BTCP Questionnaire

Please find enclosed the questionnaire for the Merseyside and Cheshire Palliative Care Network Audit Group regional audit of the management of breakthrough cancer pain in Palliative Care Patients. This survey looks at your routine practice of managing patients with breakthrough cancer pain. Please complete this survey in relation to one patient you have managed with breakthrough cancer pain. You only need to fill in this survey once.

For the immediate release Fentanyl products survey please follow this link:

1. Please select your ICN/Local area

Other (please specify)

2. Please complete the following

What is the age of the patient (years)? /
What is the setting of care of the patient? /
What is the primary diagnosis of the patient? /
What is the cause of the breakthrough cancer pain? (e.g. incident pain from hip fracture) /

3. Regarding the breakthrough cancer pain:

Yes / No
Does this occur spontaneously? / *Regarding the breakthrough cancer pain: Does this occur spontaneously? Yes / Does this occur spontaneously? No
Is the background pain adequately controlled? (i.e.no pain or mild pain for at least 12 hours per day during the previous week) / Is the background pain adequately controlled? (i.e.no pain or mild pain for at least 12 hours per day during the previous week) Yes / Is the background pain adequately controlled? (i.e.no pain or mild pain for at least 12 hours per day during the previous week) No
Does the pain occur in response to a trigger? / Does the pain occur in response to a trigger? Yes / Does the pain occur in response to a trigger? No

4. Is the patient on a regular long-acting opioid?

Yes
No
If yes please state the name and dose of the opioid

5. Which opioid is the first choice for breakthrough analgesia for this patient?

Oramorph
Sevredol
MorphineSC
Oxynorm PO
OxynormSC
Hydromorphone PO
HydromorphoneSC
DiamorphineSC
Effentora (Fentanyl buccal tablet)
Actiq (Fentanyl lozenge)
Abstral (Fentanyl sublingual citrate tablet)
Instanyl (Fentanyl nasal spray)
PectFent (Fentanyl pectin nasal spray)
None
Please indicate the dose of the above medication prescribed for the patient.

6. Did the patient experience any undesirable side-effects from their breakthrough analgesia?

Dizziness
Drowsiness
Hallucinations
Nausea / Vomiting
Oral ulceration
Constipation
Itch
Respiratory depression
Confusion / Delirium
Myoclonus
No side effects experienced
Other (please specify)

7. Did the patient feel their breakthrough analgesia is working?

Yes
No
Don't know
Comments

8. What was the pain score prior to administration of the breakthrough analgesia?

9. Was another pain score done after the administration of breakthrough analgesia? If so indicate the score below.

How long after administration of breakthrough analgesia was this pain score undertaken?

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10. Regarding this episode of pain:

How long did the analgesia take to be effective? / Did the patient require another dose for this episode?
. / /