pain and breakthrough pain

[Asterix]

In the BNF there is only reference to controlling breakthrough pain with reference to morphine. It states give a 1/6th of the normal dose for breakthrough.

What if the patient is on another medication for pain control? would it still be 1/6th for pain management

[Nik]

Morphine and oxycodone are the most commony used opioids for breakthrough pain. 1/6th the dose of regular morphine is used, or its equivalent if using say oxycodone instead. Many sources differ in whether to use 1/6th as the fraction, or as small as 1/10th or as high as 1/4. Immediate release morphine is actually not a suitable product for use as breakthrough analgesia, as oral morphine can take 30 mins to work and have an effect for up to 4 hours, and oxycodone lasts even longer. Most breakthrough episodes last up to 30 minutes so clearly it's not an ideal choice. The newer fentanyl products are much better for example, as they work much more quickly, and also have a shorter duration of action, reducing cumulative opioid side effects.

[Asterix]

so no matter what pain meds you are on, breakthrough pain is ALWAYS treated with oxycodone or morphine? so would you go for m/r morphine then

[johnep]

We had most scripts on morphine syrup for breakthrough as dose adjustment easy.
johnep

[Nik]

Diamorphine can be given to pts who are on continuous s/c diamorphine. By breakthrough pain I'm referring to treatment in chronic cancer or non cancer pain.

so would you go for m/r morphine then

Hmmm....would you want (or think it's appropriate to have) morphine modified release as breakthrough pain ? Download the pain module on cppe and have a read.

Johnep - dose titration is easy with oramorph, but the problem is the pharmacodynamics/kinetics of oral morphine. Incident pain, for example, which is related to specific triggers such as movement is often very short lived, and pts often get oramorph once the pain has kicked in. By the time it's had its effect, the pain may disappear. For incident pain therefore morphine should really be taken in advance. Fentanyl is licensed for breakthrough pain and in my opinion is probably better. If you look at Abstral, Effentora (tabs) and Actiq (lozenge) the dose is titrated according to response and isn't guided by the total amount of opioid taken during the day, as with morphine. Therefore they are allow indiviudal dose titration (particularly Actiq, where the pt can stop moving the lollipop around their mouth when their pain is relieved).

[Asterix]

If you giving a patient 10mg ormorph 4 times a day and you wanted break through pain relief would it then be 6mg (1/6th of 10mg) 4 times a day or would it be something in relation to the frequency of the dosage too

[Nik]

1/6th of the total daily dose (40mg) given every 4-6 hrs. Would usually round it to make it more appropriate for nurses to give, eg 5-10mg

[Asterix]

I have been reading up about morphine and a lot of the references are in relation to its use in cancer pain. If a patient (without cancer) had long term pain, would you see them put on morphine or something like codeine?

[Asterix]

breakthrough pain only related to palliative care?

[Nik]

As I have mentioned in an earlier post, breakthrough pain is not a concept used just in chronic cancer pain or in palliative medicine. The best definition now is " a transient exacerbation of pain, either occurring spontaneously or in relation to a specific trigger despite stable and adequately controlled background pain."