Dealing with cancer pain, along with nausea and vomiting, are top concerns of oncology patients. More than half of cancer patients experience bouts of crippling pain, according to Ashish Udhrain, M.D., FACP, and Medical Director of Oncology at East Jefferson General Hospital in Metairie, LA. And even more who are undergoing chemotherapy report bouts of nausea and vomiting.

WEEDING OUT ADDICTION: When pain meds start being a crutch, we need other options to break the cycle of opioid abuse. As TIRFs address pain, cannabinoids are helping address nausea and stimulate appetite.

Creating a pain score

Moreover, many cancer patients are under-assessed as far as measuring the characteristics and severity of crippling breakthrough pain, notes Jeannine M. Brant, Ph.D., an oncology clinical nurse specialist in Montana.

“We have to make pain a priority,” says Brant, adding that when she first started working as a clinician, pain scores were nonexistent. “Diagnosing pain and its severity is important to better palliative care.”

Proper medication

The American Society of Clinical Oncology (ASCO) recently addressed the complex issues of prescription opioids and how treating cancer patients differ from other cases. ASCO is working to protect access to appropriate medical opioid therapy for patients with cancer.

“It is already widely acknowledged that too much pain goes untreated,” ASCO said in a statement, noting cancer patients are a special population. “While not all patients with untreated pain require opioids, these agents remain an essential part of many treatment plans, especially among patients with cancer.”

What is breakthrough pain?

By definition, breakthrough cancer pain is a sudden discomfort that, Brant suggests, should be evaluated by professionals using a scale of 0 to 10.

“‘Because they are a transmucosal drug, the fentanyl is absorbed quickly into the bloodstream in as little as five minutes.’”

The agony can occur when a patient is doing something that triggers the pain, but also can happen without any cause. That suggests, says Udhrain, that cancer patients need to be on long acting medications to control baseline pain, and then transmucosal fentanyl (TIRF) for breakthrough episodes. “Cancer pain is very unique,” he sums.

TIRFs are the only class of drug specifically approved by the FDA for breakthrough cancer pain. “TIRFs for breakthrough cancer pain are a very important missing piece of the puzzle,” Udhrain adds. “They help control symptoms and help improve quality of life for patients.” Adding cancer patients may require medication long after conclusion of cancer treatment.

Brant agrees, citing more than 40 studies that drill down into breakthrough pain and what works best to quell it. “The advantage of TIRFs is they are faster. Because they are a transmucosal drug, the fentanyl is absorbed quickly into the bloodstream in as little as five minutes,” she explains. “Patients prefer these products over those that you swallow that can take up to 45 minutes to give relief.” TIRFs are typically administered nasally, sublingually (under the tongue), or through the buckle cavity in the mouth.

As with all medication, patients need to consult with physicians on the use of TIRFs.

Answers for nausea

There’s also good new for those plagued by nausea and vomiting during treatment. “We’ve gotten much better at targeting therapies to reduce nausea and vomiting,” adds Brant, noting women and younger patients are often more impacted than others.

When oral anti-ementics don’t do the job, some physicians first try a granisetron patch. “I joke with patients that it took someone this long to figure out that the last thing someone experiencing nausea wants is to swallow a pill,” chuckled Udhrain about the advantage of a patch. Additionally, more and more patients are requesting cannabinoids. “Ninety percent of patients are asking about it, even 70-to-80-year-old people bring it up,” says Brant. Cannabinoids don’t only enhance well-being; experts say they also stimulate appetite, which is crucial in chemotherapy patients.