Page 40 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Management of Cancer Pain (Second Edition)

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• Patients with persistent cancer pain should be prescribed with regular
(around-the-clock) analgesia.
{ Opioid doses must be titrated to achieve optimal pain relief with
minimal adverse events.
{ Long-acting opioid formulations may be considered for patients
once the effective opioid dose has been established.

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setting of chronic pain managed with analgesics around-the-clock. 11
• Breakthrough pain: 41
{ typically, is of rapid onset, severe in intensity and self-limiting, with an
average duration of 30 min
{ affects over 50% of patients with cancer
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stays in hospital

Every patient on an opioid should have access to rescue analgesia
in order to ensure optimal pain control. There are two subtypes of
breakthrough pain which are spontaneous pain and incident pain.
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other hand, incident pain is related to an activity e.g. movement and
is predictable. Incident pain therefore may be managed by taking
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medication prior to the action which precipitates it. This needs to be
differentiated from end-of-dose failure which occurs when medication
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and may be attributed to inadequate analgesic doses or dose intervals
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for pain control. 42

The consensus and standard of care have been on using 5% to 15%
(up to 20%) of the morphine equivalent daily dose (MEDD) in the form
of an oral IR opioid to manage transient pain episodes. 43, level III Evidence
to establish the appropriate dose of morphine for breakthrough pain is
lacking. However, the widely accepted ratio of the rescue dose to the
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4-hourly opioid dose. In cases where smaller rescue doses are required
e.g. in renal impairment, doses as low as 1/12 of the 24-hour dose can
be used. This ‘rescue’ dose may be given as frequently as required (up
to hourly). The ATC dose may be adjusted considering the total amount
of rescue morphine taken for the last 24 hours. 9; 44, level I

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