THE SCIENCE BEHIND PATIENT OUTCOMES

A 55-year-old woman was recently diagnosed with metastatic lung cancer, after several months of intractable cough and more recent onset of persistent, severe pain in her chest and upper extremities. Motivated by a desire to “get as much time as I can,” she took disability leave from her full-time job to pursue aggressive chemotherapy. Her pain has been both nociceptive and neuropathic, determined to be caused by bone metastases, pleuritic infiltration by tumor and brachial plexopathy from tumor encroachment. Baseline pain was well controlled after a course of dexamethasone and daily use of nonsteroidal anti-inflammatory drugs (NSAIDs). Celecoxib (Celebrex, Pfizer) twice daily was chosen for its “platelet-sparing” properties—especially important while undergoing chemotherapy—along with maximum titration of gabapentin (Neurontin, Pfizer) to tolerability (800 mg three times per day) and controlledrelease oxycodone (OxyContin, Purdue Pharma 40 mg three times daily, as twice-daily dosing resulted in end-ofdose failure and higher twice-daily doses caused excessive sedation). Prior use of morphine was discontinued because it made her feel “spaced out.” On this analgesic regimen, the patient continued to have a few episodes of spontaneous and incident pain each day. Spontaneous pain was predominantly neuropathic, affecting her right upper extremity, occurring rapidly and becoming “excruciating” within minutes. Incident pain in her chest wall region was highly predictable, occurring after standing and walking for more than a few minutes. The pain interfered greatly with her quality of life. She had been taking supplemental doses of hydrocodone/APAP and oxycodone, but these took too long to relieve her pain—especially when spontaneous—and lasted too long, causing her to be drowsy much of the day if she took more than a single dose. Considering the etiology and temporal patterns of this patient’s cancerrelated pain, it was determined that FENTORA would provide the flexibility required to meet her needs. Her physician discussed its use, benefits and risks, and initiated therapy with the lowest dose, 100 mcg. The patient then met with the supportive care nurse to review proper use of FENTORA, including an instruction sheet that had been prepared (Figure). They spoke briefly by phone each day to determine the optimum dose and timing of the BTP medication. After a few days, most spontaneous pain episodes could be well controlled with a single, 100-mcg dose of FENTORA. For incident pain, the patient took a dose a few minutes before initiating activity, and she would carry a second dose in the sealed blister pack if she took a walk, went shopping, attended medical appointments, etc., for additional use if needed. The result was that her pain was sufficiently well managed. Case 1 Recognition and Treatment of Breakthrough Pain