British Journal of Pain

Fentanyl and alfentanil are potent, lipophilic, fast acting opioids with short durations of action and consequently more appropriate for the treatment of breakthrough cancer pain. These agents are ideal for oral transmucosal or nasal transmucosal administration.

There are now four licensed preparations of fentanyl in the UK for the treatment of cancer breakthrough pain; lozenge, buccal tablet, sublingual tablet and nasal spray. They are not interchangeable and all require titration using the lowest dose.

Alfentanil is available as a buccal or nasal spray. It is an unlicensed product and is available as a special order from Torbay Pharmacy Manufacturing Unit.

There is a paucity of comparator studies for these new modes of administration.

Further innovative delivery systems of fentanyl are on the horizon.

Transdermal opioids are safe, effective, and produce significantly fewer side effects than oral morphine when used for moderate to severe cancer pain.

Transdermal buprenorphine has a lower incidence of systemic side effects than transdermal fentanyl and it is indicated for use in cancer patients with neuropathic pain and renal dysfunction.

Transdermal opioids require a long lag period for dose stabilisation and elimination, hence are unsuitable for acute or unstable pain, and may result in prolonged side effects.

Transdermal analgesics reduce the need for frequent dosing, clock watching and are more convenient for patients, physicians and carers, hence increasing treatment compliance.

Maintain a low threshold for further investigation of such patients and for discussing them with specialist colleagues

If MSCC is suspected, commence high dose steroids (16mg dexamethasone orally in the morning) immediately

Ensure imaging to confirm diagnosis of MSCC is carried out within 24 hours of clinical suspicion

Ensure prompt treatment within 24 hours of diagnosis

Pain physicians are uniquely placed to provide interventions for patients with difficult to manage pain.

Interventions such as acupuncture, radiofrequency ablation, neurolysis together with regional analgesia including neuraxial techniques and spinal cordotomy may provide the patient with improved analgesia.