Rapid-Onset Opioids for Management of Breakthrough Cancer Pain: Considerations for Daily Practice

Abstract

Background and ObjectiveRapid-onset opioids (ROOs) are effective treatments for breakthrough cancer pain (BTcP) given their rapid onset of action and relatively short duration of analgesia. The aim of this article is to describe specific considerations for the use of ROOs in daily practice, focusing on dose titration and treatment of specific populations.Type of ReviewWe conducted a narrative review on the use of ROOs for BTcP. We selected papers according to the following search terms: “breakthrough cancer pain” and “rapid onset opioids”.ResultsROOs may be considered as the most suitable drugs to treat BTcP and can be used “on-demand”. Several fentanyl formulations are available and have been associated with control of BTcP and with improvement in quality of life. Various titration schemes have been used to optimize ROO dosing; however, a dose-proportional scheme could be considered safe and effective in most patients. Specific formulations may be more suitable for specific patient subgroups; for example, patients with oral mucositis may prefer intranasal to oral formulations. Moreover, elderly patients or those without caregivers should be clearly educated on the use of these formulations. A key element in achieving successful treatment of BTcP is awareness of the barriers to pain management, including poor overall assessment, patient reluctance to take opioids or report pain, and physician reluctance to prescribe opioids.ConclusionA personalized approach is fundamental when prescribing a medication for BTcP, and careful attention should be given to drug choice and route of administration, and to the need for alternative therapeutic options.

Multimodality treatment in recurrent/metastatic squamous cell carcinoma of head and neck: current therapy, challenges, and future perspectives

“…Breakthrough pain in patients with head and neck cancers is characterized by a large number of episodes/day and the predictability, particularly with ingestion of food; thus, it is necessary to set up proper pain therapy based on drugs that meet the needs of patients and allows proper feeding ( 77 ), avoiding oral drugs and preferring transdermal drugs and nasal fentanyl preparations ( 78 ).…”

Scheduled and Breakthrough Opioid Use for Cancer Pain in an Inpatient Setting at a Tertiary Cancer Hospital

“…Traditionally, scheduled long-acting opioids are used for background pain and short-acting immediate-release oral opioids are used on an “as needed” basis to treat breakthrough pain [ 13 , 23 , 24 , 25 ]. There are different types of short- and long-acting opioids, such as Morphine, Hydromorphone, Oxycodone, Methadone, Oxymorphone, and Transdermal and transmucosal Fentanyl, for scheduled and breakthrough pain [ 24 , 26 , 27 ]. In hospitalized cancer patients, the use and ratios of scheduled (SCH) and breakthrough pain or rescue (BTO) opioids have a very wide range [ 24 , 27 , 28 ].…”

“…There are different types of short- and long-acting opioids, such as Morphine, Hydromorphone, Oxycodone, Methadone, Oxymorphone, and Transdermal and transmucosal Fentanyl, for scheduled and breakthrough pain [ 24 , 26 , 27 ]. In hospitalized cancer patients, the use and ratios of scheduled (SCH) and breakthrough pain or rescue (BTO) opioids have a very wide range [ 24 , 27 , 28 ]. Scheduled opioids have no ceiling effect and therefore no dosing limit may be required until they are associated with unmanageable side effects, like constipation, confusion, delirium.…”

Effectiveness of fentanyl buccal soluble film in cancer patients with inadequate breakthrough pain control

“…Given the poor analgesic efficacy of morphine for unpredictable BTcP, rapid-onset opioids (ROOs) are recently considered to be the most suitable medication for "on-demand" treatment of BTcP in cancer patients [12]. Numerous clinical trials and meta-analysis have demonstrated the superior efficacy of transmucosal fentanyl formulations over opioids in counteracting BTcP [13][14][15][16].…”