Acupuncture: a treatment for breakthrough pain in cancer?

Abstract

Patients with chronic cancer pain frequently suffer severe exacerbations of pain intensity which are difficult to control adequately via pharmaceutical management. Management of these episodes of breakthrough pain (BTP) presents a challenge both to the physician and the patient, and supplemental 'rescue' doses of opioids required to control BTP can produce intolerable side-effects and often do not act rapidly enough to provide adequate analgesia. There is very little evidence to support the use of acupuncture for BTP in cancer and few studies have considered the rapidity of the analgesic response to acupuncture for any type of pain. However, the available physiological evidence provides a convincing rationale and one which warrants research.
The objective of this paper is to debate the available physiological evidence for a rapid analgesic response to acupuncture in the context of the needs of the patient with cancer BTP, current interventions, acupuncture technique and the practical considerations involved in administering treatment rapidly and safely.
Current evidence suggests that acupuncture has the potential to produce rapid and effective analgesia when needles are inserted deeply enough and manipulated sufficiently. For cancer BTP this represents a possible adjunctive treatment, and consideration should be given to administering acupuncture alongside 'rescue' doses of medication to 'kick-start' the analgesic response before the medication takes effect. However, research is needed to provide evidence that acupuncture is effective for BTP in cancer, and the feasibility, practicality and safety of patients administering acupuncture themselves must also be taken into account.

Full text

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1Research & Effectiveness
Department, Airedale NHS
Foundation Trust, Steeton,
Keighley, UK
2Health and Social Sciences,
Leeds Metropolitan University,
Leeds, UK
3Leeds Pallium Research
Group, Leeds, UK
4Pain and Analgesia, Centre
for Pain Research, Leeds
Metropolitan University,
Leeds, UK
5Leeds Institute of Health
Sciences, School of Medicine,
University of Leeds, Leeds, UK
Correspondence to
Carole A Paley, Research &
Effectiveness Department,
Ward 12 Research Offi ce,
Airedale General Hospital,
Airedale NHS Foundation
Trust, Skipton Road, Steeton,
Keighley BD20 6TD, UK;
biodynamics.physiotherapy@
tesco.net
Accepted 25 August 2011
Published Online First
23 September 2011
Acupuncture: a treatment for breakthrough
pain in cancer?
Carole A Paley,1–3 Mark I Johnson,3,4 Michael I Bennett3,5
ABSTRACT
Context Patients with chronic cancer pain frequently
suffer severe exacerbations of pain intensity which
are diffi cult to control adequately via pharmaceutical
management. Management of these episodes of
breakthrough pain (BTP) presents a challenge both to
the physician and the patient, and supplemental ‘rescue’
doses of opioids required to control BTP can produce
intolerable side-effects and often do not act rapidly
enough to provide adequate analgesia. There is very
little evidence to support the use of acupuncture for BTP
in cancer and few studies have considered the rapidity
of the analgesic response to acupuncture for any type
of pain. However, the available physiological evidence
provides a convincing rationale and one which warrants
research.
Objective The objective of this paper is to debate the
available physiological evidence for a rapid analgesic
response to acupuncture in the context of the needs
of the patient with cancer BTP, current interventions,
acupuncture technique and the practical considerations
involved in administering treatment rapidly and safely.
Conclusion Current evidence suggests that
acupuncture has the potential to produce rapid and
effective analgesia when needles are inserted deeply
enough and manipulated suffi ciently. For cancer BTP
this represents a possible adjunctive treatment,
and consideration should be given to administering
acupuncture alongside ‘rescue’ doses of medication to
‘kick-start’ the analgesic response before the medication
takes effect. However, research is needed to provide
evidence that acupuncture is effective for BTP in cancer,
and the feasibility, practicality and safety of patients
administering acupuncture themselves must also be
taken into account.
INTRODUCTION
Pa ti en ts wi th c hr on ic c an ce r p ai n f req ue nt ly su ff er
severe exacerbations of pain intensity which are
diffi cult to control adequately via pharmaceuti-
cal management. These episodes of breakthrough
pain ( BTP) may often be movement-related but
may also occur spontaneously. Occasionally BTP
occurs as an ‘end of dose’ exacerbation of pain
shortly before the next administration of pain
relief is due, although this may be corrected by
dose-frequency alteration.1
Management of BTP presents a challenge to
both the physician and the patient. Chronic back-
ground pain may be controlled adequately by the
use of opioid-based analgesia, but the supplemen-
tal ‘rescue’ doses of opioids required to control
BTP can produce intolerable adverse events and
often do not act rapidly enough to provide ade-
quate analgesia.2–4
Non-pharmacological approaches to controlling
cancer pain have been used. These include psycho-
logical approaches1 and various complementary
therapies5–7 including massage,8 hypnosis,9 trans-
cuta neous elec trica l nerve st imul ation ( TENS )10 and
acupuncture.11–15 However, much of this literature
appears to consider chronic or background cancer
pain, or does not make a clear distinction between
this and BTP. Only one study was identifi ed which
investigated the use of TENS for the relief of BTP
in patients with pain from bone metastases.10 The
authors found that TENS showed signifi cant ben-
efi t in terms of pain relief but did not show a sig-
nifi cant benefi t on pain intensity.
