In South Africa, breakthrough Pain is managed by pain medicine & palliative cares. Breakthrough pain is a transient flare of moderate-to-severe pain that occurs in a person with otherwise well-controlled background pain on a stable analgesic regimen. The concept was first formalized by Portenoy and Hagen in 1990 and is now the dominant framework for managing acute pain spikes in cancer, end-of-life care, and selected chronic non-cancer pain.
Breakthrough pain (no specific ICD-10 code; coded under the underlying chronic pain G89 codes plus the precipitating diagnosis) is defined by the European Association for Palliative Care as a transient exacerbation of pain occurring spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. The diagnostic criteria established by Davies and colleagues require: presence of stable background pain (present for more than half of the previous 24 hours and rated mild or absent for that period), adequately controlled background pain (mild or none), and transient exacerbations of moderate or severe pain. Three subtypes are recognized by EAPC: (1) incident pain — predictable, triggered by voluntary action (movement, weight-bearing) or involuntary event (cough, sneeze, swallowing); (2) spontaneous pain — no identifiable trigger; (3) end-of-dose pain — pain returning before the next dose of scheduled long-acting analgesic, technically a failure of background therapy rather than true breakthrough pain. Approximately 65% of breakthrough episodes are nociceptive (somatic or visceral), 25% neuropathic, and 10% mixed.
The key symptoms of Breakthrough Pain are: Transient flare of moderate-to-severe pain (typically 7-10 on the 0-10 numeric rating scale) in a patient whose background pain is otherwise well-controlled., Rapid onset, typically within seconds to a few minutes; spontaneous episodes peak within 3-15 minutes., Episode duration typically 30-60 minutes, sometimes longer; resolves either spontaneously or with rescue medication., Frequency 1-6 episodes per day in patients with advanced cancer; occasional patients have more than 10 episodes daily., Predictable trigger in incident pain (movement, weight-bearing, swallowing, defecation, cough) with onset within seconds of the trigger., Unpredictable, spontaneous onset in 40-50% of episodes; often described as 'out of the blue'., Pain pattern often shares the character of the underlying chronic pain syndrome: deep aching in bone metastases, electric-shock in neuropathic syndromes, cramping in visceral cancer pain..
Diagnosis of breakthrough pain is clinical, based on a structured history that distinguishes true breakthrough pain from inadequate background analgesia and from new pain etiologies. The Davies/EAPC diagnostic algorithm requires: (1) confirmation that background pain is present and adequately controlled (numeric rating scale ≤4 most of the time on stable analgesic regimen), (2) characterization of episodes by frequency, duration, onset speed, peak intensity, trigger if any, and quality, and (3) identification of the underlying pain etiology and any reversible pathology causing breakthrough pain (impending fracture, spinal cord compression, bowel obstruction, infection). Validated tools include the Alberta Breakthrough Pain Assessment Tool, the Davies Episodic Pain Assessment Tool, and the Edmonton Symptom Assessment System used for general symptom tracking. A patient diary capturing each episode's timing, trigger, intensity, duration, and rescue dose response over 7-14 days clarifies pattern and rescue dose efficacy. Differential diagnoses to exclude include true new pain from disease progression, end-of-dose pain (resolved by titrating background therapy), opioid-induced hyperalgesia, and psychological factors mimicking pain flares. Imaging or other investigations are guided by suspected anatomical or pathological cause: plain radiograph for impending fracture, MRI for spinal cord compression, abdominal imaging for obstruction. Assessment includes review of the entire analgesic regimen including non-opioid analgesics, adjuvants, non-pharmacological measures, and prior rescue dose performance.
Outcomes depend on the underlying pain etiology. In advanced cancer, optimized multimodal management reduces breakthrough pain frequency by 50-70% and intensity by 4-5 points on the 0-10 NRS. Approximately 75-85% of cancer patients achieve clinically acceptable breakthrough pain control with current regimens. Patients with bone metastases benefit substantially from radiotherapy and bone-targeted agents. Patients with neuropathic breakthrough pain may have less complete relief and benefit more from neuromodulation and interventional procedures. Non-cancer breakthrough pain on long-term opioids is now managed more conservatively per CDC 2022 guidance, focusing on non-opioid optimization, behavioral and rehabilitative interventions, and judicious immediate-release opioid rescue use. Pediatric breakthrough pain outcomes are improving with dedicated pediatric palliative care services. Mortality from breakthrough pain is primarily related to the underlying disease; opioid overdose risk rises with rapid-onset fentanyl in non-opioid-tolerant patients (the strongest argument for cautious prescribing and CDC-mandated risk evaluation programs).
Pain medicine and palliative care specialists optimize background analgesia, characterize breakthrough pain pattern, prescribe transmucosal fentanyl and other rapid-onset options safely, identify reversible causes, and integrate radiotherapy and interventional options. Referral is appropriate when episodes are frequent (more than 4-6 per day), when first-line oral immediate-release rescue is insufficient, when an interventional procedure or rapid-onset opioid is being considered, or when end-of-life care is being planned.
Find specialists →Individual episodes: rescue medication onset within 5-15 minutes (transmucosal fentanyl) or 30-60 minutes (oral immediate-release morphine); episode resolution typically within 60 minutes after rescue dose. Overall breakthrough pain control: meaningful improvement within 1-2 weeks of optimized regimen; full benefit of palliative radiotherapy at 2-4 weeks. Long-term: pattern adjusts to disease trajectory; reassessment at each clinic visit.
Physical activity is tailored to the underlying disease and pain syndrome. Maintain mobility within tolerance and use pre-emptive rescue dose for known incident-pain triggers. Avoid weight-bearing on bony lesions at high fracture risk until orthopedic evaluation. Gentle range-of-motion exercises preserve function and reduce overall pain. Physical therapy guidance is valuable, particularly in cancer rehabilitation programs.
For cancer breakthrough pain, choose a palliative care or pain medicine specialist with cancer-specific experience and access to transmucosal fentanyl, radiotherapy, and interventional procedures. For non-cancer breakthrough pain, prioritize a pain medicine clinic with multidisciplinary capabilities. Avoid clinicians who rely solely on dose-escalation without addressing the underlying mechanism or background therapy.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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