Breakthrough Pain Definition

What happens when your usual pain management plan doesn't work?

Breakthrough pain and flare-ups are episodes in which pain is not fully managed by your usual medication.

Unrecognizable mature man having backache.
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What Is Breakthrough Pain?

Breakthrough pain, also called episodic pain and/or flare-up, is the name given to pain, both cancer and non-cancer related, although much more is known about the cancer type, that comes on very quickly and severely when you are already being treated with long-acting pain medications. 

In a flare-up, the pain "breaks through" your routine medication. 

Breakthrough pain may become severe enough to disable or immobilize. In order for pain to be identified as breakthrough pain, persistent pain that is controlled and stable, usually by medication, must first be present.

Breakthrough pain is usually, but not always, experienced at the same places as the underlying persistent pain.

If you experience breakthrough pain frequently, it may be because your persistent pain is not being treated adequately; according to a 2007 study published in the journal Pain Medicine, if you have five or more episodes per day, it may be time for a reassessment, of both the cause and the current treatment protocol, with your healthcare provider.

Up to ninety-five percent of people with persistent back pain experience breakthrough pain, the author of the Pain Medicine study reports. A more recent (2015) study, published in the journal Pain confirms that breakthrough pain is very prevalent, putting the number at eighty percent.

Who Gets Breakthrough Pain?

A 2018 study published in the journal Pain Research and Treatment found that about 37% of patients with chronic low back pain experience breakthrough pain, and that the prevalence is equal between men and women. Most are over fifty years of age.

Types of Breakthrough Pain

Experts categorize breakthrough pain in two ways: by the way it's induced and the type of pain.

Pain can be incident, idiopathic or end of dose. Of these, the incident sub-type of breakthrough pain is the most common. It tends to be predictable and related to movements such as coughing or turning over in bed.

But incident breakthrough pain may be unpredictable, too. In this case, it may be due to contraction or spasms in muscles that are in your organs.

The author of the Pain Medicine study reports that up to half of all breakthrough pain is the incident type.

Idiopathic breakthrough pain has no known cause.

In general, breakthrough pain takes about 10 minutes to ramp up to full intensity and may last up to (a median of) sixty minutes, according to a 2009 British Journal of Anesthesia study. But this can vary according to sub-type.

For example, if you have an end of dose breakthrough pain, a sub-type where the pain shows up just before your next regularly scheduled dose of medication, you may find that it takes longer than ten minutes for the pain to come to its full intensity; it also may last longer than sixty minutes.

The second type of categorization relates to the body system responsible for the pain. These are somatic, which refers to muscle, visceral, referring to organs, and neuropathic, or nerve-related breakthrough pain.

If you have nerve-related breakthrough pain, episodes may be shorter and more frequent than the typical scenario described above. This timing may then contribute to altered responses to pain and other stimuli common in people with nerve pain. Examples of such responses include:

Breakthrough Pain Medications

Regardless of the sub-type or timing of your breakthrough pain, symptoms are often subjective in nature, which may lead to missed diagnoses and under-treatment. This is why it's important to communicate accurately and thoroughly with your treating healthcare provider.

Your healthcare provider will need to know about you, your medical history, your back condition, and your recent pain, as treatment will likely be tailored to you individually. Keeping a pain chart or diary will likely help you here because it is a form of self-reporting that healthcare providers tend to rely on in their assessments. Your healthcare provider uses the information you give her about timing and frequency, cause, if you have that information, intensity, and onset to determine the type you have and to match a particular quick-acting opioid medication to it.

Medication given for breakthrough pain is referred to as rescue medication.

Breakthrough pain is most often treated with short-acting opioids or narcotics.

When breakthrough pain can be predicted, your healthcare provider may give you short-acting opioids preemptively. An entirely different type of medication may be given when breakthrough pain cannot be predicted. 

But some healthcare providers disagree with the use of narcotics to treat breakthrough pain, and, in fact, don't believe the phenomenon of breakthrough pain is even real. A 2011 review of studies published in the journal Pain Physician found no scientific evidence for the phenomenon of breakthrough pain. The authors conclude that the use of opioids to treat it is suspect. 

They report that treatment of chronic non-cancer pain with opioid narcotics has escalated in the past decade or so, and assert that the rise in prescribing has led to explosive use by healthcare providers, as well as misuse of the drug, and many complications, which are also known as adverse drug events.

The 2018 study mentioned above found that fentanyl, a narcotic opioid, is the preferred drug for controlling breakthrough pain, and just over half of the patients that take it for this purpose do so through the nose.

Non-Drug and At-Home Treatments for Breakthrough Pain

Non-drug treatments are sometimes integrated with narcotic medication. Your healthcare provider may counsel you to limit your activity, use ice or heat, or other at-home therapies. She may also refer you to physical or massage therapy, or to a specialist for a nerve block.

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By Anne Asher, CPT
Anne Asher, ACE-certified personal trainer, health coach, and orthopedic exercise specialist, is a back and neck pain expert.