Pain can be acute or chronic. The two major types of chronic pain are nociceptive pain and neuropathic pain. Nociceptive pain can be treated with nonopioid analgesics or opioids. Neuropathic pain is less responsive to opioids and is often treated with adjuvant drugs such as antidepressants and antiepileptics. Combining different types of analgesics may provide an additive analgesic effect without increasing adverse effects.

The FDA has approved a nasal spray formulation of fentanyl (Lazanda – Archimedes) for management of breakthrough pain in adult cancer patients who are already receiving and are tolerant to opioid therapy. Fentanyl is already available in the US for intravenous, intrathecal, epidural, transdermal and oral transmucosal use.

The FDA has approved the marketing of fentanyl sublingual tablets (Abstral – ProStrakan) for treatment of breakthrough pain in adult cancer patients who are already receiving and are tolerant to opioid therapy. It is the fourth transmucosal formulation of fentanyl to become available in the US for this indication.1-3

The manufacturer recommends an initial dose of 100 mcg, a maximum of 2 doses per breakthrough pain episode, and use for no more than 4 breakthrough pain episodes per day. As with all formulations of fentanyl, strong inhibitors of CYP3A4 such as clarithromycin (Biaxin, and others) or itraconazole (Sporanox, and others) can increase serum concentrations of the drug to levels that can cause respiratory depression even in opioid- tolerant patients. A single dose of any formulation of transmucosal fentanyl could be fatal for a child.

1. Fentanyl buccal tablet (Fentora) for breakthrough pain. Med Lett Drugs Ther 2007; 49:78.

2. Drugs for pain. Treat Guidel Med Lett 2010; 8:25.

3. Fentanyl buccal soluble film (Onsolis) for breakthrough cancer pain. Med Lett Drugs Ther 2010; 52:30.

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Fentanyl buccal soluble film (Onsolis – Meda) has been approved by the FDA for treatment of breakthrough pain in adult cancer patients who are already taking and are tolerant to around-the-clock opioid therapy. It is designated as a Schedule II controlled substance Two other oral transmucosal formulations of fentanyl are already available for this indication.

Pain can be acute or chronic. Chronic pain has been broadly classified into two types: nociceptive and neuropathic. Nociceptive pain can be treated with nonopioid analgesics or opioids. Neuropathic pain is less responsive to opioids; adjuvant medicines such as antidepressants and anticonvulsants are often used to treat neuropathic pain. Combining different types of analgesics may provide an additive analgesic effect without increasing adverse effects.