Monitoring therapy for breakthrough pain

The number of opioid doses taken can be used to monitor the adequacy of background pain management. If 3 or more as-required doses are used for breakthrough pain in 24 hours, review pain management.

For patients who are not taking a regular opioid, consider starting one; see Regular oral opioids for background pain in palliative care. If oral therapy is not possible, see Regular transdermal opioids for background pain in palliative care.

For patients who are taking a regular opioid, consider adjusting their regular opioid therapy; this may involve:

• increasing the dose
• switching formulations or route of administration (eg switching from regular immediate-release morphine to modified-release morphine)
• switching opioids.

For patients who feel or appear oversedated after a dose of as-required opioid for breakthrough pain, consider decreasing the next breakthrough dose. If the reduced dose does not provide adequate analgesia, consider using a rapid-acting opioid for the breakthrough pain (eg transmucosal fentanyl¹). In some cases, a patient’s preference for adequate pain relief may outweigh their desire to avoid sedation, Other patients may prefer to remain alert and be more able to interact, and accept that pain control is less than ideal.

Regularly review the breakthrough opioid doses taken and adjust the breakthrough and regular opioid dosage as needed. For the approach to monitoring analgesic therapy in palliative care, see Monitoring analgesic therapy in palliative care.