Recent systematic reviews have revealed studies
investigating the use of complementary therapies
for cancer-related pain,16 17 two of which consid-
ered acupuncture specifi cally.18 19 None of these
reviews provided suffi cient robust evidence to
support the use of acupuncture for cancer-related
pain and no published evidence investigating the
use of acupuncture specifi cally for BTP in cancer
was found. Nonetheless, the available physiologi-
cal evidence allows a convincing rationale for the
us e of acu pun cture in c anc er pai n to be proposed12
and further well-designed studies investigating
this should be encouraged.
There is ver y little evidence to support the use
of acupuncture for BTP in cancer and few stud-
ies have considered the rapidity of the analgesic
response to acupuncture for any type of pain.
For the patient with BTP the overriding factor
is the need to obtain rapid analgesia at onset of
BTP, without the unpleasant side-effects incurred
through the use of strong opioid medication. If
acupuncture proves an effective means of achiev-
ing such analgesia, it needs to be established what
dose and technique is most effective and consider-
ation should be given to the safety and practicali-
ties of pat ients self-admi nistering acupuncture. In
this paper we discuss the physiological evidence
for a rapid analgesic response to acupuncture in
the context of the needs of the patient with BTP.
BREAKTHROUGH CANCER PAIN:
CHARACTERISTICS, INCIDENCE AND
CURRENT THERAPIES
BTP i n cancer is usually defi ned as a tra nsient exac-
erbation of pain which breaks through otherwise
stable analgesia or persistent chronic pain. It may
occur as movement-related pain (incident pain), as
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a spont aneous idiopathic att ack or as an ‘end of dose’ pain that
occurs when a previous dose of analgesia is wearing off.20 The
background, persistent pain may be well controlled, but BTP is
severe with a rapid onset and is diffi cult to control.21
BTP is common in many cancer patients, particularly in
those with bone metastases,21 and surveys show an incidence
rate of between 50% and 89%.3 22–24 One study suggested
that in more than half of patients experiencing BTP the fl are-
up was movement-related23 and this closely aligns with the
fi ndings of other investigators.1 24 It has been suggested that
45% of cancer patients have inadequate pain control.25 In a
large pan-European survey, it was reported that 63% of can-
cer patients receiving prescription-only analgesics either had
BTP or inadequate pain relief and 58% of these constantly had
inadequate pain relief.26
The severity, relative unpredictability and rapid onset of
BTP make it very diffi cult to control using drug regimens. One
survey indicated that the mean time from onset to peak pain
was 3.2 min (±19.4) and almost half of these patients expe-
rienced no predictability at all.24 Another survey found that
94% of patients found BTP ‘severe’ or ‘excruciating’ and 37%
of patients reported a BTP onset to peak time of less than 5
min.3 Patients sometimes experience repeated bouts of BTP
throughout the day and the occurrence of BTP is associated
with greater psychological distress and loss of function.24
Current treatments for BTP usually involve oral ‘rescue’
doses of opioid-based analgesics, usually fentanyl preparations
which are quickly absorbed via the oral mucosa and are often
given in the form of a ‘lollipop’ or effervescent tablet, although
more recently tablets and fi lms which adhere to t he oral mucosa
have been developed.27 Most of these fast-acting preparations
become effective within 15 min of administration which,
while more rapid than other opioids, would still be inadequate
for patients who experience onset to peak BTP within just a
few minutes. Also, as these preparations are potent opioids,
patients often experience adverse events such as nausea, dizzi-
ness, somnolence, vomiting, constipation and headache, which
may continue long after the bout of BTP has resolved.4 27 There
are also issues regarding the underprescribing of these drugs for
BTP, incorrect choice or agent, formulation and frequency of
administration, either because of a poor understanding of the
nature of the drug, the pain, or inadequate pain assessment.20
The issues for patients with BTP are threefold: the need for
rapid analgesia which acts in less than 5 min after adminis-
tration; the need for analgesia which is effective in relieving
BTP; and the need for fewer analgesia-related adverse events.
