 By Adam J. Carinci, M.D.
By any measure, the American Academy of Pain Medicine’s (AAPM) 25th Annual Meeting was a fantastic success. The AAPM is a medical specialty society representing more than 2200 physicians practicing in the field of pain medicine. The Academy is involved in education, training, advocacy, and research. Held in Honolulu, Hawaii, January 28th – 31st, 2009, the annual meeting was attended by more than 750 physicians and other healthcare providers, a record-setting turnout. Not only was the venue majestic, but so too the meeting itself. According to co-chairs Dr. Perry Fine and Dr. B. Todd Sitzman, the quality, diversity, and sheer number of scientific posters, presentations, and educational sessions was the best the Academy has seen in its history. Following are highlights from some of the sessions I attended.
The pre-conference session entitled, “Opioid Therapy: Cutting Edge Scientific Approaches and Practical Strategies,” was designed to review major public health concerns, epidemiologic studies, and associations between effective chronic non-cancer pain treatment and opioid misuse. In addition to focusing on the ongoing ethical, legal and regulatory implications, alternative and long-term treatment strategies to meet the ongoing needs of patients with dependence and addiction disorders were addressed. Dr. Fine also presented new opioid therapy guidelines for non-cancer pain. The new guidelines offer details on patient selection, risk stratification, initiation, and titration strategies, informed consent, and the development of an opioid management plan. The crucial aspects of the new guidelines include the importance of a therapeutic trial, justification for long-term therapy, and continuous reevaluation and patient monitoring.
On January 28th, a satellite symposium was held that discussed “Current Treatment Landscape and Emerging Management Options in Breakthrough Pain in Cancer Patients.” The presentation was designed to address the pathophysiology and characteristics of breakthrough pain (BTP) in cancer patients, and to assess current treatments and investigational agents and the risks/benefits of the various therapies. I found this to be a highly educational symposium. BTP, in the most stringent definition in the cancer population, is defined as, “…a transitory, severe or excruciating pain, which lasts seconds to hours, and is superimposed on a baseline pain….” Opioid medications are often the mainstay of treatment for breakthrough pain in cancer patients, with these classes being employed most frequently: long-acting opioids (LAO), short-acting opioids (SAO), and rapid onset opioids (ROO).
BTP is a fertile ground for further investigation. The results of one survey suggested that only 25% of patients with BTP are satisfied with pain control compared to 78% of patients without BTP (Portenoy, RK, et al. Pain, 1999, 81:129-134.) Additionally, when compared to patients without BTP, those patients with BTP have more severe pain, reduced responsiveness to opioid therapy, pain-related functional impairment, psychological distress, and higher economic burden.
Rapid onset opioids (ROO) are an important component of a balanced analgesic plan, and newer formulations of this opioid class will have a more prominent role in BTP in the years ahead. Currently available ROOs include Oral Transdermal Fentanyl Citrate and Fentanyl Buccal Tablets. Both of these formulations have an approximate average time to significant pain relief of 10 minutes. New investigational ROOs include Bio-erodible Muccoadhesive Fentanyl, Fentanyl Buccal Soluble Film, Aerosolized Liposome Encapsulated Fentanyl, Sublingual fentanyl, and Fentanyl nasal spray. The pharmacokinetic and pharmacodynamic parameters of these formulations vary and are still under investigation and testing. While these are promising treatments for BTP that will likely lessen the burden on suffering patients, clearly more work is needed.
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