Prevalence and characteristics of breakthrough pain in patients receiving opioids for chronic back pain in pain specialty clinics

Daniel S. Bennett, MD; Steven Simon, MD, RPh; Michael Brennan, MD; Steven A. Shoemaker, MD

doi:10.5055/jom.2007.0046

Authors

Daniel S. Bennett, MD
Steven Simon, MD, RPh
Michael Brennan, MD
Steven A. Shoemaker, MD

DOI:

https://doi.org/10.5055/jom.2007.0046

Keywords:

back pain, chronic pain, breakthrough pain, prevalence, survey methodology

Abstract

Objective: We sought to assess the prevalence and characteristics of breakthrough pain (BTP) in patients with chronic back pain.
Design; Researchers utilized a telephone survey using a pain assessment algorithm. This report represents a subset of patients from a larger survey of228patients with chronic pain unrelated to cancer.
Participants: This study employed 117subjects taking opioids for a primary diagnosis of back pain and receiving care at geographically dispersed pain treatment centers. Subjects had pain lasting at least six months and had “controlled” baseline pain.
Results: Eighty-seven subjects (74 percent) experienced 93 types of BTP. The median number of BTP episodes per day was two; median time to maximum intensity was 10 minutes, and median duration was 55 minutes. Onset could not be predicted for 46 percent of pains. Eighty-three percent of subjects used shorter-acting opioids for BTP. Other medications used for pain included NSAIDs, antidepressants, anticonvulsants, skeletal muscle relaxants, intrathecal local anesthetics, and transdermal local anesthetics.
Conclusions: These patients with opioid-treated chronic back pain commonly experienced BTP, which often had a rapid onset and a relatively short duration and was difficult to predict. Opioids were the mainstay of pharmacologic therapy, but nonopioid analgesics and adjuvant analgesics were commonly used.

Author Biographies

Daniel S. Bennett, MD

Integrative Treatment Centers, Denver, Colorado.

Steven Simon, MD, RPh

Pain Management Institute, Overland Park, Kansas.

Michael Brennan, MD

The Pain Center of Fairfield, Fairfield, Connecticut.

Steven A. Shoemaker, MD

Sagemed, Inc., Boulder, Colorado.

References

Walker BF: The prevalence of low back pain: A systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000; 13(3): 205-217.

Webb R, Brammah T, Lunt M, et al.: Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population. Spine. 2003; 28(11): 1195-1202.

Waxman R, Tennant A, Helliwell P: A prospective follow-up study of low back pain in the community. Spine. 2000; 25(16): 2085-2090.

Smith BH, Elliott AM, Chambers WA, et al.: The impact of chronic pain in the community. Fam Pract. 2001; 18(3): 292299.

Guo HR, Tanaka S, Halperin WE, et al.: Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health. 1999; 89(7): 1029-1035.

Portenoy RK, Hagen NA: Breakthrough pain: Definition, prevalence and characteristics. Pain. 1990; 41(3): 273-281.

Caraceni A, Martini C, Zecca E, et al.: Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey. PalliatMed. 2004; 18(3): 177-183.

Fine PG, Busch MA: Characterization of breakthrough pain by hospice patients and their caregivers. J Pain Symptom Manage. 1998; 16(3): 179-183.

Portenoy RK, Payne D, Jacobsen P: Breakthrough pain: Characteristics and impact in patients with cancer pain. Pain. 1999; 81(1-2): 129-134.

Hwang SS, Chang VT, Kasimis B: Cancer breakthrough pain characteristics and responses to treatment at a VA medical center. Pain. 2003; 101(1-2): 55-64.

Zeppetella G, O’Doherty CA, Collins S: Prevalence and char-acteristics of breakthrough pain in patients with non-malignant terminal disease admitted to a hospice. Palliat Med. 2001; 15(3): 243-246.

Portenoy RK, Bennett DS, Rauck R, et al.: Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain. JPain. 2006; 7(8): 583-591.

Simon S, Bennett DS, Rauck R, et al.: Breakthrough pain in opioid-treated patients with neuropathic pain. J Opioid Manag. 2006; 2(6): 347-352.

Large RG, Schug SA: Opioids for chronic pain of non-malignant origin—caring or crippling. Health Care Anal. 1995; 3(1): 5-11.

Portenoy RK: Opioid therapy for chronic nonmalignant pain: A review of the critical issues. J Pain Symptom Manage. 1996; 11(4): 203-217.

Breivik H: Opioids in cancer and chronic non-cancer pain therapy—indications and controversies. Acta Anaesthesiol Scand. 2001; 45(9): 1059-1066.

Mahowald ML, Singh JA, Majeski P: Opioid use by patients in an orthopedics spine clinic. Arthritis Rheum. 2005; 52(1): 312-321.

Hale ME, Dvergsten C, Gimbel J: Efficacy and safety of oxy- morphone extended release in chronic low back pain: Results of a randomized, double-blind, placebo- and active-controlled phase III study. J Pain. 2005; 6(1): 21-28.

Jamison RN, Raymond SA, Slawsby EA, et al.: Opioid therapy for chronic noncancer back pain. A randomized prospective study. Spine. 1998; 23(23): 2591-2600.

Haddox JD, Joranson D, Angarola RT, et al.: The Use of Opioids for the Treatment of Chronic Pain: A Consensus Statement from the American Academy of Pain Medicine and the American Pain Society. Glenview, IL: American Academy of Pain Medicine and American Pain Society, 1997.

Collett BJ: Chronic opioid therapy for non-cancer pain. Br J Anaesth. 2001; 87(1): 133-143.

Bartleson JD: Evidence for and against the use of opioid analgesics for chronic nonmalignant low back pain: A review. Pain Med. 2002; 3(3): 260-271.

Ballantyne JC, Mao J: Opioid therapy for chronic pain. N Engl J Med. 2003; 349(20): 1943-1953.

Fillingim RB, Doleys DM, Edwards RR, et al.: Clinical charac-teristics of chronic back pain as a function of gender and oral opioid use. Spine. 2003; 28(2): 143-150.

Scanlon MN, Chugh U: Exploring physicians’ comfort level with opioids for chronic noncancer pain. Pain Res Manag. 2004; 9(4): 195-201.

Potter M, Schafer S, Gonzalez-Mendez E, et al.: Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. JFam Pract. 2001; 50(2): 145-151.

Morley-Forster PK, Clark AJ, Speechley M, et al.: Attitudes toward opioid use for chronic pain: A Canadian physician survey. Pain Res Manag. 2003; 8(4): 189-194.

Fanciullo GJ, Ball PA, Girault G, et al.: An observational study on the prevalence and pattern of opioid use in 25,479 patients with spine and radicular pain. Spine. 2002; 27(2): 201205.