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Breakthrough Pain

Pain expert Dr. Scott Fishman answers questions about end of life pain:

Q: What is "breakthrough" pain and how do you control it?

A: Breakthrough pain comes hard and fast. It can be an instantaneous intensifying of all-over dull pain, or it may come as a localized sharp stab or fiery sensation.

It can summon someone out of a deep sleep or freeze him mid-motion like a vicious bolt out of the blue. Its unpredictability and severity make an immediate antidote imperative. Guarding against the possibility of breakthrough pain should be a part of any prescription for end-of-life pain.

Speed is of the essence in devising a weapon for breakthrough pain. Traditionally, the fastest treatment has been doses of potent opioids (such as morphine) administered through an intravenous tube into a blood vessel heading for the brain. A remarkably effective way to do this is called patient-controlled analgesia device (PCA).

A PCA device lets the patient control the flow of pain medication and is especially effective against breakthrough pain. It is regularly used by patients recovering from surgery and can also be used by someone at home with a terminal illness.

Recently, drug manufacturers have devised a fast, noninvasive method for stopping breakthrough pain. The product is called Actiq, and it looks like a cone-shaped lollipop - though the FDA and the manufacturer don't want it to be referred to as a lollipop because it is not supposed to be sucked. Nonetheless, it is really a sweetened lozenge on a stick that is packed with high-powered fentanyl. Fentanyl travels through the mucosa tissue on the inside of the mouth.

This is an exceptionally clever and speedy delivery system to the bloodstream and brain. The Actiq has only to be rubbed on the inside of the cheek to rush opioids to the brain. It travels faster than any pill and is just about as fast as an intravenous injection of morphine. Patients say that they can feel relief from breakthrough pain within five minutes of putting the device in their mouth.