Oncological pain: the role of opioid drugs and the essential use of fentanyl

Pain, both acute and chronic, is one of the most disabling components of cancer, and its treatment is a clinical priority for our health service. The benefit is certainly a better quality of life, but also greater adherence to cancer treatments, the management of which by the patient is often compromised precisely because of a lack of pain control. A myth that needs to be dispelled is that cancer pain is exclusive to advanced-stage disease: on the contrary, it can occur at any stage of the pathway, even before the clinical manifestation of the neoplasm, during antineoplastic treatments and even after recovery, a condition that is increasingly common today thanks to advances in cancer therapies and early diagnosis.

In addition to chronic and continuous pain, which affects roughly half of all cancer patients, a very high percentage of patients suffer from violent flare-ups of their basic pain, known as breakthrough cancer pain (BTcP), which feel like stab wounds that occur rapidly and sometimes unpredictably, even several times a day, and are beyond the control of the basic medication, leading to very negative physical and psycho-emotional consequences.

The treatment of cancer pain relies on the use of known and safe drugs, and we clinicians are able to propose targeted therapeutic strategies that take into account the type of pain accompanying the malignancy and the individual needs of each patient.

According to the main national and international guidelines, the use of opioid drugs constitutes a fundamental therapeutic strategy for the treatment of cancer pain, and their appropriate and controlled use should not cause concern among patients. Among opioids, Fentanyl represents an irreplaceable therapeutic tool, long included by the World Health Organisation in the list of essential drugs for the treatment of pain in cancer patients. It is the most powerful analgesic molecule we have available in clinical practice and, compared to other drugs, it is able to enter the body through different routes of administration that guarantee immediate action of the molecule. In particular, sudden pain spikes (BTcP) need to be treated with a rapid and powerful analgesic drug such as Fentanyl, which can be administered quickly via the transmucosal route, i.e. by nasal spray and sublingual tablets, thus managing to resolve pain crises and make the patient feel better immediately. Moreover, the drug is rapidly metabolised and eliminated once absorbed, making it particularly suitable for patients with organ failure, e.g. liver or kidney failure.

Incoming innovations will make the use of Fentanyl even safer, thanks to 'smart' administration devices designed to minimise the risk of accidental overdose and abuse of the drug. This is good news for patients and the medical profession, with a view to ensuring, alongside the therapeutic benefit, the correct use of the drug. As emerged during the last Congress of the Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) dedicated to 'Pain and Palliative Care', innovation in this field can also play an important role in increasing knowledge of pain therapy and raising awareness of the importance and safety of opioids, essential drugs for the treatment of cancer pain, which should not be feared if one relies on medical supervision, in a context of personalised care.