Background Transmucosal Fentanyl products improve sleep, emotional, physical and psychological health.¹ The EAPC state Fentanyl preparations are sometimes preferable to immediate release oral opioids because of rapid onset of action and shorter duration of effect.² Recent trials initiating transmucosal Fentanyl at proportional dose to around-the-clock opioid concluded this is safe and effective.^3,4 For patients using high doses of around-the-clock opioid it is hypothesised that proportional dosing may prevent dropout of participants during titration, due to lack of confidence of efficacy before maximal dose has been achieved.³

Methods We performed a systematic review of the literature for pharmacological and non-pharmacological management of breakthrough cancer pain. A survey of healthcare professionals working in specialist palliative care and multi-centre case-note review were performed analysing current management of breakthrough cancer pain.

Results 94 Healthcare professionals (HCP’s) responded covering community, hospice and hospital settings. 57% prescribe transmucosal Fentanyl, with most initiating transmucosal Fentanyl every 2–3months. The main benefits are its’ short duration of action and rapid onset of action. 73% found the greatest barrier is the titration schedule. 90% found heat and cold packs helpful. Davies⁵ also concluded heat, rest and positional change were most beneficial non-pharmacological options. 179 patient case notes were analysed. 56% of those prescribed transmucosal Fentanyl were using equivalent to 60mg morphine as background opioid, 34% were using less than equivalent 60mg morphine. 65% of cases had pain assessed using a tool, 74% of these used the Numeric rating scale. In 84% of patients the titration schedule was used. 83% of patients initiated on transmucosal Fentanyl continued to use it, discontinuation was most commonly due to entering the dying phase.

Conclusion Regional standards and guidelines have been updated following this review. There was consensus that under specialist palliative care guidance where patients are using the equivalent or higher than 60mg Morphine per 24hours it might be appropriate to consider starting transmucosal Fentanyl at higher doses than manufacturer recommendation.

References

1. Cuomo A, Cascella M, Forte CA, et al. Careful breakthrough cancer pain treatment through rapid-onset transmucosal fentanyl improves the quality of life in cancer patients: results from the BEST Multicentre Study. Journal of Clinical Medicine 2020;9:1003.

2. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncology 2012; 13:58–68

3. Mercadante S, Prestia G. The use of sublingual fentanyl for breakthrough pain by using doses proportional to opioid basal regimen. Current Medical Research & Opinion. 2013;1–6.

4. Yen T, Chiou J, Chiang W, et al. Proportional dose of rapid-onset opioid in breakthrough cancer pain management. An open-label multi-centre study. Medicine 2018;97:30(e11593).

5. Davies A, Buchanan A, Zeppetella G, et al. Breakthrough Cancer Pain: An Observational Study of 1000 European Oncology Patients. Journal of Pain and Symptom Management 2013; 46(5):619–627.