Year 2020 / Volume 27 / Number 2


Management of breakthrough pain associated with the cure of skin ulcers

Rev. Soc. Esp. Dolor. 2020; 27(2): 113-126 / DOI: 10.20986/resed.2020.3755/2019

Vicente Domingo Triadó, Dolores López-Alarcón, Francisco Villegas-Estévez, Carmen Alba-Moratilla, Beatriz Massa-Domínguez, Laura Alepuz, Federico Palomar-Llatas, Ana Mínguez-Martí, Almudena Sanz, Antonio Javier Jiménez, Laura Debón-Vicent


Objective: to assess the prophylactic management of breakthrough pain associated with skin ulcers care procedures, considering the different treatments used in clinical practice for the prevention and minimization of pain.
Material and methods: A multicenter, cross-sectional, observational study. The study was conducted in 11 hospitals distributed throughout Spain. Ulcer features, patient demographics and clinical characteristics were recorded. Pain assessment, and patients’ anxiety and satisfaction were measured using McGill Pain Questionnaire, Hamilton Anxiety Rating Scale and visual analogue scales (VAS).
Result: Low levels of anxiety were registered (74.2%, none or mild) and patient and healthcare professional satisfaction was high (8.3 and 7.7, respectively). Opioid drugs were administered to 73.8% of patients, who experienced significantly less pain than those who did not receive treatment or who received non-opioid drugs (p<0.0001). Type of management was related to patient age, ulcer characteristics, treatment for background pain, patient anxiety levels, perception of pain during the procedure, years of experience of the healthcare professional, the use of clinical guidelines, and the unit in which it was performed. Factors significantly related to the use of prophylaxis were treatment for background pain, more severe ulcers, and treatment by a professional with <20 years of experience who followed clinical guidelines. Significant factors related to the use of opioids were anxiety, the care unit, and the years of experience of the healthcare professional.
Conclusión: Differences in patient management depended on numerous factors. Prophylaxis with opioids, mainly fentanyl, resulted in less pain for the patient.


Objetivos: Valorar el manejo profiláctico del dolor irruptivo asociado a la cura de úlceras cutáneas, teniendo en cuenta los diferentes tratamientos que se usan en la práctica clínica para la prevención y la reducción del dolor.
Material y métodos: Estudio multicéntrico, observacional y transversal. El estudio se llevó a cabo en 11 hospitales en España. Se recopilaron datos sobre las características de las úlceras, además de variables demográficas y clínicas de los pacientes. La valoración del dolor, la ansiedad y la satisfacción del paciente se midieron mediante el cuestionario del dolor de McGill, la escala de ansiedad de Hamilton y escalas visuales analógicas.
Resultados: La mayoría de los pacientes presentaba niveles bajos de ansiedad (74,2 %, ninguna o leve), mientras que la satisfacción de los pacientes y los profesionales sanitarios era alta (8,3 y 7,7, respectivamente). Se administraron medicamentos opioides al 73,8 % de los pacientes, que experimentaron significativamente (p < 0,0001) menos dolor que aquellos que no recibieron tratamiento o que recibieron medicamentos no opioides. El tipo de tratamiento se relacionó con la edad del paciente, la percepción del dolor durante la cura, los años de experiencia del profesional, el uso de guías clínicas y el servicio o unidad en el que se llevó a cabo la cura. El uso de profilaxis se relacionó significativamente con el tratamiento del dolor irruptivo, con úlceras más graves y con el tratamiento realizado por un profesional con menos de 20 años de experiencia, que siguió las guías clínicas. Otros factores relacionados con el uso de opioides fueron la presencia de ansiedad, la unidad donde se realizaron los cuidados y los años de experiencia del profesional de la salud.
Conclusiones: Las diferencias en el manejo del paciente dependieron de numerosos factores. La profilaxis con opioides se asoció con una menor percepción del dolor para el paciente.

