Page 289 Guide to Pain Management in Low-Resource Settings

Chapter 36

Breakthrough Pain, the Pain Emergency, and Incident Pain

Gona Ali and Andreas Kopf

Th e concept of “breakthrough pain” is a relatively new At rest, the pain was now controlled well, such
one, and it receives much less attention than “back- as when she was in bed or watching television. But Mrs.
ground” pain. As a result, breakthrough pain is much Nadhari was very disappointed that she was no longer
less well understood and managed than background able to do the cooking for her family since longer peri-
pain. Indeed, breakthrough pain has a number of “un- ods of standing or bending down at the oven had be-
met needs.” come impossible.

Case report Case report discussion

Tabitha Nadhari, a 66-year-old woman from Basra, Th is patient with breast cancer and auxiliary lymph
Iraq, has a history of breast cancer. Seven years ago, node involvement complains of severe pain due to
she had a mastectomy with auxiliary clearance, fol- multiple bone metastasis. As it is typical in these cas-
lowed by radiotherapy and chemotherapy. She was free es, pain at rest is well controlled by analgesics (accord-
of pain up to a year ago, when she started to complain ing to the World Health Organization [WHO] ladder),
about low back pain, which was mild and misdiag- but pain on movement is not controlled at all. Since
nosed fi rst as “functional.” MRI showed, unfortunately, all pain exacerbations did occur in conjunction with
metastasis to cervical, thoracic, and lumbar vertebrae. physical activity, such pain is called incident pain (as
At that time, Mrs. Nadhari took nonopioid analgesics opposed to breakthrough pain, which would appear
as needed, such as paracetamol (acetaminophen) or di- also spontaneously). Th e best thing for Dr. Foud to do
clofenac. Due to the social problems after the war, nei- would be to prescribe 10-mg tablets of morphine for
ther chemotherapy or radiotherapy was available in the Mrs. Nadhari and to instruct her to use them when
health system. physical activity is planned. For example, before start-
Recently, her pain became more severe and intol- ing cooking, Mrs. Nadhari should take a 10-mg tablet
erable. Th e pain was no longer responding to diclofenac. (a titration dose), wait approximately 30 minutes, and
She found a very caring physician, Dr. Foud, who started then start to go to the kitchen. Of course, she should
her fi rst on the weak opioid tramadol in addition to the be warned that the extra morphine, especially if she
diclofenac. After a few days, when it was evident that the needs more than one titration dose, might produce se-
tramadol was ineff ective, Dr. Foud changed the opioid dation and nausea, or both. If it is available, metoclo-
medication of Mrs. Nadhari to morphine (30 mg q.i.d.). pramide should therefore be provided if necessary, and
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 277
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
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