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Procedural Pain in Palliative Care: Is It Breakthrough Pain? A Multicenter National Prospective Study to Assess Prevalence, Intensity, and Treatment of Procedure-related Pain in Patients With Advanced Disease

Magnani, Caterina MD*; Giannarelli, Diana MSc; Casale, Giuseppe MD*

doi: 10.1097/AJP.0000000000000450
Original Articles

Objective: To assess the prevalence of breakthrough pain (BTP) provoked by 6 common procedures in patients with advanced disease.

Methods: A prospective, cross-sectional, multicenter, national study was performed in 23 palliative care units in Italy. Patients were recruited if they were undergoing one of the following procedures as part of normal care: turning, personal hygiene care, transfer from bed to chair, bladder catheterization, pressure ulcer care, and subcutaneous drug administration. The Numerical Rating Scale was used to measure pain intensity before, during, and after the procedure.

Results: One thousand seventy-nine eligible patients were enrolled: 49.7% were male and their mean age was 78.0±11.2 years. Of all patients, 20.9% had experienced a BTP episode within the 24 hours before recruitment. The overall prevalence of procedure-induced BTP was 11.8%, and the mean intensity score (Numeric Rating Scale) was 4.72±1.81. Notably, patients experienced a significant increase in pain intensity during all procedures (P<0.0001). A small proportion of patients (12.7%) received analgesics before undergoing any of the procedures, and almost none (1.7%) received analgesics during the procedures to alleviate acute pain.

Discussion: Our findings highlight that simple daily care procedures can lead to BTP among patients with advanced disease. Because such procedures are performed very often during palliative care, more individualized attention to procedural pain control is necessary. Additional research on procedural pain in patients with advanced disease should be encouraged to provide further evidence-based guidance on the use of the available medication for predictable pain flares.

*Palliative Care Unit Antea

Biostatistic Department Regina Elena National Cancer Institute, Rome, Italy identifier: NCT02437929.

On behalf of the “Procedural Pain in Palliative Care” Study Group: Chiara Mastroianni, RN, Antea Palliative Care Unit, Rome; Alice Calvieri, MD, Palliative Care Unit Antea, Rome; Arianna Lombardi, MD, Antea Palliative Care Unit, Rome; Maria Consiglia Stefanelli, RN, Antea Palliative Care Unit, Rome; Paola Ruggeri, RN, Antea Palliative Care Unit, Rome; Laura Carbonara, RN, Antea Palliative Care Unit, Rome; Ana Dardeli, Antea Palliative Care Unit; Domenico Russo, MD, San Marco Palliative Care Unit, Latina; Michela Guarda, RN San Marco Palliative Care Unit, Latina; Francesca Bordin, MD, Palliative Care Unit INI, Grottaferrata, Rome; Roberto Rossi, MD, San Raffaele Palliative Care Unit, Rocca di Papa, Rome; Maria Pietropaolo, MD, San Raffaele Palliative Care Centre, Montecompatri, Rome; Luigi Galli, MD, Villa Rosa Palliative Care Unit, Viterbo; Patrizia Ginobbi, MD, Palliative Care Rome Foundation, Rome; Pierpaolo Carinci, MD, Albachiara Palliative Care Unit, Chieti; Nadia Peta, Teramo Psychologist Palliative Care Unit, Teramo; Barbara Rizzi, MD, Palliative Care Vidas Foundation, Milan; Alessandro Valle, MD, Palliative Care F.A.R.O., Turin; Azzurra Ottone, MD, Luce per la vita Palliative Care Unit, Rivoli, Turin; Eugenia Malinverni, RN, Luce per la vita Palliative Care Unit, Rivoli, Turin; Cinzia Possenti, MD, Seragnoli Fundation Bentivoglio Hospice, Bentivoglio, Bologna; Raffaella D’Ambrosio, MD, Orsa Maggiore Palliative Care Unit, Biella; Girolamo Del Monte, MD, San Raffaele Palliative Care Unit, Cassino, Frosinone; Alessandro Marra, MD, Il Giardino dei Girasoli Palliative Care Unit, Eboli, Salerno; Patrizia Giardina, MD, Papardo Hospital Palliative Care Unit, Messina; Tania Gallo, RN, Niguarda Ca’Granda Hospital, Palliative Care Department, Milan; Elisa Biscaldi, MD, Palliative Care Unit, Salvatore Maugeri Foundation, Pavia; Marcello Ricciuti, MD, San Carlo Hospital, Palliative Care Department, Potenza; and Rossella Ziliotto, MD, Fatebenefratelli Hospital, Palliative Care Department, Venice.

The authors declare no conflict of interest.

Reprints: Caterina Magnani, MD, Piazza Santa Maria della Pietà, 5, Pad XXII, Rome 00135, Italy (e-mail:;

Received June 17, 2016

Received in revised form November 30, 2016

Accepted October 11, 2016

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