Inadequate treatment of chronic pain remains a problem. In particular, breakthrough pain is a component of chronic pain that is often poorly recognized and poorly controlled; and the existence of breakthrough pain can lead to anxiety, depression, chronic insomnia and difficulties with day to day functioning. It is imperative that providers of pain management recognize breakthrough pain, and treat it aggressively.

Breakthrough pain occurs at some point in up to 95% of patients treated for pain. It is pain which is experienced as a "flare" in those with persistent baseline pain. Breakthrough pain can have an abrupt onset, often reaching its peak intensity within five minutes, and can subside within one hour. In one study of cancer patients, it struck on average four times a day with a severity described as intense. This can in turn result in an increased number of visits to the doctor, and actual hospitalization, resulting in significantly increased health care costs-for patients and society.

Breakthrough pain can be triggered by simple physical activity, advancing disease, or inadequate analgesic dosing. It is important that the treating physician listen closely to the patient, and specifically ask about breakthrough pain, as many patients will not spontaneously admit to breakthrough pain. The doctor must ask about pain at rest and pain with activity, what causes a flare of pain and what is done to avoid a painful flare-up. A patient pain diary can be very helpful, as can patient questionnaires.

Once the doctor has concluded that breakthrough pain is present, any and all correctable causes of such pain should be treated; the doctor needs to rule out the presence of such complications such as fracture or infection. And, of course, the appropriate pain medications must be used: for example, treatment of persistent pain usually requires long-acting opioids; and it may be necessary to shorten the interval of dosing. It may also be necessary to add another pain medication which has a rapid onset when the pain flares.

Unfortunately, determining the dose of medications for breakthrough pain is difficult, and depending on the patient, may need to be titrated just as the long-acting medications for chronic pain must be titrated. For the safety of the patient this should be done slowly, with close monitoring for effectiveness and toxicity. The use of non-opioid pain medications for breakthrough pain is not supported by studies; they often have a slow onset and sometimes significant side effects.

Of course, chronic pain of any kind should be approached with the help of other health care professionals, such as physical therapists and psychologists. And helping the patient gain insight into his or her unique pain problems can be extremely helpful: What activities cause pain? What can the patient do to alleviate the pain, short of taking more medications?

Perhaps new treatments currently being developed can aid in the battle against breakthrough pain: fast-acting oral medications are under study, as are a variety of different pain patches. Different approaches to stress management are being studied in patients with breakthrough pain. However, I feel that the first step in alleviating pain is a healthy communication between doctor and patient: the doctor and the patient both must understand what is causing the pain, and as outlined above, once they share these realizations, they both have the ability to actively participate in improving the pain.

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