Non-oncologists, including primary care doctors and pharmacists, have a great deal to contribute to the management of breakthrough pain in patients with cancer.
Bruce Nicholson, MD
Oncologists tend to be too busy to deal with breakthrough cancer pain, and often do not realize how adversely such pain can affect their patients, says Bruce Nicholson, MD, director of the division of pain medicine, Lehigh Valley Health Network, and clinical associate professor of anesthesia at Penn State School of Medicine in Allentown, PA.
“There is no question that there is underutilization of effective management when it comes to cancer patients with advanced pain-related problems. Oncologists tend to dismiss the pain or else under-appreciate the severity of the impact of pain,” Nicholson says. “This is not because they are indifferent to pain; instead it reflects their lack of training on how to evaluate and manage patients with significant refractory pain.”
When it comes to oncologists and cancer pain management, Nicholson says that “It’s all on-the-job training. There is no formalized approach teaching the oncologist how to manage patients, how to properly select opioids, and how to look at the pharmacology of opioids to understand the best pharmacodynamic match for patients and their type of pain.”
"There is no formalized approach teaching oncologists how to manage patients, how to properly select opioids, and how to look at the pharmacology of opioids to understand the best pharmacodynamic match for patients and their type of pain."
—Bruce Nicholson, MD, Director of the division of pain medicine, Lehigh Valley Health Network
This leaves a window of opportunity for non-oncologists, who often end up seeing these patients more often than the oncologist. “Primary care doctors can do a lot to see that their patients with breakthrough cancer pain get the right treatment by carefully evaluating them and then referring to an appropriate pain specialist. To burden a primary care doctor with trying to treat a patient with severe pain related to cancer, or breakthrough pain related to cancer, is asking a lot,” Nicholson says. He recommends that primary care physicians consult the American Pain Society (www.ampainsoc.org) or the American Academy of Pain Medicine (www.painmed.org) to locate a certified pain specialist. Primary care providers should also consider doing telephone consults with a certified pain specialist if there is not one in their area. These consultations will help primary care doctors gain a good understanding of how to utilize some of the more advanced therapies, such as the transmucosal formulations of fentanyl, that are now available, Nicholson says.
Role for non-physician health care professionals
Kathryn L. Hahn, PharmD, Chair of the Oregon Pain Management Commission and on the faculty of Oregon State University College of Pharmacy in Springfield, Oregon, says that knowledgeable pharmacists can also play an important role in managing breakthrough cancer pain. “Oncologists are busy,” says Hahn, who sees many cancer patients in her practice. “It’s a rare time when I see an oncologist treating pain, but that is not their focus, so they may not be schooled in the latest treatment options.”
The recent development of fast-acting, immediate-release fentanyls has facilitated the treatment of breakthrough cancer pain, she says. But prescribing these drugs has become more difficult with the recent introduction of the Risk Evaluation Mitigation Strategies (REMS) program by the US Food and Drug Administration (FDA). “The fast-acting fentanyls, or transmucosal immediate-release fentanyl products (aka TIRFs), are the first to fall under this scrutiny,” Hahn says.
The aim of REMS is to reduce inappropriate access to and accidental death from exposure to opioids. It requires all providers, prescribers, and dispensers to go through an education program that teaches them about the correct use, benefits, and potential harms of using this class of drug. Even patients who are receiving the fastacting fentanyls have to go through a brief training process.