Understanding Breakthrough Pain
By Jaspal Ricky Singh, MD
People taking narcotic pain medication around the clock may experience
sudden, more intense spikes of pain called breakthrough pain.
Also called flare-ups or flares, breakthrough pain has a distinct pattern.
It typically reaches a peak quickly, then dissipates in less than an hour,
but may last longer.
The term breakthrough pain stems from the nature of the pain, which breaks
through the protection offered by narcotic medications.
In a national research study, patients with chronic pain who were being
treated with narcotics reported one to 50 flares a day. The median occurrence
was two per day, and the median length of time for a flare was 45 minutes.1
This article discusses the course of breakthrough pain, medication options,
and other strategies for controlling or reducing the pain.
Breakthrough Pain Is Widespread
Research on breakthrough pain initially focused on people with cancer,
but it is now generally recognized in patients with chronic pain non-cancer
pain as well. A large number of people who experience breakthrough pain
have low back pain or arthritis pain.2
Estimates vary, but medical research indicates breakthrough pain occurs
in about 70% of people with chronic non-cancer pain, and in up to 65%
of people with chronic cancer pain.3
The majority of flares do not have a clear cause, and the unpredictable
nature of the pain can be disruptive and stressful.
In other cases, certain activities can trigger breakthrough pain. Keeping
track of the circumstances preceding a flare can help patients and their
doctors develop a strategy to prevent or minimize the pain. It is often
important to note alleviating and aggravating factors contributing to
Medication to Treat Breakthrough Pain
Rather than use more of the same narcotic used for chronic pain, breakthrough
pain is usually treated with another narcotic medication better suited
due to its sudden onset and short duration. Breakthrough pain often peaks
within 5 to 15 minutes, though there is considerable variation.4
The added medication for breakthrough pain may be a faster-acting version
of the round-the-clock medication or a completely different narcotic.
It is common for people using narcotic medications daily to gradually become
more tolerant of and even physically dependent on the medications.
Undertreatment of Breakthrough Pain
While there has been considerable media attention to the problem of medication
overuse, under-treatment of breakthrough pain can also be an issue.
Fear of addiction among patients, family members, and doctors as well as
safety concerns may discourage some people from getting needed pain relief.
Other times, the patient’s system has developed a tolerance for
a medication, so it is no longer as effective as before. There may also
be problems tolerating additional medications, including unpleasant side effects.
Discussing concerns about pain relief with the doctor is advised.