Breakthrough Pain
Pain
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R52.9
DESCRIPITION
Breakthrough pain is a transient exacerbation of pain which either occurs spontaneously or in relation to a specific trigger, despite relatively stable and adequately controlled background pain. It may or may not be at the same location as the background (controlled) pain.
MEDICINE TREATMENT
- Treat breakthrough pain by giving an extra dose of immediate-release morphine equal to the regular 4-hour dose (i.e., one-sixth of the total daily dose).
- The next regular dose of morphine must still be given at the prescribed time, and not be delayed because of the additional dose.
LoE:IVb30
- The regular 4-hourly dosage should be titrated upward against the effect on pain in the following way:
- Add up the amount of “breakthrough morphine” used in the previous 24 hours.
- Divide this amount by 6 (the number of 4-hourly doses in 24 hours).
- Increase maintenance dose on the following day by that amount.
Example:
- Patient receives 10 mg morphine every four hours.
- The patient has 3 episodes of breakthrough pain over 24 hours and is given an additional 10 mg during each episode:
- Total breakthrough pain dosage: 3 x 10 mg = 30 mg.
- Dose to add to maintenance dose the following day: 30 mg ÷ 6 = 5 mg.
- The day following the breakthrough pain, the regular 4 hourly dose of 10 mg will be increased by 5 mg, i.e., 10 mg + 5 mg = 15 mg.
- The new morphine dose will be 15 mg 4 hourly.
CAUTION
Morphine can cause respiratory depression, monitor carefully.
REFERRAL
- Uncontrolled pain.
- Pain uncontrolled by step 1 of the stepwise management approach where no doctor is available.
- Severe emotional, or other distress, which may aggravate the perception of pain.
- Nausea and vomiting associated with pain in children.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024
Chapter 20: Pain_20.5 Breakthrough Pain