Acupuncture has been untested in this respect, although there
are indications that it might prove to be effective in provid-
ing acute pain relief28 and could possibly be used either alone
or in combination with fentanyl or other opioid preparations.
Controlled studies of acupuncture and other stimulatory tech-
niques will provide useful evidence in this respect.
ACUPUNCTURE ANALGESIA
Acupuncture has been shown to be an intervention with few
adverse effects and one which is relatively safe if administered
by well-trained practitioners.29–31 However, a recent system-
atic review has highlighted the fact that acupuncture is still
associated with serious compl ications, often from pneumotho-
rax or infection due to practitioner malpractice, resulting in
some fatalities.32 Peer-reviewed safety guidelines are available
for the use of acupuncture with cancer patients33 and a recent
review suggests practical strategies for enhancing safety.34 If
it is feasible to induce rapid onset analgesia through acupunc-
ture, the ideal scenario is one where patients can self-needle as
soon as BTP occurs. Self-needling is a controversial subject in
itself35 and safety/infection control is an important consider-
ation. Serious adverse events in acupuncture are often a result
of inappropriate deep needling and poor anatomical knowl-
edge, suggesting that self-needling techniques should be at
relatively ‘safe’ points which are easy to locate. The education
of patients would therefore be crucial to the success and safety
of the treatment. However, putting this debate to one side, the
main practical issues for patients would include:
the ease of administering the needles;
▶
the ease of locating needle placements; ▶
the number of needles to be inserted; ▶
the ease of stimulating the needles once in situ. ▶
In spite of its obvious potential, there has been relatively
little published research investigating rapid onset acupuncture
analgesia (AA) for any condition. Nevertheless, recent studies
looking at the mechanical effects of needle stimulation36 and
others investigating needle sensation and the effects of acu-
puncture are encouraging.37 38
Carlsson39 distinguishes between AA which has been used
in China for powerful and immediate analgesia during surgery,
and therapeutic acupuncture which takes longer to act but has
longer term effects. Mann40 reported observations on patients
receiving AA and found that relatively few of them (approxi-
mately 10%) experie nced analge sia which would be ad equate for
surgery and that those patients who did were ‘strong reactors’
to acupuncture. He suggested that in order to achieve rapid and
effective analgesia in more patients, the acupuncture stimulus
would have to be so intense as to be unbearably uncomfortable.
This fi nding may be explained by the phenomenon of ‘counter-
irritation’ as seen in the physiological mechanism underlying
the concept of diffuse noxious inhibitory control (DNIC).41– 44
However, in cancer BTP while it might not be realistic to expect
complete analgesia, it may be possible to lessen the severity of
the pain while giving time for supplementar y medication to act,
thus allowing more patients to benefi t from it.
Literature reviews have revealed a few studies investigating
the use of acupuncture for acute pain conditions, although it
has been used with some success in postoperative pain.45 The
results of a recent systematic review suggested that periopera-
tive acupuncture might help reduce postoperative pain in some
patients28 and a more recent study revealed that preoperative
electroacupuncture reduced the use of postoperative fentanyl
in patients undergoing cardiac surgery.46 The authors specu-
late that the use of both low and high frequencies adminis-
tered in a number of sessions for a few days before surgery
might maximise the analgesic effect via the release of differ-
ent opioid peptides. With cancer BTP this might be diffi cult
to achieve, as the incidence is often spontaneous and unpre-
dictable, but it does suggest that by maintaining an optimal
background level of analgesia for cancer pain, bouts of BTP
would be less severe in their intensity. This is supported by
the fi ndings of a survey of 164 patients with BTP where it was
found that background pain was more severe and intense in
patients suffering from BTP.24
PHYSIOLOGICAL RATIONALE FOR RAPID
ACUPUNCTURE ANALGESIA
Although little has been published on the speed of AA, recent
evidence suggests that the mechan ical effect s of manual needle
stimulation are more extensive than was once thought.36 47 48
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Needle manipulation has traditionally been carried out to
enhance needle sensation (‘de qi’) and although some inves-
tigators consider this sensation to be a marker of analgesic
response,49 50 this is by no means a universal opinion.51 Recent
research has suggested that the intensity of the ‘de qi’ response
to acupuncture is a direct result of the mechanical transduc-
tion which occurs during needle manipulation and the greater
the mechanical effect, the more intense the needle sensation.37
38 Whether the ‘de qi’ sensations are linked with therapeutic
response is unclear, however studies carried out by Langevin
and colleagues have clearly shown the relationship between
bi-directional needle rotation and connective tissue response,
and have also demonstrated a relationship between connective
tissue planes and traditional Chinese meridians.36 48 Therefore
the evidence suggests that intensive needle manipulation will
achieve maximal tissue response to acupuncture which will
occur along connective tissue planes that correspond closely
with acupuncture meridians. It should be possible to pro-
duce this effect as soon as the needles are inserted into the
tissues via digital stimulation and maintain it throughout the
treatment.
