres (i.e. improved understanding of the pain) outweigh the costs of these manoeuvres (i.e. causation of the pain).
It should be noted that many patients have more than one type of breakthrough pain (Portenoy & Hagen, 1990; Portenoy et al., 1999; Davies et al., 2013). Each breakthrough pain should be individually assessed, since each breakthrough pain may require a different form of treatment.
3.4 Reassessment of breakthrough pain
The primary objective of reassessment is to determine the efficacy and tolerability of any therapeutic intervention. A further objective of reassessment is the identification of significant changes in the breakthrough pain. For example, increasing pain in a bone may represent impending fracture of that bone (which may necessitate a more invasive therapeutic intervention, e.g. surgical stabilization).
There is little consensus on the specific outcome measure that should be used to assess treatment response (de Wit et al., 1999). Nevertheless, it is important that a suitable (individualized) outcome measure is used to assess response in all patients and that the same outcome measure is used to assess response in the patient over time. For example, successful treatment for a patient with spontaneous pain could involve shorter duration of pain episodes (or decreased severity of pain episodes). Equally, successful treatment for a patient with volitional incident pain could involve greater mobility (or ability to undertake activities of daily living).
3.5 Assessment tools
A number of different tools have been developed for the assessment of cancer-related pain (Caraceni et al., 2002). However, these tools invariably focus on the background pain rather than the breakthrough pain. Moreover, most of these tools provide little, or no, information about the breakthrough pain.
Portenoy and Hagen developed the Breakthrough Pain Questionnaire (BPQ) to specifically assess breakthrough pain (Portenoy & Hagen, 1990). The BPQ has not been formally validated, although it has been used in a number of clinical studies (Portenoy & Hagen, 1990; Portenoy et al., 1999). Of note, the BPQ has changed/developed over the years (Russell Portenoy, personal communication). Subsequently, Hagen and colleagues developed the Alberta Breakthrough Pain Assessment Tool to specifically assess breakthrough pain in the research setting (Hagen et al., 2009). The Alberta Breakthrough Pain Assessment Tool has been validated to a limited degree and used in a number of clinical studies (Sperlinga et al., 2015; Hjermstad et al., 2016).
More recently, Webber et al. (2014) developed the Breakthrough Pain Assessment Tool (the ‘BAT’). The BAT was developed for clinical practice, has been formally validated, and is being translated into/validated in a number of different languages (Shin et al., 2017). The BAT is shown in Figure 3.2.
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