For people in chronic pain, sharp spikes of breakthrough pain can be a big problem. What causes it -- and how can you find pain relief? That's an important question for many patients, especially those with cancer.
"Breakthrough pain occurs when you're doing something that triggers extra pain, like getting up after knee surgery," explains Michael Ferrante, MD, director of the UCLA Pain Management Center. "Sometimes breakthrough pain just occurs, without any obvious trigger. In essence, it means the patient needs more medication to cover the chronic pain and another drug for the breakthrough pain."
For those taking narcotics, breakthrough pain might be a sign that the body is developing tolerance to the narcotic, Ferrante says. "Tolerance means you need to take more of the drug over time to achieve the same pain relief."
When a patient develops a narcotic tolerance, the doctor can increase the dosage to provide the same pain relief -- but the risk of side effects gets higher with the higher dose, explains Salahadin Abdi, MD, PhD, chief of pain medicine at the University of Miami School of Medicine.
"Instead of increasing the dosage of that narcotic, a good solution is to change to a different narcotic," Abdi tells WebMD. "You can then use a relatively small dose of the new narcotic to get the same effect. You can switch to yet another narcotic later on if you need to."
Drugs called NMDA antagonists (N-methyl-D-aspartate) have been another advance in narcotics for pain relief, says Rollin M. Gallagher, MD, MPH, director of pain management at the Philadelphia VA Medical Center. NMDA antagonists block NMDA receptors to stop or minimize opioid drug tolerance.
"NMDAs allow us to provide pain relief with a lower dose of a narcotic drug," Gallagher tells WebMD. "Opioids are very effective, very safe, because they don't damage organs like other drugs do -- but you can develop tolerance. NMDAs can help prevent tolerance." Meaning less drugs and better pain relief.
Options for Breakthrough Pain Relief
With cancer pain, an extended-release morphine drug is often prescribed for the underlying pain. A faster-acting narcotic is used to treat the breakthrough pain, Ferrante explains. These are potent, immediate-release narcotics often referred to as rescue medications -- to "rescue the individual from that pain," he says.
Actiq and Fentora contain the narcotic fentanyl, and are FDA-approved for breakthrough cancer pain in adult patients who are already taking other opioid medicines for pain relief:
Actiq comes in a "lollipop" form for people who cannot take pills.
Fentora is a tablet that dissolves in the mouth.
Dilaudid (hydromorphone), MSIR (morphine), oxycodone, and other narcotics can also be prescribed for breakthrough pain relief, says Abdi. "They work similarly, but depending on the severity of breakthrough pain, one may work better than another. These drugs act quickly, then disappear from the system relatively quickly."
"You want something that gets into the bloodstream fast," Ferrante tells WebMD. "That's what breakthrough medication does... you put it in your mouth, and you get a good dose real quick. For people with severe cancer pain, these are really good. They are serious, potent medications."
For less severe breakthrough pain, doctors prescribe two narcotics that also contain acetaminophen (the active ingredient in Tylenol): Percocet (with oxycodone), or Vicodin (with hydrocodone), he adds.
In the pipeline: Ferrante expects even better pain relief medications to become available -- administered via the nose or dissolved under the tongue. "These are excellent ways to get the drug in the bloodstream very, very quickly," Ferrante says.
SOURCES: Michael Ferrante, MD, director, UCLA Pain Management Center. Rollin M. Gallagher, MD, MPH, director of pain management, Philadelphia VA Medical Center. Salahadin Abdi, MD, PhD, chief of pain medicine, University of Miami School of Medicine. Drugs.com: Actiq, Fentora, Percocet, Vicodin, Ionsys. WebMD Medical News: "FDA OKs New Cancer Pain Drug." Medscape Medical News: "FDA Approvals: Keflex, Barley Qualified Health Claim, Ionsys."