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Integrated Therapeutics Iii

The document discusses different types of pain that may occur in patients with chronic pain, including breakthrough pain, pain emergencies, incident pain, and end-of-dose failure. It defines each type of pain and provides guidance on treatment approaches, including administering rescue doses of opioids to manage breakthrough pain or pain associated with activities. The goal in treating pain emergencies is to control pain as quickly as possible using intravenous opioids if needed. Adjusting background opioid doses based on rescue dose requirements can help manage breakthrough pain.

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Salahadin
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155 views

Integrated Therapeutics Iii

The document discusses different types of pain that may occur in patients with chronic pain, including breakthrough pain, pain emergencies, incident pain, and end-of-dose failure. It defines each type of pain and provides guidance on treatment approaches, including administering rescue doses of opioids to manage breakthrough pain or pain associated with activities. The goal in treating pain emergencies is to control pain as quickly as possible using intravenous opioids if needed. Adjusting background opioid doses based on rescue dose requirements can help manage breakthrough pain.

Uploaded by

Salahadin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 16

Breakthrough, emergency, and

incident pain
By Salahadin A.

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

2
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) 3


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) 4


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) 5


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) 6


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) 7


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) 8


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) 9


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) 10


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) 11


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

12
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) 13


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) 14


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

15
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.

16

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