Complete Article


1. Mustoe TA, O'Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current treatment strategies: A unifying hypothesis. Plastic Reconstr Surg. 2006;117(7 Suppl):35S-41S. DOI: 10.1097/01.prs.0000225431.63010.1b.
2. Payne R. Recognition and diagnosis of breakthrough pain. Pain Med. 2007;8(Suppl 1):S3-S7. DOI: 10.1111/j.1526-4637.2006.00269.x.
3. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA), editores. Prevention and treatment of pressure ulcers: clinical practice guideline. Perth, Australia: Cambridge Media; 2014. Disponible en:
4. National Institute for Health and Care Excellence UK (NICE). The prevention and management of pressure ulcers in primary and secondary care. NICE clinical guidelines. London: NICE; 2014.
5. Qaseem A, Mir TP, Starkey M, Denberg TD. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):359-69. DOI: 10.7326/M14-1567.
6. Bennett D, Burton AW, Fishman S, Fortner B, McCarberg B, Miaskowski C, et al. Consensus panel recommendations for the assessment and management of breakthrough pain: Part 2 management. P and T. 2005;30(6):354-61.
7. Magnani C, Giannarelli D, Casale G. 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. Clin J Pain. 2017;33(8):707-14. DOI: 10.1097/AJP.0000000000000450.
8. Cánovas Martínez ML, Rodríguez Rodríguez AB, Castro Bande M, Pérez Arviza L, López Soto C, Román Nuñez R. Treatment of breakthrough pain. Rev Soc Esp Dolor. 2012;19(6):318-24.
9. Giuggioli D, Manfredi A, Vacchi C, Sebastiani M, Spinella A, Ferri C. Procedural pain management in the treatment of scleroderma digital ulcers. Clin Exp Rheumatol. 2015;33(1):5-10.
10. Bastami S, Frodin T, Ahlner J, Uppugunduri S. Topical morphine gel in the treatment of painful leg ulcers, a double-blind, placebo-controlled clinical trial: a pilot study. Int Wound J. 2012;9(4):419-27. DOI: 10.1111/j.1742-481X.2011.00901.x.
11. Argoff CE. Topical analgesics in the management of acute and chronic pain. Mayo Clin Proc. 2013;88(2):195-205. DOI: 10.1016/j.mayocp.2012.11.015.
12. Domingo-Triado V, Lopez Alarcon MD, Villegas Estevez F, Alba Moratillas C, Massa Dominguez B, Palomares Paya F, et al. [Breakthrough pain treatment with sublingual fentanyl in patients with chronic cutaneous ulcers]. Rev Esp Anestesiol Reanim. 2014;61(8):429-33.
13. World Union of Wound Healing Societies. Principles of best practice: minimising pain at wound dressing-related procedures. A consensus document. 2007.
14. Pellicano R, Guerra L. [Skin ulcer pain]. Minerva Med. 2012;103(6):525-31.
15. Rook JL. Wound care pain management. ADv Wound Care. 1996;9(6):24-31.
16. Rosenthal D, Murphy F, Gottschalk R, Baxter M, Lycka B, Nevin K. Using a topical anaesthetic cream to reduce pain during sharp debridement of chronic leg ulcers. J Wound Care. 2001;10(1):503-05. DOI: 10.12968/jowc.2001.10.1.26042.
17. Vernassiere C, Cornet C, Trechot P, Alla F, Truchetet F, Cuny JF, et al. Study to determine the efficacy of topical morphine on painful chronic skin ulcers. J Wound Care. 2005;14(6):289-93. DOI: 10.12968/jowc.2005.14.6.26793.
18. Panuncialman J, Falanga V. Unusual causes of cutaneous ulceration. Surg Clin North Am. 2010;90(6):1161-80. DOI: 10.1016/j.suc.2010.08.006.
19. Scimeca CL, Fisher TK, Bharara M, Armstrong DG. Chronic, painful lower extremity wounds: postoperative pain management through the use of continuous infusion of regional anaesthesia supplied by a portable pump device. Int Wound J. 2010;7(3):195-8. DOI: 10.1111/j.1742-481X.2010.00675.x.
20. Cepeda MS, Africano JM, Polo R, Alcala R, Carr DB. What decline in pain intensity is meaningful to patients with acute pain? Pain. 2003;105(1-2):151-57.
21. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975;1(3):277-99. DOI: 10.1016/0304-3959(75)90044-5.
22. Walters SJ, Morrell CJ, Dixon S. Measuring health-related quality of life in patients with venous leg ulcers. Qual Life Res. 1999;8(4):327-36. DOI: 10.1023/A:1008992006845.
23. Price DD, Barrell JJ, Gracely RH. A psychophysical analysis of experimential factors that selectively influence the affective dimension of pain. Pain. 1980;8(2):137-49. DOI: 10.1016/0304-3959(88)90001-2.
24. Farrar JT, Young Jr JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149-58. DOI: 10.1016/S0304-3959(01)00349-9.
25. Lobo A, Chamorro L, Luque A, Dal-Re R, Badia X, Baro E, et al. [Validation of the Spanish versions of the Montgomery-Asberg depression and Hamilton anxiety rating scales]. Med Clin (Barc). 2002;118(13):493-99. DOI: 10.1016/S0025-7753(02)72429-9.
26. Girouard K, Harrison MB, VanDenKerkof E. The symptom of pain with pressure ulcers: A review of the literature. Ost Wound Manag. 2008;54(5):30-42.
27. Gorecki C, Closs SJ, Nixon J, Briggs M. Patient-reported pressure ulcer pain: A mixed-methods systematic review. J Pain Sympt Manag. 2011;42(3):443-59. DOI: 10.1016/j.jpainsymman.2010.11.016.
28. Herberger K, Rustenbach SJ, Haartje O, Blome C, Franzke N, Schafer I, et al. Quality of life and satisfaction of patients with leg ulcers--results of a community-based study. Vasa. 2011;40(2):131-38. DOI: 10.1024/0301-1526/a000083.
29. Palomar Llatas F, Fornes Pujalte B, Sierra Talamantes C, Millá Tamarit I, Debon Vicent L. A cross-sectional observational study of the management of breakthrough pain associated with the treatments in patients with cutaneous ulcers. Enferm Dermatol. 2016;10(27):36-42.
30. Hopman WM, Buchanan M, VanDenKerkhof EG, Harrison MB. Pain and health-related quality of life in people with chronic leg ulcers. Chronic Dis Inj Can. 2013;33(3):167-74.
31. Schneider I, Keller A, Fleischer S, Berg A. "And there are always enough 'promo leaflets' ". A qualitative study on the situation of leg ulcer patients and their needs in regard to patient education. Pflege Z. 2013;66(8):488-93.
32. Herber OR, Schnepp W, Rieger MA. A systematic review on the impact of leg ulceration on patients' quality of life. Health Qual Life Outcomes. 2007;5:44. DOI: 10.1186/1477-7525-5-44.

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Domingo Triadó V, López-Alarcón D, Villegas-Estévez F, Alba-Moratilla C, Massa-Domínguez B, Alepuz L, et all. Management of breakthrough pain associated with the cure of skin ulcers. Rev Soc Esp Dolor 2020; 27(2): 113-126 / DOI: 1020986/resed20203755/2019

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Recibido: 18/07/2019

Aceptado: 18/01/2020

Prepublicado: 16/03/2020

Publicado: 17/04/2020

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