Breakthrough pain: Finding the right balance

Written by: Roanne Weisman
Published: July 22, 2008
Reviewed by: Kevin Zacharoff, MD

The term “breakthrough pain” was originally coined by anesthesiologists. After surgery, patients are given post-operative pain medication. Sometimes, however, pain “breaks through” the medication. In recent years, breakthrough pain has come to mean any pain that occurs despite pain medication. The meaning of the term is no longer restricted to post-operative pain. Breakthrough pain can occur whenever you are on pain medication for any condition, whether acute or chronic. The solution lies in finding the right balance between medication and physical activity.

In this article, you will learn:

• The causes of breakthrough pain
  
• Treatment strategies to discuss with your health care provider
  

The causes of breakthrough pain

Understanding breakthrough pain requires an understanding of how medicines work in your body: When you take a pain pill, whether to treat back pain, migraine, cancer pain or some other kind of pain, a large amount of pain medicine is released into your bloodstream. The moment that happens the body immediately begins to eliminate it by the filtering actions of the liver and kidneys. Therein lies the challenge.

Problems arise in trying to treat a steady state of pain with fluctuating levels of pain medication. Compounding the difficulty is your level of activity. One of the ways pain is often treated is by rest and reduced activity. So adding movement, or increasing activity, can combine with changes in the levels of pain medicine in the body to cause breakthrough pain.

Strategies to treat breakthrough pain

One way to think of pain treatment is by comparing it to building a brick wall against the pain. As the levels of pain medication go down, ‘leaks’ in the wall can open up, causing breakthrough pain. It is hard to plug these leaks once they start happening, so one strategy is to prevent them in the first place. The answer is not to keep piling on more and more medication, but to use medication strategically.

Pain is a very personal experience, affecting each person’s quality of life in different ways, so it is very important to discuss how both your pain and your medication are affecting your ability to do what you want to do. This makes it possible for your healthcare provider to match your medications to your lifestyle needs.

• Combine medications.
  
  
  • One strategy, for example, is to pair a longer-acting pain medication that is taken regularly with a shorter-acting one that is taken before heightened physical activity. These might include medications given by injection, or absorbed under the tongue or through the cheek, or in standard pill form. It’s not a good idea to move furniture if you have back pain, but if you know you are going to have to do something strenuous, ask your healthcare provider for a short-term medication that you can take beforehand, to head off the possibility of breakthrough pain.
    
    
• Add other pain therapies.
  
  
  • Medications are not the only answer to treating breakthrough pain. Other strategies include modifying your activity level (ask someone else to move the furniture!), physical therapy, biofeedback, and relaxation techniques. Striking the right balance between pain medications and activity level takes time. You and your provider may not get it right the first time, especially if you are treating a chronic pain condition.
    
    
• Record incidents of breakthrough pain.
  
  
  • Another strategy is to keep a “pain journal”, such as the “Daily Tracker”, and keep notes about which kinds of activities set off breakthrough pain. Some people, for example, have fewer episodes when they engage in moderate exercise, such as walking. The key is to discover your own pattern, and then communicate this clearly to your healthcare provider so that your pain medications can be tailored to fit your lifestyle and needs. Set a goal with your clinician between ‘I want to have as little pain as possible,’ and ‘I want to do what I need to do’.
    
    
• Take some responsibility.
  
  
  • Solving breakthrough pain needs to be a joint project between you and your healthcare provider. You can help by taking a commonsense approach to your pain. Review your notes to determine which are the activities that set off breakthrough pain, and work with your provider either to modify the activity or find the best preventive medication to take before beginning the activity. And even if you feel better, don’t then go back to the activities that caused the pain. Take some responsibility to plan what you do according to the way your body responds. Your provider cannot do all of this without your participation.
    
    
• Recognize that breakthrough pain is a “moving target."
  
  
  • If your breakthrough pain comes back even after treatment, do not think that the treatment has failed. Your body and your life change every day, so your strategies have to be dynamic and responsive to your varying needs. You and your provider should be asking, ‘How can we improve our accuracy and hit the target as often as possible?’