Managing Breakthrough Pain Across the Provider Continuum

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Release Date: December 06, 2013
Expiration Date: December 06, 2014

Expected time to complete this activity as designed: 90 minutes
There are no fees for participating in or receiving credit for this online activity.

Program Overview

This accredited activity will focus on providing the target audience of oncologists, pain medicine specialists, and primary care clinicians with not only an increased awareness of breakthrough pain (BTP), but also of strategies for assessing and treating this type of pain that will support improved patient outcomes. This program will stress the importance of facilitating clear and effective communications among the diverse members of the multi-specialty treatment team.

Target Audience

This activity is designed for physicians, pharmacists, and nurses who have an interest in enhancing their clinical skills in BTP.

Learning Objectives

Upon completion of this educational activity, participants should be able to:

  • Outline the difference between persistent pain and BTP assessment in cancer patients
  • Develop appropriate treatment plans for patients who are experiencing BTP based on clinical evidence and pharmacologic therapeutic strategies tailored to the unique needs of the individual patient
  • Describe risk reduction methods and criteria for use in the selection and long-term management of patients with BTP prescribed to chronic opioid therapy
  • Identify how the multi-specialist health care professional team may work together, through proactive communication and referral strategies, to ensure a consistently effective approach to the treatment of BTP in cancer patients


Welcome and Introductions – Michael J. Brennan, MD

Breakthrough Pain: Who, How and Why? – Paul Arnstein, RN, PhD, FAAN

Safe and Effective Treatment of Breakthrough Pain: Risk Assessment and Evaluation – Paul P. Doghramji, MD, FAAFP

Strategic Approaches to the Individualized Treatment of Breakthrough Pain – Michael J. Brennan, MD

Instructions for Participation and Credit

This activity is eligible for credit through December 6, 2014. After this date, this activity will expire and no further credit will be awarded.
1. Read the target audience, learning objectives, and faculty disclosures.
2. You may be asked to complete a short pre-test before accessing the educational content. This must be completed in order to move forward in the activity.
3. Complete the educational content as designed.
4. Complete the post-test. To receive a certificate, you must receive a passing score of 70%.
5. Complete the activity evaluation survey to provide feedback and information useful for future programming.
6. Certificates may be printed immediately after successfully completing the post-test and activity evaluation.

Faculty Biographies

Michael J. Brennan, MD
Medical Director
The Pain Center of Fairfield
Fairfield, Connecticut
Associate Director, Chronic Pain and Recovery Center
Silver Hill Hospital
New Canaan, Connecticut

Dr. Michael J. Brennan received his medical degree at the State University of New York Downstate Medical Center, and completed a residency in physical medicine and rehabilitation at the New York Hospital-Cornell University Medical Center, where he served as chief resident. While at New York Hospital, Dr. Brennan also served as chief resident at the International Center for the Disabled in New York City. Dr. Brennan is a board certified physiatrist in private practice in Fairfield, Connecticut.

After completing his residency, Dr. Brennan was appointed to the faculty of New York Hospital and Cornell Medical College in the Department of Physical Medicine and Rehabilitation. He served as acting chief of the rehabilitation service in the Department of Neurology at Memorial Sloan-Kettering Cancer Center. After leaving Sloan-Kettering, Dr. Brennan became the medical director of the Rehabilitation Center of Fairfield County and Ahlbin Centers for Rehabilitation Medicine and chief of the section of physical medicine at Bridgeport Hospital in Bridgeport, Connecticut. He is currently a senior attending physician in the Department of Medicine at Bridgeport Hospital and consulting physician at St. Vincent's Hospital in Bridgeport, Connecticut. He is associate director of the interdisciplinary chronic pain and addiction program at Silver Hill Hospital in New Canaan, Connecticut, which is designed to address the complex needs of patients suffering with chronic pain and substance misuse, addiction and behavioral disorders.

Dr. Brennan has special interests in the emerging role of pharmacogenomics, particularly as to the role of variability and vulnerability to opioid and adjuvant analgesics in individuals suffering with pain. He has recently published articles on opioids and pharmacogenomics opioid metabolism as well as articles concerning deleterious effects of opioids on the endocrine system. Dr. Brennan has a long-held interest in the management of pain as well as disability in patients suffering from the acute and long-term effects of musculoskeletal diseases, neurological disorders, cancer, and various cancer treatments. He has published over 40 scholarly articles, abstracts, and textbook chapters on the treatment of cancer and noncancer related disabilities including lymphedema and pain. He is a reviewer for several medical journals and has served as guest editor for the Journal of Musculoskeletal Rehabilitation and as online editor for Recently, Dr. Brennan was awarded the Dr. Elizabeth Narcessian Memorial Award from Kessler Institute, recognizing his commitment to the treatment of patients suffering from chronic pain.

Paul Arnstein, RN, PhD, FAAN
Clinical Nurse Specialist for Pain Relief
Massachusetts General Hospital
Boston, Massachusetts

Dr. Paul Arnstein earned a doctorate in nursing from Boston College in Chestnut Hill, Massachusetts and completed research training fellowships from the National Institutes of Health. For over 30 years, he has helped thousands of patients in pain. His work with patients, professionals, and policymakers is driven by a desire to ensure that no patient lives or dies with needless pain due to unrealistic fears and mistaken beliefs about pain and its treatment. His research has been referenced in the popular media and supports the value of nurse-led interventions that help chronic pain patients think, feel, and do better.

