Presentation on theme: "The Management of Incident Pain in Palliative Care."— Presentation transcript:
1 The Management ofIncident Painin 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 metastasesNeuropathic painIntra-abdominal disease aggravated by respiration“incident” = breathingruptured viscus, peritonitis, liver hemorrhageSkin ulcer ® dressing change, debridementDisimpactionCatheterization
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 stimulusopioid dose for incident pain may far exceedthat needed for background pain controlmay be little warning of incidenteffective premedication before activity is timeconsuming
6 Having a steady level of enough opioid to treat the peaks of incident pain... ...would result in excessive dosing for the periods between incidentsPainIncidentIncidentIncidentTime
7 Considerations In Managing Incident Pain usually predictablestimulus is usually brieffrequency of incidents may vary fromseveral per minute to once per day or less.
8 Approach to Incident Pain treat underlying problemradiation Tx, chemotherapybisphosphonatesorthopedic interventionnerve blocksideal analgesic:easily administeredrapid onsetshort-duration of actionin patient’s control
9 Sublingual Absorption of Selected Opioid Analgesics Weinberg DS, et al Clin Pharmacol Ther 1988;44:335-43fentanyl approx. 51% absorbedhigher lipid solubility ® higher absorptionpeak absorption by 10 min.60% of max absorption by 2 1/2 min
10 Fentanyl and Sufentanil synthetic µ agonist opioidshighly lipid soluble ®transmucosal absorptionrapid redistribution, including in / out of CSFfentanyl » 100x stronger than morphinesufentanil » 1000x stronger than morphine10 mg morphine» 10 µg sufentanil» 100 µg fentanyl
12 Intranasal Sufentanil for Pre-operative Sedation Vercauteren M. et al; Anaesthesia :270-73n = 39all opioid naïvegiven 5, 10, or 20 µg nasallymedian 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 ProtocolThe Incident Pain Protocol may be used up to q 1h prn
15 Nasal SufentanilAs 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.