Breakthrough Cancer Pain: Promote Relief with Customized Treatment and Counseling

Breakthrough Cancer Pain: Promote Relief with Customized Treatment and Counseling patient receiving combination chemotherapy and radiation therapy for bladder cancer stood strong through treatment. With medication, his pain was controlled well enough that he sometimes ran errands and visited friends. Just as he thought the worst was over, it hit—pain so severe he couldn’t move or breathe. It dissipated in a few minutes, then struck again a few hours later. No one had warned him about breakthrough pain.

The estimated prevalence of breakthrough cancer pain varies, but it’s safe to say that it occurs in at least a third of all cancer patients and affects up to 95 percent with some types of cancer. Many of these patients continue to suffer because breakthrough cancer pain is substantially undertreated. Insufficient pain management impacts more than comfort, as higher levels of pain are associated with more frequent hospitalizations and an increased risk of death. Compounding pharmacists can improve outcomes with customized medications and counseling that supports their patients’ quality of life.

Challenges Identifying and Treating Breakthrough Cancer Pain

Breakthrough cancer pain is tricky to diagnose and treat. Even though transitory flare-ups are marked by severe pain, it’s still not always easy to discern breakthrough pain from uncontrolled persistent pain and end-of-dose failure. Patients may prefer to avoid opioids, while physicians may hesitate to add more to a regimen that already relies on sufficient opioids to keep baseline pain under control.

It’s important for compounding pharmacists to know the characteristics of breakthrough pain so they can determine when pain isn’t properly managed.1 Encourage patients to visit their oncologist if you suspect uncontrolled pain, whether breakthrough or chronic.

Characteristics of breakthrough pain:

  • Daily episodes: The average is three to six episodes daily. A greater number may indicate uncontrolled baseline pain.
  • Time to peak intensity: Pain usually peaks in three to five minutes but may peak in seconds.
  • Duration: This is the biggest variable. The typical duration is 15 to 30 minutes but breakthrough pain can last 60 minutes.
  • Predictable vs. unpredictable: Episodes are predictable in about 78 percent of patients.

Fentanyl formulated for sublingual or buccal delivery is the active ingredient in medications used to treat breakthrough pain. Sublingual spray provides significant pain relief at five minutes and relieves pain for at least 60 minutes. 2

Counseling Cancer Patients

Compounding pharmacists are often the most accessible member of the health care team, which is a profound responsibility, especially for patients fighting cancer. In addition to counseling about medication, it may be beneficial to increase communication to offer some basic support for the emotional and physical challenges patients face. If you’re not comfortable delving into more than medication management, you’re not alone. This type of counseling demands skills that generally exceed pharmacists’ training.3 Consider these tips for connecting with cancer patients:

  • Don’t worry about what you’ll say. You only need to open the door and take your lead from the patient’s response.
    • Simply asking “how are you?” tells the patient you’re available to talk about more than medication.
    • Keep it casual and be patiently insistent if they seem hesitant to talk. Many cancer patients don’t want to complain or talk about their pain.
    • Listen carefully to pick up on their concerns and fears.
  • Ask whether their pain is under control. Cancer patients tend to assume—or they’ve been told—that pain is to be expected. They may not realize that better control is possible.
  • Evaluate whether patients are using breakthrough pain medication properly.
    • Make sure they’re not waiting too long to take sublingual or buccal fentanyl, thus missing peak pain.
    • Assess their pain to be sure it qualifies as breakthrough pain. Ask about frequency of flare-ups, how long before pain increases and how long it lasts.
    • Ask whether breakthrough pain is limiting activity or causing psychological distress such as depression. Reinforce the value of seeking professional help to improve these areas.4
  • Ask for permission to include nurse navigators, family members and caregivers in the discussion. If they don’t have anyone, give them a resource list or suggest they go online to, which offers telephone counseling, online support groups and information about financial assistance.
  • Have a resource list ready to hand out that includes programs offered by local hospitals, mental health facilities and the nearest American Cancer Society. (Hospitals may have a list you can copy and use.)

Collaborating with the Health Care Team

By definition, cancer treatment demands a team of health care professionals. You can improve the patient’s quality of care by taking the lead to establish a collaborative team. Communicating with physicians when the patient’s treatment starts is beneficial because it paves the way for meaningful discussion without tension if you need to discuss dosing or pain management down the road.

According to a nationwide survey, the expertise of compounding pharmacists is more crucial than other team members may realize. The survey found that oncologists—and even pain medication specialists—have “knowledge deficiencies” regarding pain management.5

  • Initiate contact: Reach out to oncologists and primary care physicians when the patient fills their first prescription.
  • Nurse navigators: If nurse navigators are available at health care facilities in your area, take time to talk with them and establish yourself as a resource
  • Programs in the area: Offer to participate in local cancer-support and education programs.
  • Start a support group: If you’re in an area where local health care facilities don’t have cancer support groups, or you don’t have an American Cancer Society location nearby, spearhead efforts to create programs.

Proactive Compounding Pharmacists Improve Patient Outcomes

Regulations requiring pharmacists to reach out to patients are vital, yet counseling sessions often take the form of quick and routine interactions about medication basics. When compounding pharmacists take the extra step to mindfully counsel cancer patients—especially those taking meds for breakthrough pain—they can promote better outcomes and significantly contribute to their patients’ quality of life. In the process, compounding pharmacists stand out as caring and active members of the community.

Pharmaceutica North America provides top quality bulk pharmaceuticals for compounding medications that meet the diverse needs of your patients, including pain medications. Please contact us today if you have any questions and to learn about our complete product line.

Show 5 footnotes

  1. “Breakthrough Cancer Pain—Still a Challenge,” November 2012,
  2. Single-Dose Fentanyl Sublingual Spray for Breakthrough Cancer Pain,” July 2013,
  3. “Counseling Skills You Didn’t Learn in Pharmacy School,” September 2015,
  4. “Pharmacologic Management of Adult Breakthrough Cancer Pain, December 2014,
  5. How Well do Medical Oncologists Manage Chronic Cancer Pain? A National Survey,” February 2015,

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