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Robert's story - managing escalating pain

What can I do if a patient, who has stable disease, previously has had well controlled chronic pain on Durogesic DTrans patch and is not imminently dying, suddenly develops uncontrolled severe pain?

Patients whose pain has been well controlled may find as their illness progresses this control may be lost and they may experience unacceptable episodes of breakthrough pain. After increasing Durogesic DTrans patch strength increases in plasma fentanyl concentrations are relatively slow (6-12 hours). Hence Durogesic DTrans is not considered to be appropriate for situations of unstable pain.

The situation described below is one where the pain must be controlled as rapidly as possible due to the change in the severity of the pain and the distress this has caused Robert.

In this case the goal is to add to the analgesia provided by the Durogesic DTrans patch with a normal release opioid formulation.

This will enable rapid assessment of the response to each dose of the normal release opioids and make upward titration of opioids more rapid and practical.

Robert is a 50 year old man with a bowel cancer originally diagnosed 2 years ago.
Recently his cancer has recurred and it is now known to have spread to his liver.
Living at home, he has been managing well on his current medication of a 50mcg per hour patch.
Over the last day his pain has become increasingly unstable and he is now taking his breakthrough analgesia 4 times a day. This eases the pain.
He is on 30mg of normal release morphine orally for breakthrough pain.

Follow these three steps

1. Leave the patch on

The average elimination half life of fentanyl is 17 hours. Removing the Durogesic DTrans patch means the plasma fentanyl concentration will fall slowly and introduce a decreasing level of analgesia. This will complicate the titration required to regain pain control.

2. Prescribe REGULAR 4 hourly oral morphine at a dose of 30 mgs

Robert has been taking breakthrough morphine 30 mgs four times in 24 hours. Therefore to gain pain control, Robert requires a regular normal release opioid in addition to the analgesia provided by the patch.

3. Calculate new breakthrough dose

A new breakthrough dose needs to be calculated as Robert is getting regular oral morphine plus his Durogesic DTrans patch. This new breakthrough dose is calculated by adding the breakthrough dose of the Durogesic DTrans patch and the breakthrough dose of his regular oral morphine.

Regular analgesia	Breakthrough dose
Oral morphine 30 mgs 4 hourly (180mg in 24hours)	= 30 mgs (1/6th of total regular 24 hour morphine dose)
Durogesic DTrans 50 mcg / hour	= 30 mgs (conversion chart)
NEW breakthrough dose	= 60 mgs (30 + 30)

Hence Robert’s prescription is now
1. Durogesic DTrans patch	= 50 mcg / hour
2. Oral morphine	= 30 mgs REGULARLY EVERY 4 HOURS
3. Breakthrough Oral morphine	= 60 mgs as needed

Two days later Robert is taking 3 doses of breakthrough in 24 hours. His pain is not yet controlled. Do not be tempted to increase the Durogesic DTrans patch as this will introduce a slowly rising analgesic effect which will not be suitable in Robert’s case. Instead the regular morphine and the breakthrough morphine dose needs increasing. 1. Calculate the new regular 4 hourly oral morphine dose as follows:
In the previous 24 hours Robert has required	Dose taken
Six doses of regular 4 hourly morphine	= 180 mgs (6 X 30 mgs)
Three breakthrough doses	= 180 mgs (3 X 60 mgs)
Total morphine taken in 24 hours	= 360 mgs (180 + 180)
NEW regular 4 hourly oral morphine dose	= 60 mgs (360 ÷ 6)

2. Calculate the new breakthrough oral morphine dose:
Breakthrough dose of:
Durogesic DTrans 50 mcg / hour	= 30 mgs (conversion chart)
Oral morphine 60 mgs 4 hourly	= 60 mgs (1/6th of total regular 24 hour morphine dose)
NEW breakthrough dose	= 90 mgs (30 + 60)

Hence Robert’s prescription is now
1. Durogesic DTrans patch	= 50 mcgs / hour
2. Oral morphine	= 60 mgs REGULARLY EVERY 4 HOURS
3. Oral morphine as needed	= 90 mgs for BREAKTHROUGH

Two days later, Robert has only taken ONE breakthrough dose per 24 hours. His pain is now stable and you can now consider increasing the patch strength.

HOW IS THIS DONE?
Calculate Robert’s 24 hour intake of morphine.
Regular oral 4 hourly morphine (60 x 6)	= 360 mgs
One breakthrough oral morphine dose	= 90 mgs.
Total daily oral morphine taken (360 + 90)	= 450 mgs per 24 hours

Caution SWITCHING LARGE DOSES OF OPIOIDS: When SWITCHING large doses of a strong opioid to another opioid, a commonly accepted practice is to reduce the calculated dose of opioid by one third. SEEK ADVICE FROM SPECIALIST PALLIATIVE CARE.

Robert is needing 450mg in 24 hours:
One third of 450	= 150
Therefore the dose of oral morphine to be switched is (450 - 150)	= 300 mgs oral morphine.
300 mgs Oral Morphine in 24 hours	= 75 mcg / hour Durogesic DTrans patch (from conversion chart)
Please Note
Robert is already on a 50 mcg / hour patch. His NEW Durogesic DTrans dose should be 50 + 75	= 125 mcg / hour Durogesic DTrans patch

Increasing the dose of the Durogesic DTrans patch from 50 mcg per hour to 125 mcg per hour is a large rise in fentanyl. Some healthcare professional might make this increase in gradual steps, monitoring each dose increment for toxicity and efficacy, rather than in a single step. If in doubt seek your local Specialist Palliative Care advice.

Hence Robert’s final prescription is now

1. Durogesic DTrans patch	= 125 mcg / hour
2. Breakthrough oral morphine	= 80 mgs as needed (conversion chart)

REVIEW WITHIN 24 hours to monitor for possible side effects and 2-3 days to assess for analgesic response.