Dr. Arnstein was a founder and first president of the New Hampshire Cancer Pain Initiative and has served as president of the New England Pain Association and the American Society for Pain Management Nursing (ASPMN). He presided over ASPMN at a time when pain management nursing emerged as a specialty within nursing. Dr. Arnstein helped develop the core curricula, exam, and certification preparation materials that have benefited over 1,000 nurses and the patients they serve. As a liaison to the Joint Commission, and an advisor to legislators through the Pain Care Forum, Dr. Arnstein has expanded nursing's influence in promoting access to pain relievers and ensuring their safe use.

Dr. Arnstein has participated in the development and dissemination of several position papers to help reduce pain in vulnerable populations. He is a strong spokesperson for nursing's contributions for interdisciplinary programs and clinical guidelines developed by the American Pain Society, American Pain Foundation, and the Agency for Healthcare Research and Quality. Dr. Arnstein is widely published and frequently speaks at local, regional, and national levels addressing topics that help improve the way pain is managed.

Paul P. Doghramji, MD, FAAFP
Brookside Family Practice and Pediatrics
Pottstown, Pennsylvania
Medical Director, Health Services
Ursinus College
Collegeville, Pennsylvania

Dr. Paul Doghramji received his medical degree from Jefferson Medical College in Philadelphia and completed his residency in family practice at Chestnut Hill Hospital, also in Philadelphia. He is cofounder of Brookside Family Practice & Pediatrics in Pottstown, Pennsylvania. He has also been an attending physician in family practice, chair of the Utilization Management Committee, and physician advisor at Pottstown Memorial Medical Center. In addition, Dr. Doghramji is also medical director for health services at Ursinus College in Collegeville, Pennsylvania, and has been assistant medical director for health services at the Hill School in Pottstown.

Dr. Doghramji is certified by the American Board of Family Practice, a fellow of the American Academy of Family Physicians, and a member of the National Headache Foundation, and the Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS) Association of America. His work on sleep medicine has been published in Postgraduate Medicine, The Journal of Clinical Psychiatry, INSOM Magazine, and The International Journal of Clinical Practice, as well as various websites including Medscape and Pri-Med. He is co-author of the textbook Clinical Management of Insomnia.


Accreditation Statement: MediCom Worldwide, Inc. is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Designation Statement: MediCom Worldwide, Inc. designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

MediCom Worldwide, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity is acceptable for 1.5 contact hours of Continuing Education Credit. Universal Activity Number: 827-0000-13-377-H01-P. Knowledge-based CPE activity.

In order for CPE Monitor to authenticate credit, pharmacists/technicians must provide their e-Profile ID number from NABP and date of birth (in MMDD format) when registering for a CPE program. Please make sure to provide this information in your Member Profile accessed through the Member Center on the home page of this site.

Accreditation Statement: MediCom Worldwide, Inc., 101 Washington Street, Morrisville, PA 19067 is approved by the California Board of Registered Nursing, Provider Number CEP11380. MediCom designates this CNE activity for 1.5 contact hours. Program Number: 13-377-339


As an organization accredited by the Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE) and California State Board of Registered Nursing, MediCom Worldwide, Inc. requires everyone who is a position to control the content of an educational activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest. Accordingly, the following disclosures were made.

Faculty Disclosures

Dr. Michael Brennan has received honoraria related to speakers' bureau activities and as a consultant from Covidien; Endo Pharmaceuticals Inc.; Insys Therapeutics, Inc.; Millennium Pharmaceuticals, Inc. (A wholly-owned subsidiary of Takeda Pharmaceutical Company Limited); Purdue Pharma L.P.; Teva Pharmaceuticals; and Zogenix, Inc., as well as speakers' bureau activities from Johnson & Johnson Services, Inc.

Dr. Paul Arnstein has disclosed no relevant financial relationships.

Dr. Paul Doghramji has received honoraria related to formal advisory activities from Teva Pharmaceuticals, Merck & Co., Inc., URL Pharma Inc. (now Sun Pharmaceutical Industries Ltd.), as well as speakers' bureau activities from Purdue Pharma L.P. and Takeda Pharmaceutical Company Limited.

Planning Committee Disclosures

The individuals listed below from MediCom Worldwide, Inc. reported the following for this activity: Joan Meyer, RN, MHA, executive director, has no relevant financial relationships.

Peer Reviewer Disclosure

In accordance with MediCom Worldwide, Inc. policy, all content is reviewed by external independent peer reviewers for balance, objectivity and commercial bias. The peer reviewers have no relevant financial relationships to disclose.

Off-Label Disclosures/Investigational Disclosures

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Further, attendees/participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this program.

Dr. Brennan and Dr. Doghramji have indicated that they do not intend to discuss off-label uses of drugs, mechanical devices, biologics or diagnostics approved by the US Food and Drug Administration (FDA) for use in the US.

Drs. Brennan, Doghramji, and Arnstein have indicated that they do not intend to discuss investigational drugs, mechanical devices, biologics or diagnostics not approved by the FDA for use in the US.

Dr. Arnstein has indicated that he does intend to discuss off-label uses of drugs, mechanical devices, biologics or diagnostics approved by the US Food and Drug Administration (FDA) for use in the US.

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If you have any questions or concerns regarding this activity, please contact MediCom Worldwide, Inc. at 1-800-408-4242 or email us at

Provided by MediCom Worldwide, Inc.

This activity is supported by educational grants from Teva Pharmaceuticals

©2013 MediCom Worldwide, Inc., 101 Washington St., Morrisville, PA 19067, 800-408-4242.
No portion of this material may be copied or duplicated without the expressed permission of MediCom Worldwide, Inc.

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