Persistent and Breakthrough Pain Individualizing Opioid Therapy for Fluctuating Cancer Pain

Michelle I. Rhiner, RN-BC, MSN, GNP-BC, ACHPN, CCM; Neal E. Slatkin, MD; April Hazard Vallerand, PhD, RN, FAAN

As presented Friday, May 2, 2014 in Anaheim, California

This activity is co-provided by Global Education Group and Integritas Communications.


This activity is supported by an educational grant from Teva CNS. 


Michelle I. Rhiner, RN-BC, MSN, GNP-BC, ACHPN, CCM
Nurse Practitioner, Department of Palliative Medicine
Instructor, Department of Family Medicine
Loma Linda University School of Medicine
Loma Linda, California

Neal E. Slatkin, MD
Vice-President Medical Services
Chief Medical Officer
Hospice of the Valley
Palliative Care Center Silicon Valley
San Jose, California

April Hazard Vallerand, PhD, RN, FAAN
Professor, College of Nursing
Wayne State University
Detroit, Michigan

Target Audience

The educational design of this activity addresses the needs of oncology nurses and other health care professionals who collaboratively provide supportive care to patients with pain related to malignancy, anticancer surgery, chemotherapy, or radiation therapy.

Educational Objectives

At the conclusion of this educational activity, participants should be better prepared to:

  • Describe the diagnostic criteria for BTP and clinical characteristics of various episode subtypes
  • Assess patients with cancer for transient increases in pain that compromise function or reduce quality of life
  • Tailor multimodal opioid-based regimens for cancer-related persistent pain and BTP to achieve adequate analgesia, reach functional goals, and minimize treatment-related risks
  • Comply with medical standards of care and Risk Evaluation and Mitigation Strategies when treating and monitoring patients who require prescription opioids for cancer pain
  • Educate patients with cancer pain about the safe use of prescription opioids, including transmucosal immediate-release fentanyl products

Statement of Need and Learner’s Gap

Cancer pain is prevalent and often inadequately treated.1,2 Affecting approximately one quarter of patients with newly diagnosed malignancy and more than three quarters of those with advanced cancer, pain is consistently reported as one of the most troubling cancer symptoms for patients and their families.1-4 Because pain is biopsychosocial in nature, it manifests clinically as a dynamic condition, with pain levels fluctuating over days, hours, and even minutes.5 Indeed, even when the persistent baseline component of cancer pain is generally controlled with an analgesic regimen, most patients will continue to experience short periods during the day when their pain spikes. Referred to as breakthrough pain (BTP), these transient episodes have been linked to increased physical disability, poor psychological status, and higher health care costs.3,6-8 In the oncology setting, the treatment of persistent and BTP frequently relies on opioid agonists.9,10 Implementing and tailoring opioid-based therapy require consideration of potential pain etiologies and patient-specific treatment goals and risks—a challenging task in the context of the myriad issues faced by the oncology health care team.10-12 Oncology nurses, in particular, often interact with patients throughout the continuum of cancer care, allowing them to identify untreated pain and advocate for affected individuals. This Evidence-Based Best Practices program will discuss comprehensive assessment and treatment approaches for cancer-related BTP, including Risk Evaluation and Mitigation Strategies associated with prescription opioids and patient-monitoring strategies to promote safe opioid use.


  1. Cohen MZ, Easley MK, Ellis C, et al. Cancer pain management and the JCAHO’s pain standards: an institutional challenge. J Pain Symptom Manage. 2003;25(6):519-527.
  2. Goudas LC, Bloch R, Gialeli-Goudas M, Lau J, Carr DB. The epidemiology of cancer pain. Cancer Invest. 2005;23(2):182-190.
  3. Svendsen KB, Andersen S, Arnason S, et al. Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms. Eur J Pain. 2005;9(2):195-206.
  4. Bruera E, Kim HN. Cancer pain. JAMA. 2003;290(18):2476-2479.
  5. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581-624.
  6. Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: characteristics and impact in patients with cancer pain. Pain. 1999;81(1-2):129-134.
  7. Fortner BV, Okon TA, Portenoy RK. A survey of pain-related hospitalizations, emergency department visits, and physician office visits reported by cancer patients with and without history of breakthrough pain. J Pain. 2002;3(1):38-44.
  8. Hwang SS, Chang VT, Kasimis B. Dynamic cancer pain management outcomes: the relationship between pain severity, pain relief, functional interference, satisfaction and global quality of life over time. J Pain Symptom Manage. 2002;23(3):190-200.
  9. Nalamachu S, Hassman D, Wallace MS, Dumble S, Derrick R, Howell J. Long-term effectiveness and tolerability of sublingual fentanyl orally disintegrating tablet for the treatment of breakthrough cancer pain. Curr Med Res Opin. 2010;27(3):519-530.
  10. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Fort Washington, Pennsylvania; 2010.
  11. Fine PG, Portenoy RK. A Clinical Guide to Opioid Analgesia. 2nd ed. New York: Vendome Group, LLC; 2007.
  12. Starr TD, Rogak LJ, Passik SD. Substance abuse in cancer pain. Curr Pain Headache Rep.2010;14(4):268-275.

Term of Offering

This activity was released on August 27, 2014 and is valid for one year. Requests for credit must be made no later than August 27, 2015.

For information about the accreditation of this program, please contact Global at 303-395-1782 or

Nursing Continuing Education

Global Education Group is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s COA.

This educational activity for 1.0 contact hours is provided by Global Education Group. Nurses should claim only the credit commensurate with the extent of their participation in the activity.

Instructions for Obtaining Credit

In order to receive credit, participants must complete the pre activity questionnaire, view the activity and complete the post test and evaluation form. Participants must also score at least a 75% on the post-test.

Fee Information & Refund/Cancellation Policy

There is no fee for this educational activity.

Disclosure of Conflicts of Interest

Global Education Group (Global) requires instructors, planners, managers and other individuals and their spouses/life partners who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity:

Michelle I. Rhiner, RN-BC, MSN, GNP-BC, ACHPN, CCN: Consultant/Independent contractor to INSYS Therapeutics Inc., and Speaker’s Bureau for Teva Pharmaceuticals, Inc.

Neal E. Slatkin, MD:Consultant/Independent contractor to INSYS Therapeutics Inc.

April Hazard Vallerand, PhD, RN, FAAN: Consultant/Independent contractor to AcelRx Pharmaceuticals Inc., and Speaker’s Bureau for Teva Pharmaceuticals, Inc.

The planners and managers reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity:

Ashley Marostica, RN, MSN: Nothing to disclose

Amanda Glazar, PhD: Nothing to disclose

Jim Kappler, PhD: Nothing to disclose

Stacey Hansen: Nothing to disclose

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global Education Group (Global) and Integritas Communications do not recommend the use of any agent outside of the labeled indications. 

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.


Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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expiration 08/27/2015

type Webcast