Fast-acting fentanyl for breakthrough pain

The landmark paper discussed in this chapter is ‘Oral transmucosal fentanyl citrate: Randomized, double-blinded, placebo-controlled trial for treatment of breakthrough pain in cancer patients’, published by Farrar et al. in 1998. It was the first description of a randomized controlled trial of a fast-acting fentanyl formulation for the management of breakthrough pain (i.e. oral transmucosal fentanyl citrate (OTFC)). Indeed, it was the first description of a randomized controlled trial of any of the so-called fast-acting fentanyl/rapid-onset opioid formulations for the management of breakthrough cancer pain. Moreover, the methodology employed in this study formed the basis for the methodology employed in many later studies (of other fast-acting fentanyl formulations).

Association of transdermal fentanyl and oral transmucosal fentanyl citrate in the treatment of opioid naïve patients with severe chronic noncancer pain

Background: Chronic noncancer pain is often undertreated.Aims: To assess the efficacy of fentanyl transdermal therapeutic system (TTS) associated with oral transmucosal fentanyl citrate (OTFC) for breakthrough pain in patients with chronic noncancer pain.Methods: A total of 215 patients with chronic (≥6 months), severe (VAS ≥ 8) noncancer pain participated in a 6-month prospective study. The starting dose of 12 μg/h fentanyl TTS was titrated in 25 μg/h increments to a visual analog scale (VAS) score ≤ 4. OTFC was administered as single-unit doses of 400 μg.Results: The mean (SD) VAS score decreased from 9.86 (0.35) at baseline to 2.05 (0.96) at 6 months. The percentage of patients with poor quality of sleep decreased from 99 percent at baseline to 2.8 percent at the end of the study. The percentage of patients with inadequate pain control decreased from 16.2 percent at month 1 to 2.3 percent at month 6. Pain control was achieved with the 50 μg/h dose in 48 percent of patients, the 75 μg/h dose in 18 percent, and the 100 μg/h dose in 5 percent (only two patients required >100 μg/h). The daily use of single-unit doses of OTFC decreased from 4.64 at month 1 to 2.62 at month 6. Headache, nausea/vomiting, constipation, and somnolence of mild or moderate intensity were the most common side effects. Treatment was discontinued because of nausea/vomiting in seven patients, somnolence in three, and dermatitis in two.Conclusions: Fentanyl TTS associated with OTFC for breakthrough pain is a feasible and effective strategy in opioid naïve patients with severe chronic nonmalignant pain.