By Phil Walls, RPh, Chief Clinical Officer, myMatrixx
Breakthrough pain is typically defined as a sudden and usually brief flare-up or period of pain that occurs in a chronic pain patient that otherwise has been well managed with either narcotic or non-narcotic analgesics. In this discussion, we will focus on the use of long-acting opioids for the management of chronic pain, but it is important to point out that non-narcotic analgesics should be the first choice in the majority of cases. This flare-up is severe enough to break through the analgesia that is normally adequate to control the patient’s pain, and this phenomenon is the principle reason cited for prescribing more than one opioid for a chronic pain patient: a long-acting opioid for pain management plus a short-acting opioid for breakthrough pain. However, is this the best approach and if not, is there a better method?
To answer this question, we must first look at the possible causes of breakthrough pain and its prevalence. Few studies have studied this phenomenon in non-cancer patients, and even within the cancer patient population, estimates of occurrence range from approximately 40% to 80% of all cancer patients. Therefore, it is safe to estimate that one out of two patients with cancer pain will experience breakthrough pain at some time during treatment. For the sake of this discussion, we will assume the same rate applies to non-cancer patients. In addition, we will assume that we are describing patients that are appropriate candidates for opioid therapy according to guidelines and evidence-based medicine.
In general, there are then three likely causes:
- The patient is participating in an activity that causes a flare-up of pain,
- The patient is developing tolerance to their maintenance opioid therapy, or
- The effect of the long-acting opioid is wearing off before the next dose is due.
The obvious solution to the first cause is very straightforward – avoid or limit the activity. The latter two are more problematic because a prescriber does not know if any given patient will ever experience breakthrough pain; therefore, a patient may have to experience an episode of breakthrough pain before a second analgesic is prescribed. In an ideal situation, a prescriber will add a short-acting opioid for breakthrough pain on a short-term basis and then use the dose of the short-term acting opioid as a basis for adjusting the long-acting opioid upward.
What we more commonly see are prescribing trends where practitioners routinely prescribe a combination of long- and short-acting opioids. In this case, it is unlikely that all of the short-acting opioids are necessary. This may be viewed as inappropriate prescribing. If breakthrough pain has been established, one must next look at the pharmacy history of the patient in order to distinguish tolerance from actual breakthrough pain.
It is unlikely that breakthrough pain is going to occur on a regular periodic basis. Therefore, a pharmacy history that indicates a patient always fills prescriptions for long-acting and short-acting opioids with the same frequency for the same duration of therapy indicates that the patient is unlikely to be experiencing breakthrough pain. But they may instead be using the short-acting opioid to offset the tolerance that is developing to the long-acting opioid or they may be stockpiling unused doses of the short-acting drug neither of which represent good outcomes.
True breakthrough pain will occur on a random basis, and as a result, the need for a short-acting opioid will be less frequent than that of a long-acting opioid. Appropriate counselling of the patient by their pharmacist regarding correct use of the short-acting opioid is vital to ensure that the directions are understood. The pharmacist should warn the patient of the dangers of stockpiling narcotics and may discuss appropriate disposal of any unused medications.
Furthermore, it may be time to re-examine the use of the phrase “as needed” in patient directions. PRN or pro re nata literally translates from the Latin to mean in the circumstance, which on a prescription label equates to as needed. To many patients, however, this means to go ahead and take that dose. A better translation may be if needed, meaning to take only if the dose is needed. A small change with vital implications.
About Phil Walls
Phil Walls is the Chief Clinical Officer for myMatrixx. He joined the company in 2006 and oversees all aspects of myMatrixx’s clinical program including drug utilization review, formulary management, drug regimen reviews and targeted intervention with prescribing physicians.
Phil has been instrumental in developing myMatrixx’s clinical program, Get Ahead of the Claim™, designed to mitigate risk earlier in the claim process and provide better outcomes for injured workers. This includes the proprietary myRisk Predictor tool and medication therapy management program designed to reduce the use of opioids in the industry.
Phil is a clinical pharmacist with over 25 years of experience in pharmacy, healthcare informatics and workers’ compensation. Previously he served in leadership positions within the industry with Health Information Designs, Inc., PMSI and Cigna Healthcare of Florida, Inc. He is a published author and frequent national speaker on clinical issues in workers’ compensation.
In recognition of his contributions to the industry, Phil was honored to be named CompPharma’s 2015 Person of the Year and to receive the Dorland Health People Pharmacist Award. He is a member of the AMCP, APhA, APS, ASAP, ASHP, FPA and the International Society for Pharmacoeconomics and Outcomes Research. Phil received his Bachelor in Science in Pharmacy from Mercer University School of Pharmacy and was awarded Doctoral Candidate status in Pharmacology at Ohio State University.
About myMatrixx, an Express Scripts company
myMatrixx® is a full-service workers compensation pharmacy benefit management company focused on patient advocacy. By combining agile technology, clinical expertise and advanced business analytics, myMatrixx simplifies workers’ compensation claims management. Located in Tampa, Florida, myMatrixx has positioned itself as a thought leader in the workers’ compensation industry. For more information, please visit www.myMatrixx.com.
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