Objectives
To assess the availability and appropriateness of breakthrough pain medication in cancer patients using fentanyl patches for pain.

Methods
An observational, cohort-based study was conducted using administrative healthcare data (2001-2014) to assess pain management in a cohort of fentanyl treated cancer patients. Fentanyl doses were calculated per patient-month, and used to determine an appropriate dose of immediate release (IR) opioid for breakthrough pain. Medication history for the month of the fentanyl use, and the preceding two months was reviewed to determine if such an appropriate IR opioid had been dispensed to the patient. Each patient-month of fentanyl use was then classified according to whether an appropriate dose of IR opioid was available for treating breakthrough pain.

Results
A total of 7,910 cancer patients using transdermal fentanyl patches were identified, for a total of 47,371 patient-months of observation time. Of this, 21,138 (44.6%) patient-months were associated with no concurrent IR opioid prescriptions. A further 8,694 (18.4%) patient-months were associated with inadequate levels of concurrent IR opioids. Only 17,539 (37.0%) patient-months were found where patients had filled prescriptions that could provide adequate breakthrough pain relief if required.

Conclusion
The availability of a breakthrough IR opioid medication for cancer patients using long action opioids is considered to be a standard of care. The recent Centers for Disease Control (CDC) opioid guideline suggests that transdermal fentanyl is often misunderstood by both clinician and patients”. More than half of cancer patients treated with fentanyl patches did not receive appropriate breakthrough medications. Pharmacists, as the keeper the patients medication history, should be playing a key role in management by making recommendations to improve the quality of care provided to patients with cancer.