How to manage breakthrough pain in a patient on morphine 15mg TID?

From the Guidelines

Breakthrough pain in a patient on morphine 15mg TID should be managed with an immediate-release opioid at a dose of 5%-20% of the daily regular morphine equivalent daily dose.

Key Considerations

• The patient's daily regular morphine equivalent daily dose is 45mg (15mg TID), so the breakthrough pain dose would be 2.25mg to 9mg of immediate-release morphine 1.
• The choice of short-acting opioid for breakthrough pain is not specifically recommended, but immediate-release morphine can be used 1.
• Breakthrough pain can be categorized as incident pain, end-of-dose failure pain, or persistent pain, and management may vary depending on the type of pain 1.
• The dose of breakthrough pain medication may need to be titrated to achieve adequate pain relief, and the patient should have access to a rescue dose at all times 1.
• The use of buccal, sublingual, or oral/nasal transmucosal formulations of fentanyl may be effective for managing episodic breakthrough pain, but this is not specifically recommended for a patient already on morphine 1.

Clinical Application

• In clinical practice, the simplest method of dose titration is with a dose of immediate release morphine given every four hours and the same dose for breakthrough pain 1.
• The total daily dose of morphine can be reviewed daily, and the regular dose can be adjusted according to how many rescue doses have been given 1.

From the Research

Management of Breakthrough Pain

To manage breakthrough pain in a patient on morphine 15mg TID, the following options can be considered:

• Supplemental analgesia, known as rescue medication, is a common pharmacological treatment option 2
• Breakthrough pain can be treated with supplemental short-acting opioid use, as needed, e.g. short-acting morphine, intranasal fentanyl and buccal tablets of fentanyl 2
• Intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) can be used to manage breakthrough pain, with IV-MO having a shorter onset than OTFC 3

Treatment Options

Some treatment options for breakthrough pain include:

• Oral transmucosal fentanyl citrate (OTFC) 4
• Intravenous morphine (IV-MO) at a dose equivalent to 20% of the basal oral dosage 5
• IV-MO can be used in combination with transdermal buprenorphine (TTS-BUP) 6

Dosage and Administration

The dosage and administration of breakthrough pain medication can be based on the following:

• A dose proportional to the total around-the-clock (ATC) opioid dose 4
• A fixed ratio with the oral daily morphine dose 5
• A ratio of TTS-BUP/oral morphine of 1:75, and a morphine IV/oral ratio of 1:3 6