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Defaecation-Triggered Incident Pain — SCE Palliative Medicine MCQ

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ModeratePain ManagementDefaecation-Triggered Incident PainSCE Palliative Medicine

A 60‑year‑old man with advanced colorectal cancer on morphine MR 90 mg BD reports breakthrough pain triggered specifically by defaecation due to a pelvic mass. The episodes last 10–15 minutes. What is the optimal breakthrough opioid formulation?

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Correct answer: E — Sublingual or intranasal fentanyl taken 5–10 minutes before anticipated defaecation

Option E is correct. This patient has predictable, short‑duration breakthrough pain related to defaecation, in the context of opioid tolerance. Sublingual or intranasal fentanyl has a rapid onset (within minutes) and brief duration, matching the timing of this incident pain. NICE CG140 states that oral immediate‑release morphine is the first‑line rescue medication, but transmucosal fentanyl may be more effective for short, predictable episodes when immediate‑release morphine has poor pharmacokinetic matching. The other options either act too slowly (oral IR morphine), are impractical (IV bolus), inappropriate (patch increase), or uncomfortable and poorly absorbed (rectal suppository).

Reference: NICE CG140 (2012, updated 2016): breakthrough pain rescue; Evidence Update May 2014: transmucosal fentanyl efficacy, https://www.nice.org.uk/guidance/cg140/chapter/Recommendations