Intravenous Morphine for Breakthrough (Episodic-) Pain in an Acute Palliative Care Unit: A Confirmatory Study

Abstract

The aim of this prospective cohort study was to confirm the safety of intravenous morphine (IV-M) used in doses proportional to the basal opioid regimen for the management of breakthrough pain and to record the nurse compliance on regularly recording data regarding breakthrough pain treated by IV-M. Over a one-year period, 99 patients received IV-M for breakthrough pain during 116 admissions. The IV-M dose was 1/5 of the oral daily dose, converted using an equianalgesic ratio of 1/3 (IV/oral). For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to reassess the patient 15minutes after IV-M injection (T15). Nurses were unaware of the aim of the study and just followed department policy. In total, 945 breakthrough events treated by IV-M were recorded and the mean number of events per patient per admission was eight (95% confidence interval (CI) 6.9-9.5). The mean dose of IV-M was 12mg (95% CI 9-14mg). In the 469 events (49.6%) with a complete assessment, a decrease in pain of more than 33% and 50% was observed in 287 (61.2%) and 115 (24.5%) breakthrough events, respectively. The mean pain intensity decreased from 7.2 (T0) to 2.7 (T15). In eight episodes, no changes in pain intensity were observed and a further dose of IV-M was given. The remaining patients did not require further interventions. No clinical events requiring medical intervention were recorded. In this confirmatory study, IV-M was administered for the management of breakthrough pain in doses proportional to the basal opioid regimen to all patients, including older patients and those requiring relatively large doses. This did not result in life-threatening adverse effects in a large number of patients and was effective in most cases. The role of nurses is of paramount importance in monitoring and collecting data and gathering information for audit purposes on the unit.

The use of fentanyl buccal tablets for breakthrough pain by using doses proportional to opioid basal regimen in a home care setting

“…This finding was not associated with differences in adverse effect intensity between the two groups [14]. In other words, proportional doses could be given more effectively, without exposing patients to more adverse effects, as suggested by several practical experiences with intravenous morphine and ROOs, even at high doses and in elderly patients [16][17][18][19][20][21].…”

“…This is confirmed by the fact that intravenous morphine, given as a bolus in doses proportional to basal opioid regimen in a thousand of episodes, has been proved to be safe and effective even at high doses and in the elderly [16][17][18][19].…”

“…A predictable dose could favor an easy prescription resulting in a better patients' compliance. The use of proportional doses has been shown to be safe and effective in a large number of patients in several open-label and controlled studies [16][17][18][19][20]. FBT given even at high doses proportional to the opioid doses used for background analgesia was safe and effective [21].…”

Fentanyl Buccal Tablets for Breakthrough Pain in Highly Tolerant Cancer Patients: Preliminary Data on the Proportionality Between Breakthrough Pain Dose and Background Dose

“…6,7 The number of patients who reported a decrease in pain intensity of >33% and >50% was recorded 15 minutes after the administration of FBT. Episodes with less than a 33% reduction in pain or requiring further treatment were considered unsuccessful.…”

The Use of Opioids for Breakthrough Pain in Acute Palliative Care Unit by Using Doses Proportional to Opioid Basal Regimen

“…In preliminary experiences, intravenous morphine (IV-MO) proved to be safe and effective for the management of BTP 4,5 and has been the preferred treatment in the last 5 years in our acute pain relief and palliative care unit. In studies of the oral transmucosal fentanyl citrate (OTFC), [6][7][8][9] the anecdotal assumption that the effective dose as needed is a percentage of the opioid daily dose was contradicted by the observation that the OTFC dose needs to be titrated, introducing a new variable in choosing the doses to be administered, which could reduce patient's and physician's compliance.…”