Pain Crisis

• It is a palliative care emergency.
• A pain crisis is defined as severe, uncontrolled pain and causes distress for the patient.

During a pain crisis, assessment needs to be focused and it usually occurs simultaneously with management. Important aspects of assessment include:

• Etiology and nature of the pain 
• Intensity of pain
• Elicit if this is a new pain or an exacerbation of an existing pain
• Exclude reversible factors (e.g. acute retention of urine)
  

• Respond promptly in a calm and reassuring manner
• Seek help from senior members in the team, and/or a specialist palliative care team
• Use strong opioids for rapid titration
  
  • Opioid selection is based on pain assessment, patient’s response to opioids, and if there is renal/liver impairment.
  • Use parenteral route for rapid onset of analgesia.
  • Commonly used opioids locally include Morphine, Fentanyl or Oxycodone .
• Aim to achieve ‘acceptable subjective analgesia’, or reduction of pain severity by 50%
• Initiate Rapid Opioid Titration (see below)
• Monitor for signs of opioid toxicity (e.g. low respiratory rate, excessive sedation, myoclonic jerks and hallucinations).

It is advisable to have another healthcare provider around to document the process. In the example below, a total of 4mg IV Morphine was required to achieve pain control.

Table 1. Example of documentation of rapid opioid titration.

For opioid-naïve patients:

• IV Morphine 1-2.5mg every 5-15min or SC morphine 1-2.5mg every 15-30min, or
• IV Fentanyl 10-25mcg every 5-15min or SC Fentanyl 10- 25mcg every 15-30min till significant pain control is achieved or side effects develop

For patients already on regular opioids, including parenteral opioid infusions:

• Convert to the equivalent parenteral daily dose using conversion ratios (refer to Opioid Conversion Calculator)
• Administer at 1/10th or 1/12th of the daily dose every 5-15min (if IV route) or every 15-30min (if SC route) till analgesia is achieved.
• If ineffective after 3 doses, please call for help.

After rapid opioid titration:

• Once analgesia is achieved, start a continuous infusion of the opioid, or increase the baseline opioid infusion to maintain analgesia. 
• The total effective dose of Morphine is assumed to last for 4 hours; hence the infusion rate is obtained by total effective dose of Morphine divide by 4.
• The total effective dose of Fentanyl is assumed to last for 2 hours; hence the infusion rate is obtained by total effective dose of Fentanyl divide by 2.    
• Breakthrough doses should be available for breakthrough pain.
• Start a pain chart.
• Revisit the pain history in greater detail when the patient is more comfortable.
• Titrate the opioid infusion over a period of time (usually few days) until pain is well-controlled, then consider converting to a non-parenteral route.
  

Other Considerations:

• Optimize adjuvant agents.
• Consider interventional techniques, if appropriate.
• If rapid opioid titration is required, it is recommended to involve specialist palliative care or pain team to advise on the doses.
• Address any mood issues like anxiety.

• Moryl N, Coyle N, Foley KM. Managing an Acute Pain Crisis in a Patient With Advanced Cancer: “This Is as Much of a Crisis as a Code”. JAMA. 2008;299(12):1457–1467.
• Mercadante S. Opioid titration in cancer pain: A critical review. Eur J Pain. 2007;11(8):823–830.
• Mercadante S, Villari P, Ferrera P, Casuccio A, Fulfaro F; Rapid titration with intravenous morphine for severe cancer pain and immediate oral conversion. Cancer. 2002;95(1):203–208.