1. 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

2. 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

3. 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)

4. 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)

5. 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)

6. 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)

7. 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)

8. 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)

9. 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)

10. 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)

11. 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)

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

13. 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 minutes before the activity
Guide to Pain Management in Low-Resource Settings, IASP (2010)

14. 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)

15. 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

16. References
African Palliative Care Association. Beating Pain: a pocketguide for pain management in Africa, 2nd Ed. [Internet] Available from:
African Palliative Care Association. Using opioids to manage pain: a pocket guide for health professionals in Africa [Internet] Available from:
Amery J, editor. Children’s Palliative Care in Africa [Internet] Available from: Africa-Full-Text.pdf
Kopf A, Patel N, editors. Guide to Pain Management in Low-Resource Settings [Internet] Available from: 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