The Management of The Management of

Incident Pain Incident Pain

in Palliative Carein Palliative Care

What is Incident Pain?What is Incident Pain?

Pain occurring as a direct Pain occurring as a direct

and immediate consequence and immediate consequence

of a movement or activityof a movement or activity

Circumstances In Which Circumstances In Which Incident Pain Often OccursIncident Pain Often Occurs

• Bone metastasesBone metastases• Neuropathic painNeuropathic pain• Intra-abdominal disease aggravated by respirationIntra-abdominal disease aggravated by respiration

» “ “incident” = breathingincident” = breathing» ruptured viscus, peritonitis, liver hemorrhageruptured viscus, peritonitis, liver hemorrhage

• Skin ulcer Skin ulcer dressing change, debridement dressing change, debridement• DisimpactionDisimpaction• CatheterizationCatheterization

28 had pain w ith precipitant 23 had pain w ith no precipitant

51 pains

41 had 1 episodes of breakthrough pain in 24 hrs

n = 90 patientsstudied over 3 m onths

How Common is Incident Pain?How Common is Incident Pain?

Portenoy RK, Hagen NA Breakthrough pain: definition, prevalence, Portenoy RK, Hagen NA Breakthrough pain: definition, prevalence, and characteristics. Pain 1990 42:135-144and characteristics. Pain 1990 42:135-144

Barriers to Managing Incident Pain

• common opioids outlast painful stimuluscommon opioids outlast painful stimulus• opioid dose for incident pain may far exceedopioid dose for incident pain may far exceed that needed for background pain controlthat needed for background pain control• may be little warning of incidentmay be little warning of incident• effective premedication before activity is timeeffective premedication before activity is time consumingconsuming

Time

Incident Incident Incident

Pai

nHaving a steady level of enough opioid to treat the peaks of incident pain...

...would result in excessive dosing for the periods between incidents

Considerations In Managing Incident Pain

• usually predictable usually predictable

• stimulus is usually briefstimulus is usually brief

• frequency of incidents may vary fromfrequency of incidents may vary from several per minute to once per day or less.several per minute to once per day or less.

Approach to Incident Pain• treat underlying problemtreat underlying problem

» radiation Tx, chemotherapyradiation Tx, chemotherapy» bisphosphonatesbisphosphonates» orthopedic interventionorthopedic intervention» nerve blocksnerve blocks

• ideal analgesic:ideal analgesic:» easily administeredeasily administered» rapid onsetrapid onset» short-duration of actionshort-duration of action» in patient’s controlin patient’s control

Sublingual Absorption of Selected Opioid Analgesics

• fentanyl approx. 51% absorbed fentanyl approx. 51% absorbed

• higher lipid solubility higher lipid solubility higher absorptionhigher absorption

• peak absorption by 10 min.peak absorption by 10 min.

• 60% of max absorption by 2 60% of max absorption by 2 11//22 min min

Weinberg DS, et al Clin Pharmacol Ther 1988;44:335-43

Fentanyl and Sufentanil• synthetic synthetic µ agonist µ agonist opioids opioids • highly lipid soluble highly lipid soluble

» transmucosal absorptiontransmucosal absorption» rapid redistribution, including in / out of CSFrapid redistribution, including in / out of CSF

• fentanyl fentanyl 100x stronger than morphine100x stronger than morphine• sufentanil sufentanil 1000x stronger than morphine1000x stronger than morphine

10 mg morphine 10 mg morphine 10 µg sufentanil 10 µg sufentanil 100 µg fentanyl100 µg fentanyl

0

0.5

1

1.5

2

2.5

3

3.5

4

Onset (min) Peak (min) Duration(hr)

t 1/2 alpha(min)

t 1/2 beta(hr)

Ther.Index/10,000

Fentanyl

Sufentanil

Comparison of Fentanyl and SufentanilComparison of Fentanyl and Sufentanil

Intranasal Sufentanil for Pre-operative Sedation

• n = 39n = 39• all opioid naïveall opioid naïve• given 5, 10, or 20 µg nasallygiven 5, 10, or 20 µg nasally• median onset of sedation 10 min.median onset of sedation 10 min.• average duration of sedation 40.8 min.average duration of sedation 40.8 min.• 5 µg ineffective; all doses tolerated well5 µg ineffective; all doses tolerated well

Vercauteren M. et al; Anaesthesia 1988 43:270-73

INCIDENT PAIN PROTOCOLINCIDENT PAIN PROTOCOLSt. Boniface General Hospital Palliative CareSt. Boniface General Hospital Palliative Care

Step Medication # micrograms SL (50 g/ml)

1 Fentanyl 50 2 Sufentanil 25 3 Sufentanil 50 4 Sufentanil 100

INCIDENT PAIN PROTOCOL INCIDENT PAIN PROTOCOL ctd...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

Nasal SufentanilNasal 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.