What is the best option for a patient experiencing breakthrough pain while taking hydrocodone (Hydrocodone bitartrate) 10/325 (Acetaminophen) two tablets every eight hours?

From the Guidelines

For a patient experiencing breakthrough pain while on hydrocodone 10/325 mg 2 tablets every 8 hours, the best option would be to add a short-acting rescue medication, such as immediate-release opioids, at a dose of 5%-20% of the daily regular morphine equivalent daily dose, as needed for breakthrough pain. This approach is supported by the most recent and highest quality study, which recommends prescribing immediate-release opioids for breakthrough pain 1. The daily regular morphine equivalent daily dose for the patient's current hydrocodone regimen can be calculated to determine the appropriate dose for the rescue medication.

Key Considerations

• The patient's current opioid regimen should be assessed to determine the daily regular morphine equivalent daily dose.
• The rescue medication dose should be calculated as 5%-20% of the daily regular morphine equivalent daily dose, as recommended by the ASCO guideline 1.
• The patient should be monitored for side effects, such as sedation, respiratory depression, and constipation, with appropriate preventive measures implemented.
• Regular reassessment of the patient's pain is crucial to determine if additional non-opioid interventions might be beneficial.

Breakthrough Pain Management

• The use of immediate-release opioids for breakthrough pain is recommended, with the dose based on the patient's daily regular morphine equivalent daily dose 1.
• Opioids with a rapid onset and short duration are preferred for breakthrough doses, as they can provide quick relief from pain.
• The repeated need for rescue doses per day may indicate the need to adjust the baseline treatment, such as increasing the dose or switching to a long-acting opioid formulation.

Additional Interventions

• Non-opioid interventions, such as NSAIDs or acetaminophen, may be considered for patients with mild pain intensity or as adjuvant analgesics to enhance the effects of opioids.
• Consultation with a pain specialist may be warranted if pain continues to be poorly controlled, to consider other options such as long-acting opioid formulations or adjuvant medications.

From the FDA Drug Label

The usual adult dosage is one tablet every four to six hours as needed for pain. If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the hydrocodone bitartrate and acetaminophen tablets dosage Individually titrate hydrocodone bitartrate and acetaminophen tablets to a dose that provides adequate analgesia and minimizes adverse reactions

The best option for a patient on hydrocodone 10/325 2 tabs q8 with breakthrough pain would be to:

• Attempt to identify the source of increased pain before adjusting the dosage
• Consider increasing the dosage, but individually titrate to a dose that provides adequate analgesia and minimizes adverse reactions, as the current dosage is already 2 tabs q8 which is higher than the recommended 1 tab q4-6h 2
• Monitor for adverse reactions and adjust the dosage accordingly to obtain an appropriate balance between management of pain and opioid-related adverse reactions.

From the Research

Breakthrough Pain Management

The patient is currently on hydrocodone 10/325 2 tabs q8 and is experiencing breakthrough pain. To manage this, several options can be considered:

• Short-acting opioid analgesics are the primary treatment for breakthrough pain, as stated in 3.
• The absorption characteristics, onset of action, and duration of effect vary among available opioid compounds based on their lipophilicity, as mentioned in 3.
• Rapid-onset transmucosal lipophilic opioids are most effective for patients with unpredictable incident or idiopathic breakthrough pain, as noted in 3 and 4.
• Transmucosal, buccal, sublingual, and intranasal fentanyl have been shown to provide rapid analgesia in comparison with oral morphine or placebo, as stated in 5.
• The dose and/or dosing frequency of the around-the-clock (ATC) analgesic should be adjusted for patients with end-of-dose breakthrough pain, as recommended in 3.

Considerations for Opioid Selection

When selecting an opioid for breakthrough pain management, the following factors should be considered:

• The patient's current opioid regimen and tolerance, as mentioned in 5.
• The severity and frequency of breakthrough pain episodes, as noted in 3.
• The potential for opioid-related adverse outcomes, such as overdose or substance use disorder, as discussed in 6.
• The benefits of pain control and functioning associated with oxycodone use, as mentioned in 6.

Potential Treatment Options

Based on the available evidence, potential treatment options for the patient's breakthrough pain include:

• Adding a short-acting opioid analgesic, such as oxycodone or fentanyl, to the patient's current regimen, as suggested in 3 and 5.
• Adjusting the dose and/or dosing frequency of the patient's current ATC analgesic, as recommended in 3.
• Considering alternative opioid formulations, such as transmucosal or buccal fentanyl, for rapid pain relief, as noted in 4 and 5.