The Management of Incident Pain in Palliative Care

1. The Management of Incident Pain in 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 metastases • Neuropathic pain • Intra-abdominal disease aggravated by respiration • “incident” = breathing • ruptured viscus, peritonitis, liver hemorrhage • Skin ulcer ® dressing change, debridement • Disimpaction • Catheterization

4. How Common is Incident Pain? Portenoy RK, Hagen NA Breakthrough pain: definition, prevalence, and characteristics. Pain 1990 42:135-144

5. Barriers to Managing Incident Pain • common opioids outlast painful stimulus • opioid dose for incident pain may far exceed • that needed for background pain control • may be little warning of incident • effective premedication before activity is time • consuming

6. Incident Incident Incident Having a steady level of enough opioid to treat the peaks of incident pain... ...would result in excessive dosing for the periods between incidents Pain Time

7. Considerations In Managing Incident Pain • usually predictable • stimulus is usually brief • frequency of incidents may vary from • several per minute to once per day or less.

8. Approach to Incident Pain • treat underlying problem • radiation Tx, chemotherapy • bisphosphonates • orthopedic intervention • nerve blocks • ideal analgesic: • easily administered • rapid onset • short-duration of action • in patient’s control

9. Sublingual Absorption of Selected Opioid Analgesics Weinberg DS, et al Clin Pharmacol Ther 1988;44:335-43 • fentanyl approx. 51% absorbed • higher lipid solubility ® higher absorption • peak absorption by 10 min. • 60% of max absorption by 2 1/2 min

10. Fentanyl and Sufentanil • synthetic µ agonist opioids • highly lipid soluble ® • transmucosal absorption • rapid redistribution, including in / out of CSF • fentanyl » 100x stronger than morphine • sufentanil » 1000x stronger than morphine 10 mg morphine » 10 µg sufentanil » 100 µg fentanyl

11. Comparison of Fentanyl and Sufentanil

12. Intranasal Sufentanil for Pre-operative Sedation Vercauteren M. et al; Anaesthesia 1988 43:270-73 • n = 39 • all opioid naïve • given 5, 10, or 20 µg nasally • median 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 10-15 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 10-15 minute intervals. • If a given dose is sufficient, the patient will typically appear drowsy 10 - 15 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 Protocol • The Incident Pain Protocol may be used up to q 1h prn

15. Nasal Sufentanil As 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.