Immediate-release opioid therapy for breakthrough pain in patients who take a regular opioid

For patients with palliative care needs who take a regular opioid, the opioid dose for breakthrough pain (to be taken as required) is usually calculated as one-twelfth to one-sixth of the total amount of opioid taken in the previous 24 hours; do not include doses taken for incident pain. For patients who are older, frail, or have kidney or liver impairment, consider using a dose at the lower end of the range (ie one-twelfth).

If possible, use an immediate-release formulation of the same opioid for breakthrough pain as used for regular opioid therapy. Otherwise, use an equianalgesic dose of another opioid that is available as an immediate-release formulation1. However, if starting transmucosal fentanyl for breakthrough pain, do not use this approach as dose equivalence between transmucosal fentanyl formulations and other opioid formulations has not been established—seek expert advice.

The dose frequency for breakthrough doses depends on the opioid and formulation used, pain severity and stability, care setting and the patient’s goals of care.

Example of calculating a dose increase of opioid therapy in palliative care provides an example of calculating an increase in the breakthrough dose of an opioid in conjunction with an increase to the regular opioid dose.

1 Exercise caution when calculating breakthrough doses for cachectic patients receiving transdermal fentanyl because fentanyl absorption can be variable in these patients; breakthrough dose requirements are often significantly lower than would be suggested by conversion charts.Return