Background and Breakthrough Analgesia

Background analgesia is prescribed regularly to treat constant pain, ie pain at rest.  It may be simple analgesia such as Paracetamol or Ibuprofen, adjuvant drugs for neuropathic or nociplastic pain [Physiology and management of chronic pain] such as Gabapentin or Amitriptyline; or an opioid.

To provide clarity of prescription, avoid polypharmacy and reduce opioid side effects, only ONE opioid should be prescribed for background analgesia.

This would usually be a regular weak opioid, eg Codeine, Tramadol or Dihydrocodeine. Occasionally it might be a regular short-acting strong opioid such as immediate release Morphine or Oxycodone qds; or, if a patient has no reliable enteral route, possibly a background infusion of an opioid via a PCA (Starting a PCA), or in an epidural infusate (ie Fentanyl What is an Epidural?

Long-acting, modified-release opioids, such as MST, Zomorph, OxyContin, are NOT appropriate for acute pain and MUST not be initiated in hospital.

Breakthrough analgesia is prescribed pro re nata (prn) to treat intermittent pain or pain on movement. The breakthrough analgesia should be stronger than the background (eg immediate release Morphine for breakthrough, regular Codeine for background).

The role of breakthrough analgesia is crucial in acute pain to cover peaks of intermittent pain to allow a functional recovery, facilitating physiotherapy, mobilisation or to cover the pain of dressing changes etc. 

If frequent use is made of the breakthrough analgesia, then the background analgesia could be increased. If breakthrough analgesia is rarely used, the background analgesia should be reduced.

To provide clarity of prescription, avoid polypharmacy and reduce opioid side effects, only ONE opioid should be prescribed for breakthrough analgesia.

This could be immediate release Morphine or Oxycodone, or, if a patient has no reliable enteral route, a PCA bolus (Starting a PCA).