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Ovid: Oxford Handbook of Palliative Care

Editors: Watson, Max S.; Lucas, Caroline F.; Hoy, Andrew M.; Back, Ian N. Title: Oxford Handbook of Palliative Care, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Symptom Management > Chapter 6a – The management of pain > Breakthrough pain Breakthrough pain Breakthrough pain is a flare in pain of rapid onset, moderate to severe intensity and of short duration. It may be precipitated by activity but it can also happen spontaneously. If pain starts to occur regularly before the next dose is due, this is probably an indication to increase the regular background dose.

  • Analyse and avoid precipitating activities if possible. Predict pain and give analgesia 20 minutes prior to activity e.g. prior to changing dressings or movement

Treatment options to consider:

  • Immediate release oral morphine or other opioid according to background analgesia (or diamorphine SC/ i/v if unable to swallow) at 50–100 per cent of the equivalent regular background 4 h dose
  • Oral transmucosal fentanyl citrate lozenges (OTFC) or other fentanyl-like drugs
  • Midazolam 2.5–5mg SC/lorazepam 0.5mg sublingually to allay anxiety
  • NSAID SC e.g. parecoxib 40mg

Other therapies include:

  • Visualization techniques, hypnotherapy, reassurance and a calm professional manner, distraction etc.

NB Nitrous oxide gas (Entonox) inhalation is now rarely used prior to painful procedures. For this means of analgesia to be effective, the patient needs to be able to inhale deeply, whilst holding the mask to the face. It is therefore not very useful with the weak, infirm or older patient. It must be administered with the demand valve and this must be held to the face by the patient alone. If the patient is made drowsy by the Entonox, the mask automatically falls away from the face and the patient breathes air again and recovers, before there is any risk of losing protective reflexes. Entonox should never be used on patients who have any air where it should not be e.g. pneumothorax, or pneumoperitoneum. Nitrous oxide rapidly enters these areas, causing potentially dangerous expansion.

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