What Is Break-Through Pain?

by Christina Lasich, MD Health Professional

Patients with chronic pain and doctors that treat chronic pain, use a term called "break-through pain." What is break-through pain?
And how is this term used in the context of a pain management clinic? Is this concept out-dated or is it still useful?

In its most basic form, this term is used to describe a pain that "breaks through" the ceiling of pain relief that is provided by other means.
Usually, a person's chronic pain is controlled by a primary treatment; and at times, that same individual experiences sudden spikes of pain. These "break-through" spikes in pain burst through the coverage provided by a pain reliever. In order to cover those spikes in pain intensity, doctors prescribe short-acting pain relievers to be used as needed to rescue someone from uncontrolled pain.

The problem with this concept is that some people experience "break-through" pain every 4 to 6 hours; and in turn, may utilize a short-acting medication every 4 to 6 hours. This cycle causes doctors to wonder why this type of pain is occurring so often in some individuals. Based on experience and research in the field of pain medicine, doctors now are beginning to realize that two problems can lead to frequent break-through pain: conditioned pain responses and opioid-induced hyperalgesia. Both of these problems are a consequence of the round-the-clock usage of short-acting pain medications. In other words, the treatment of break-through pain with rescue medication can result in more break-through pain.

This realization has caused some doctors to completely discontinue the prescribing of short-acting opioids like Vicodin, Percocet and Dilaudid to people with chronic pain. Instead, they feel that it is best to treat chronic 24/7 pain solely with long-acting opioid products like buprenorphine, fentanyl transdermal patches, and other extended-release formulas. But that seems a bit extreme because there really are occasional times when the pain intensity gets worse. What is a patient to do if she/he needs to be rescued at those times?

What is needed to aid in the understanding between doctors and patients is a new term to replace the out-dated term of "break-through pain." Some doctors are now starting to call the occasional spike in pain an "activity-related pain" instead of a break-through pain. This new term addresses one of the real problems in calling a pain a break-through pain. This older concept had no link to function or activity. A pain was just thought to mysteriously break-through, without trying understanding why or what the treatment goal should be. With the new term, "activity-related pain," this situational pain can be linked to a specific activity like going shopping, playing with the children, or cleaning the house. Thus, the treatment of activity-related pain becomes focused on accomplishing a functional goal, a goal to do something. Plus, these activities occur infrequently enough that the utilization of short-acting rescue medication as needed for activity-related pain should also be infrequent enough to avoid a problematic, vicious cycle of ups and downs.

Anyone who has experienced that roller-coaster of ups and downs while trying to manage so called break-through pain knows that it is very unnerving and frustrating. Getting off this roller coaster can be as simple as changing the long-acting opioid dose enough to discontinue the round-the-clock usage of short-acting drugs. But instead of discounting the need for short-acting opioids all together, doctors and patients can start working together by replacing the out-dated term, "break-through pain," with "activity-related pain.

Christina Lasich, MD
Meet Our Writer
Christina Lasich, MD

Christina Lasich, M.D., wrote about chronic pain and osteoarthritis for HealthCentral. She is physiatrist in Grass Valley, California. She specializes in pain management and spine rehabilitation.