End of Life Concerns Pain & Symptom Control How to Recognize and Treat Breakthrough Pain (BTP) By Angela Morrow, RN Angela Morrow, RN LinkedIn Angela Morrow, RN, BSN, CHPN, is a certified hospice and palliative care nurse. Learn about our editorial process Updated on October 24, 2020 Medically reviewed by Cristian Zanartu, MD Medically reviewed by Cristian Zanartu, MD Twitter Cristian Zanartu, MD, is a licensed board-certified internist who has worked for over five years in pain and palliative medicine. Learn about our Medical Expert Board Print Breakthrough pain (BTP) is the pain that occurs between regularly scheduled doses of pain medication. It is a distressing symptom requiring prompt treatment. delihayat / Getty Images Most patients with chronic pain, including palliative care and hospice patients, are given medication to use as needed to treat breakthrough pain. Medication for BTP is typically fast-acting with a relatively short duration of action (usually providing relief for two to four hours). Unfortunately, studies have shown that although breakthrough pain is common in patients with advanced disease at home, medications to relieve it are not always prescribed, and patients in pain don't always use as much medication to treat their pain as is allowed. When Does BTP Occur? Patients experiencing chronic pain are most often prescribed around-the-clock (ATC) doses of opioid pain medication. Breakthrough pain shows up between doses of the medication and often cause the person much discomfort. It is important to be able to recognize BTP and keep an accurate record of it so that your healthcare provider, or that of the person you're caring for, can treat it properly. Breakthrough pain has three basic categories: incident pain, spontaneous pain, and end-of-dose medication failure. It's important for your healthcare provider to recognize which type of BTP you are experiencing since the treatment for each can be quite different. Treating Incident Pain Incident pain is pain that can be predicted and occurs with specific activities. An example of this is a person who has pain every time they are turned from side to side for personal care. Incident pain is often treated proactively. Because the pain is predictable, people with incident pain can be pre-medicated with quick-acting, short-term pain medication before activities that cause pain. The dose may be adjusted based on the level and duration of activity expected to cause pain. Treating Spontaneous Pain Spontaneous pain is unpredictable and not associated with any specific activity. Because of its unpredictability, it is often difficult to treat. Spontaneous pain is most often treated with a quick-acting, short-term pain medication given as soon as the pain occurs. Adjuvant medications may also be tried to offer better pain control. Adjuvant medications include antidepressants, anti-seizure, and other non-opioid medications that enhance the pain management of some patients. Treating End-of-Dose Medication Failure End-of-dose medication failure is just what it sounds like: pain that occurs toward the end of the time frame in which a medication dose is intended to be effective. For example, in a patient who takes long-acting morphine every 12 hours (this is a morphine tablet taken twice a day with the intention of keeping the patient pain-free for 12 hours), pain that occurs at the end of this 12-hour period usually signifies that the frequency or the dose of the drug is not enough to carry the patient over until the next dose. Treatment of end-of-dose failure may include shortening the interval between doses or increasing the dose of medication. For example, a patient experiencing pain after eight hours while on a drug intended to offer relief for 12 hours may have the interval between doses decreased to every eight hours, or their dose may be increased by 25% to 50%. Sometimes end-of-dose-failure is treated with an extra dose of BTP medication. A common medication often used in the hospice setting to treat BTP is oral morphine solution (OMS). OMS is a concentrated liquid form of morphine that begins working quickly and generally provides relief for two to four hours. Keeping a Record of Breakthrough Pain The best way to make sure breakthrough pain is being adequately treated is to keep a thorough and accurate medication log. Keeping an accurate record of pain levels, medications used to treat it, and response to the medication will help a healthcare provider determine the best treatment. Your medication log may look similar to the one below. Example Breakthrough Pain Medication Log Date/Time/Pain Level Dec. 8th, 9:00a, pain 5/10 Dec. 8th, 5:00p, pain 6/10 Dec. 11th, 11:00a, pain 4/10 Dec. 12th, 2:00a, pain 6/10 Medication/Dose/Response morphine 5mg, pain unrelieved, another 5mg given with relief morphine 10mg, pain relieved morphine 10mg, pain relieved morphine 10mg, pain relieved 2 Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Mercadante C, Costanzo BV, Fusco F, Buttà V, Vitrano V, Casuccio A. Breakthrough pain in advanced cancer patients followed at home: a longitudinal study. J Pain Symptom Manage. 2009;38(4):554-560. doi:10.1016/j.jpainsymman.2008.12.008 Mishra S, Bhatnagar S, Chaudhary P, Rana SP. Breakthrough cancer pain: review of prevalence, characteristics and management. Indian J Palliat Care. 2009;15(1):14–18. doi:10.4103/0973-1075.53506 Additional Reading Ferrell, BR and Coyle, N; Textbook of Palliative Nursing, Oxford University Press, 2006. Ferrell BR, McGuire DB, and Yarbro CH; Cancer Pain Management, Jones and Bartlett Publishers, 1995. Mercadante S, Costanzo BV, Fusco F, Buttà V, Vitrano V, Casuccio A. Breakthrough pain in advanced cancer patients followed at home: a longitudinal study. Journal of Pain and Symptom Management. 2009 Oct 1;38(4):554-60. By Angela Morrow, RN Angela Morrow, RN, BSN, CHPN, is a certified hospice and palliative care nurse. See Our Editorial Process Meet Our Medical Expert Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? Other Helpful Report an Error Submit By clicking “Accept All Cookies”, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. Cookies Settings Accept All Cookies