Barriers to prescription of sublingual fentanyl tablets for breakthrough cancer pain in an out-patient cancer center

Breakthrough cancer pain (BTcP) is a significant source of distress for patients with cancer. Sublingual fentanyl tablets are the first rapid onset opioid targeted to treat BTcP available in Canada. Objectives: In this study we sought to review the use of this product in consecutive patients for efficacy and safety. Methods: A retrospective chart review was conducted of patients attending an out-patient palliative care clinic who received prescriptions for fentanyl tablets over six months. Data extracted included age, gender, palliative performance status (PPS), primary and secondary disease sites, concurrent cancer therapy, concurrent analgesics, and efficacy of sublingual fentanyl. Efficacy was defined as titration of sublingual fentanyl to achieve satisfactory control of pain as per patient report. Results: Twenty charts were reviewed. The mean age of patients was 58 years and the mean PPS score was 77%. The dose range of sublingual fentanyl was 100 micrograms (mcg) up to 800 mcg. The drug was documented to be effective and was continued through the follow-up period in nine patients. It was ineffective by ten patients. Only one patient experienced side effects. Conclusion: Successful titration of sublingual fentanyl for BTcP occurred in 50% of patients managed in our clinic. The safety profile in our case review was excellent with only one patient experiencing side effects requiring discontinuation of the medication.Coordinated efforts to improve out-patient titration (e.g. written instructions) as well as research into initiation of drug at higher doses (thereby requiring fewer titration steps) may improve the utility of this agent.