• Give adequate instructions (written if possible) on how to control breakthrough pain. Inform other healthcare team members, including out-of-hours staff, as appropriate.
• The person should take breakthrough analgesia before the pain gets severe, as it may take 30–60 minutes for the analgesia to reach full effect.
• When deciding whether more than one breakthrough dose is needed, consider the time required for medication to take effect and its potential for adverse effects before administering another dose.
• In a person taking regular analgesia, breakthrough pain indicates a need for reassessment of the analgesic dosage and the underlying cause of pain. For more information on how to increase the dose of oral morphine, see Initiating and titrating morphine.
• If the person is taking regular paracetamol and/or a nonsteroidal anti-inflammatory drug (NSAID), consider:
• Treating with an additional dose of the regular analgesic as long as it does not exceed the maximum licensed dose, or
• Adding in a weak opioid on an as-required or regular basis.
• If the person is taking regular paracetamol and/or an NSAID plus a weak opioid, consider:
• Treating with an additional dose of the regular analgesic as long as it does not exceed the maximum licensed dose, or
• Switching to a strong opioid.
• For people taking oral morphine:
• If the person is using immediate-release or modified-release morphine regularly — treat with immediate-release oral morphine (tablets or liquid), at a dose of one tenth of the total daily oral morphine dose, to be taken when required and repeated no more than 2-hourly.
• The breakthrough dose may need to be individually titrated to between 5% and 20% of the regular daily dose.
• If the person is in severe pain and needs another dose sooner than 2 hourly, seek specialist advice.
• The onset of action of immediate release morphine is about 20–30 minutes; this may not be ideal for those patients with rapid onset severe episodes of breakthrough pain. An immediate-release fentanyl product may be useful in these circumstances. However, immediate-release fentanyl products should only be started by a specialist because:
• There are four immediate release fentanyl products available, all with different routes of absorption: transmucosal lozenges (Actiq^®), sublingual tablets (Abstral^®), buccal tablets (Effentora^®), and intranasal (Instanyl^®).
• These products are not bioequivalent and cannot be substituted for one another.
• The rescue dose needs to be individually titrated — there is no correlation between the regular dose of strong opioid and the effective rescue dose.
• Serious adverse effects and deaths can occur if the products are not used correctly, or if they are used in opioid naive individuals, or for transient pain (such as migraine).
• These products are markedly more expensive than immediate release morphine.
• If the person is receiving a subcutaneous infusion of diamorphine or morphine:
• Treat with a subcutaneous bolus dose at one tenth of the 24-hour infusion dose, when required, and repeated no more than 2-hourly. If the person is in severe pain and needs another dose sooner, seek specialist advice.
• Oramorph^® is an alternative for people who can manage liquids but are on an infusion because they cannot swallow tablets. It allows the person and their family greater control over managing episodes of breakthrough pain without having to wait for a healthcare professional to attend to give a breakthrough subcutaneous dose. Specialist advice should be sought in this situation to check the oral route is appropriate and to clarify the dose of Oramorph^® because the doses suggested by experts vary.
• If using other strong opioid analgesics, seek specialist advice.
• If the person's background pain is satisfactorily controlled but they experience incident pain (pain on movement or particular events, such as micturition, wound dressing, bed care, travel):
• Do not keep increasing the 24-hour dose of opioid.
• Give a breakthrough dose of an immediate-release opioid approximately 30 minutes before the precipitating factor occurs. In some situations, transmucosal fentanyl can be useful for this purpose, but this should be used only on the advice of a specialist.
• Do not include the breakthrough doses administered for incident pain when reassessing maintenance opioid analgesia requirements.

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