Breakthrough, emergency, and incident pain Disclaimer: This presentation contains information on the general principles of pain management. This presentation cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician, or health care provider, to determine the best course of treatment for the patient. Treat the Pain and its partners assume no responsibility for any injury or damage to persons or property arising out of or related to any use of these materials, or for any errors or omissions. Last updated on January 12, 2015

Objectives Define breakthrough pain and learn how to use rescue doses to treat it Learn how to adjust daily doses of opioids based on rescue dose requirements Learn how to diagnose a pain emergency and how to treat it Define and outline treatment for incident or procedural pain Define and outline treatment for end-of-dose failure

Breakthrough pain Breakthrough pain: a sudden, temporary flare of severe pain that occurs on a background of otherwise controlled pain May be more common during first three days of treatment as morphine dose is titrated from starting dose to effective dose Beating Pain, 2nd Ed. APCA (2012)

Breakthrough pain 50-70% of patients with chronic cancer-related pain also experience episodes of breakthrough pain Associated with greater pain-related functional impairment, worse mood, and more anxiety Healthcare providers routinely under-diagnose and under-treat breakthrough pain Guide to Pain Management in Low-Resource Settings, IASP (2010)

Diagnostic criteria Stable analgesic regimen in the previous 48 hours Presence of controlled background pain in the previous 24 hours (i.e. average pain score <5 out of 10) Temporary flare of severe or excruciating pain in the previous 24 hours Guide to Pain Management in Low-Resource Settings, IASP (2010)

Rescue dose Rescue dose: a dose of immediate-release morphine that is the same as the dose given every 4 hours and can be given as often as required to treat breakthrough pain Note these in the patient chart Write orders that include rescue doses Guide to Pain Management in Low-Resource Settings, IASP (2010)

Breakthrough pain and rescue doses Rescue dose should be administered at the first sign of breakthrough pain Pain that is allowed to build up is harder to control When you give a rescue dose of morphine to treat breakthrough pain you should still give the next regular dose on schedule The rescue dose must be increased whenever the regular dose is increased Rescue dosing is suitable for all immediate-release opioids, not just morphine Guide to Pain Management in Low-Resource Settings, IASP (2010)

Adjusting the background dose A frequency of 4 or fewer rescue doses per day is normal If a patient requires more than 4 rescue doses per day, you should increase the background dose Add total rescue doses to normal daily dose and divide by 6 Example: in a patient taking 10mg every 4 hours and 5 rescue doses of 10mg, new daily dose is (10*6)+(10*5)=110mg, given as 15 or 20mg every 4 hours If there is no need for rescue doses, you may try a small reduction in background dose Guide to Pain Management in Low-Resource Settings, IASP (2010)

Pain emergency The goal is to control pain (i.e. to get pain score below 5 out of 10) If patient is in excruciating pain (pain score=9 or 10), it is considered a pain emergency Administer rescue dose intravenously (IV) Remember to convert oral dose to IV dose by dividing by 2-3 Otherwise rescue doses can be oral Wait for dose to take effect (10 minutes for IV and 30 minutes for oral) and then reassess Repeat dose if pain score is 5 or higher Guide to Pain Management in Low-Resource Setting,. IASP (2010)

Spinal cord compression Spinal cord compression can cause severe pain Treat with dexamethasone 16-24mg per day In a pain emergency, may treat with IV dexamethasone: initial dose up to 100mg, followed by 60mg in three divided doses Continue dexamethasone until other treatment is started (radiotherapy or drug therapy), then taper off gradually Guide to Pain Management in Low-Resource Settings. IASP (2010)

Respiratory depression Pain is an antagonist for all depressing effects of opioids As long as the pain and the opioid dose are balanced, there will only be tolerable sedation and no respiratory depression That is why the goal of titration is to get to tolerable pain level (pain score <5 out of 10), not to get to no pain (pain score=0) Guide to Pain Management in Low-Resource Settings, IASP (2010)

Incident pain and end-of-dose failure Types of pain that are similar to breakthrough pain Incident pain End-of-dose failure

Incident or procedural pain Incident or procedural pain: Pain precipitated by a particular activity or procedure, such as dressing change, washing, change in position, eating, or disimpaction Can be anticipated Supplement regular analgesic regimen with a rescue dose given 20-30 minutes before the activity Guide to Pain Management in Low-Resource Settings, IASP (2010)

End-of-dose failure End-of-dose failure: Effect of analgesia wears off after a few hours and pain returns Treatment Change to a longer-acting medicine Increase the dose of the current medicine Reduce the dosing interval Guide to Pain Management in Low-Resource Settings, IASP (2010)

Take home messages Breakthrough pain may require rescue doses that are determined by the patient’s pain, in addition to regular pain treatment The goal of treating pain emergencies is to control pain Respiratory depression can be prevented with the proper balance of pain and opioid doses Rescue doses given before painful procedures or activities can reduce the pain they cause

References African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet]. 2012. Available from: http://www.africanpalliativecare.org/images/stories/pdf/beating_pain.pdf African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet]. 2010. Available from: http://www.africanpalliativecare.org/images/stories/pdf/using_opiods.pdf Amery J, editor. Children’s Palliative Care in Africa [Internet]. 2009. Available from: http://www.icpcn.org/wp-content/uploads/2013/08/Childrens-Palliative-Care-in- Africa-Full-Text.pdf Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet]. 2010. Available from: http://www.iasp- pain.org/files/Content/ContentFolders/Publications2/FreeBooks/Guide_to_Pain_ Management_in_Low-Resource_Settings.pdf The Palliative Care Association of Uganda and the Uganda Ministry of Health. Introductory Palliative Care Course for Healthcare Professionals. 2013.