1. The Management of
Incident Pain
in Palliative Care

2. What is Incident Pain?
Pain occurring as a direct and immediate consequence of a movement or activity

3. Circumstances In Which Incident Pain Often Occurs
Bone metastases
Neuropathic pain
Intra-abdominal disease aggravated by respiration
“incident” = breathing
ruptured viscus, peritonitis, liver hemorrhage
Skin ulcer ® dressing change, debridement
Disimpaction
Catheterization

4. How Common is Incident Pain?
Portenoy RK, Hagen NA Breakthrough pain: definition, prevalence, and characteristics. Pain :

5. Barriers to Managing Incident Pain
common opioids outlast painful stimulus
opioid dose for incident pain may far exceed
that needed for background pain control
may be little warning of incident
effective premedication before activity is time
consuming

6. Having a steady level of enough opioid to treat the peaks of incident pain...
...would result in excessive dosing for the periods between incidents
Pain
Incident
Incident
Incident
Time

7. Considerations In Managing Incident Pain
usually predictable
stimulus is usually brief
frequency of incidents may vary from
several per minute to once per day or less.

8. Approach to Incident Pain
treat underlying problem
radiation Tx, chemotherapy
bisphosphonates
orthopedic intervention
nerve blocks
ideal analgesic:
easily administered
rapid onset
short-duration of action
in patient’s control

9. Sublingual Absorption of Selected Opioid Analgesics
Weinberg DS, et al Clin Pharmacol Ther 1988;44:335-43
fentanyl approx. 51% absorbed
higher lipid solubility ® higher absorption
peak absorption by 10 min.
60% of max absorption by 2 1/2 min

10. Fentanyl and Sufentanil
synthetic µ agonist opioids
highly lipid soluble ®
transmucosal absorption
rapid redistribution, including in / out of CSF
fentanyl » 100x stronger than morphine
sufentanil » 1000x stronger than morphine
10 mg morphine
» 10 µg sufentanil
» 100 µg fentanyl

11. Comparison of Fentanyl and Sufentanil

12. Intranasal Sufentanil for Pre-operative Sedation
Vercauteren M. et al; Anaesthesia :270-73
n = 39
all opioid naïve
given 5, 10, or 20 µg nasally
median onset of sedation 10 min.
average duration of sedation 40.8 min.
5 µg ineffective; all doses tolerated well

13. INCIDENT PAIN PROTOCOL St. Boniface General Hospital Palliative Care

14. INCIDENT PAIN PROTOCOL ctd...
The opioid (fentanyl or sufentanil) is administered sublingually minutes prior to anticipated activity. The patient is asked to try to hold the liquid under the tongue for about 10 minutes if possible without swallowing it.
If the initial dose appears to be insufficient, that same dose may be repeated up to two further doses, at minute intervals.
If a given dose is sufficient, the patient will typically appear drowsy minutes following the dose. If this is not the case, or if the patient experiences discomfort during the planned activity, then repeat doses may be given as above.
Increasing to the next step of the Incident Pain Protocol is undertaken if the maximum number of doses (three) is required to achieve comfort, or is insufficient to achieve comfort with activity. Increasing to the next step of the Incident Pain Protocol cannot be done within one hour of the most recent fentanyl or sufentanil dose, except after contacting the physician. If the maximum number of doses (three) has been given, and the patient remains in discomfort with activity that must be undertaken presently, the physician should be contacted for consideration of immediately proceeding to the next step of the Incident Pain Protocol
The Incident Pain Protocol may be used up to q 1h prn

15. Nasal Sufentanil
As an alternative approach (this isn't part of the protocol)...
Consider nasal sufentanil (50 micrograms/ml undiluted injectable preparation) using a metered-dose nasal sprayer which delivers 0.1 ml per spray. This will deliver 5 micrograms sufentanil per spray, which is roughly equivalent to 5 mg morphine. This can be very useful for in-home care, where the preparation of pre-drawn syringes for sublingual administration can be tedious.
The patient simply takes one or more sprays approximately 10 to 15 minutes prior to activity, such as mobilizing to the toilet, or having a dressing changed.