Dr. Sinatra: As a Board Certified Anesthesiologist and Pain Management specialist, I have been the director of Inpatient Pain Management Services at the Yale University School of Medicine for the last 12 years. I have authored numerous publications and a textbook: "Acute Pain: Mechanisms and Management".

Dr. Gudin: Can you tell us about pain management in the hospital setting?

Dr. Sinatra: Clearly pain is under treated in many hospitals. As a baseline, physicians are taught very little about the assessment or management of pain in their medical training. In 2001, the Joint Commission on Healthcare Accreditation (JCAHO) enacted a series of guidelines aimed at improving pain management in hospitals, nursing homes, rehabilitation centers and ambulatory medical facilities. JCAHO mandated that healthcare practitioners be educated about pain scales, analgesic medications and nonpharmacological techniques for pain control.

Dr. Gudin: Can you define breakthrough pain?

Dr. Sinatra: Breakthrough Pain is a transitory flare of pain, usually superimposed on a more stable level of baseline pain. It is usually very rapid in onset, lasts about 30 minutes, and can occur anytime - be episodic- throughout the day. When this pain occurs with activity, we describe it as incident pain.

Dr. Gudin: As a hospital based pain specialist, can you describe some of the clinical scenarios where breakthrough pain exists?

Dr. Sinatra: Patients are not protected from pain in any ward of the hospital. On the Pain Management team, we service mostly patients on the postoperative, oncology and medical wards. Studies have shown that pain is also a problem in the Emergency Department, Labor and Delivery Ward, Procedure Suites and other ambulatory areas of the hospital. (Clearly, the majority of what we treat is post-operative pain.)

Dr. Gudin: Can you discuss how BTP is treated?

Dr. Sinatra: Breakthrough pain in the hospital setting is usually severe enough in nature to require opioid analgesics. We can divide the treatment of pain in these patients into 2 categories: those that require continuous/long-lasting analgesics, and those that need quick onset, short-acting agents only. Patients unable to eat or drink (post-op, bowel obstruction, head/neck breakthroughs, etc.) require parenteral, rectal, sublingual or oral transmucosal analgesics. Morphine has been the gold standard, although opioids such as Dilaudid and Fentanyl have gained popularity in the last few years. Patients requiring continuous relief are given a constant IV infusion along with a PCA (Patient Controlled Analgesia) device for breakthrough pain. For more extensive procedures or recovery from highly invasive surgery or severe trauma, continuous epidural analgesia or regional blockade may be initiated. As they resume po intake, we convert the IV agents to continuous release (SR) and breakthrough oral analgesics.

Dr. Gudin: How about patients who do not require a constant infusion, like patients that have just a few bouts of severe pain per day?

Dr. Sinatra: These patients can be extremely challenging. What we try to do is offer them a PCA device, and find the appropriate dose to control these episodes of pain. Fentanyl, being a very lipophilic drug that enters the CNS rapidly, may be a good choice of drug for these patients who have short-lived bouts of pain.

Dr. Gudin: What if the patient is being discharged and still has bouts of breakthrough pain?

Dr. Sinatra: At Yale, we are proponents of continuing pain management well into the postoperative period- even after discharge from the hospital. We make use of all of the short-acting opioid analgesics, including morphine, hydromorphone, fentanyl, oxycodone and hydrocodone.

Dr. Gudin: How can you use fentanyl in the outpatient setting?

Dr. Sinatra: Fentanyl is a potent lipophilic opioid that is available in a number of formulations. It comes as an IV solution, a 72-hour patch, and as an oral transmucosal lozenge (OTFC- oral transmucosal fentanyl citrate). We studied OTFC for postoperative pain and found the onset and efficacy of analgesia equal to that of IV Morphine. This is a very potent, fast acting analgesic. OTFC is a useful and efficient substitute for IV-PCA or nurse administered IV boluses of opioid, particularly for patients undergoing short yet painful medical or surgical procedures.

Dr. Gudin: Are long acting (Sustained Released) Opioids appropriate for the treatment of BTP?

Dr. Sinatra: SR agents are not good choices for BTP as they have a significant lag until time of onset (take too long to kick in) and usually last far longer than the episodes of pain. Patients can also experience pain when their SR analgesic starts to wear off. Oftentimes we mistake this for BTP; we label this "end-of-dose" failure, and usually escalate the dose of SR agents until the patient is comfortable around the clock.
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