In addition to the mechanical effects of needle stimulation,
acupuncture is thought to produce analgesia via segmental
and extra-segmental inhibitory mechanisms via the stimula-
tion of Aδ, Aδ and C fi bres in the skin and underlying tissues.
However, the resultant release of chemical mediators of pain,
such as endogenous opioids, serotonin, noradrenalin, adreno-
corticotrophic hormone, cholecystokinin, nerve growth factor
and oxytocin, is not immediate and analgesia resulting from
this is more useful for chronic pain conditions.52–54
DNIC may explain why pain mediation occurs only while
the stimulation lasts.42 55 56 The process of DNIC describes
the application of a noxious stimulus outside the receptive
fi eld of the original painful stimulus which effectively blocks
the original sensation of pain.42 57 58 There is a clear relation-
ship between the intensit y of the stimulus and the strength
of DNIC and this helps to explain the ‘counter-irritation’ the-
ory which has been utilised in therapeutic interventions for
many decades. DNIC is activated by intense stimulation of
Aδ and C fi bre afferents arising from peripheral receptors and
may be initiated by noxious mechanical stimulation, noxious
heat, cold, TENS or injection of bradykinin.43 44 56 In manual
acupuncture it has been suggested that DNIC-like inhibitory
effects are produced by needle manipulation of muscle rather
than cutaneous tissue and that this typically produces a ‘de
qi’ sensation.59 60 It has also been demonstrated that bi-direc-
tional needle rotation produces signifi cant mechanical stimu-
lation of intramuscular primary afferents (Aδ and C fi bres) via
the deformation of connective tissues which wind themselves
around the needle36 and therefore suggests that deeper nee-
dling is required to initiate DNIC. The speed of pain inhibition
elicited by DNIC has also been illustrated in a recent study
which reported a signifi cant decrea se in pai n scores on a visual
analogue scale only a few seconds after a heterotopic noxious
conditioning stimulus was applied.56
THE WAY FORWARD
Fast-acting fentanyl-based drugs using different routes of
administration (sublingual/intranasal) are currently being
developed. It is probably unlikely that acupuncture will pro-
vide complete relief from BTP in the majority of patients,
as complete hypoalgesia using acupuncture has only been
achieved in a few individuals during surgery. The current
evidence indicates that ac upuncture has the potential to deliver
short-term, rapid-onset analgesia to provide early support for
the patient with BT P in conjunction with conventional phar-
macological management. Additionally, as it has been shown
that improved background pain control lessens the severity
of BTP, regular acupuncture treatments aimed at controlling
background pain might also be effective.
CONCLUSIONS
Current evidence suggests that acupuncture has the poten-
tial to produce rapid and effective analgesia when needles are
inserted deeply enough and manipulated suffi ciently to pro-
duce intense stimulation of afferent Aδ and C fi bres. It is likely
that the inhibition of pain occurs due to DNIC mechanisms
and might only last for the duration of the stimulation. For
cance r BT P thi s re prese nts a poss ible ad jun ctive tre atment, a nd
consideration should be given to administering acupuncture
alongside ‘rescue’ doses of medication to ‘kick-start’ the anal-
gesic response before the medication takes effect. However,
research is needed to provide evidence that acupuncture is
effective for BTP in cancer, and the feasibility, practicality and
safety of patients administering acupuncture themselves must
also be taken into account. Consideration might also be given
to less invasive techniques such as acupressure which may be
safer, easier to teach and more acceptable to patients.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Contributors CAP contributed substantially to the concept, review of the
literature, discussion and analysis of the topic covered in this review. MIJ made
a substantial contribution to the analysis of information and the discussion. MIB
made a substantial contribution to the factual content and the analysis of cancer-
related information. All three authors were responsible for drafting the article and
approving the fi nal version.
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doi: 10.1136/bmjspcare-2011-000066
September 23, 2011 2011 1: 335-338 originally published onlineBMJ Support Palliat Care
Carole A Paley, Mark I Johnson and Michael I Bennett
pain in cancer?
Acupuncture: a treatment for breakthrough
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