In my practice as a clinical pharmacist, I see the use of fentanyl patches on pretty much a daily basis. I’ve seen numerous mistakes with fentanyl patches and wanted to put together a list of 5 dangerous mistakes. In no particular order:
1. Fentanyl patches are extremely potent. Many healthcare professionals don’t realize how strong a fentanyl patch is. Opioid conversions are never perfect, but conservatively, a total daily dose of oral morphine 45-60 mg is approximately equivalent to fentanyl 25 mcg patch. Because of this, I’ve seen numerous cases of inappropriately high starting doses, especially in the elderly population.
2. Lost or missing patches should scare you. Fentanyl as mentioned above, is extremely potent. There is significant risk of children/pets getting access to a used patch. Take a lost or missing patch very seriously. Simply do a google search of fentanyl patch deaths and you’ll understand what I’m talking about. Flushing of used patches is recommended per ISMP.
3. Fentanyl patches are meant for chronic pain. I’ve seen orders numerous times for fentanyl patches from the ED or primary providers for the treatment of acute pain. You are not helping patients relieve their acute pain. With an onset of action that takes hours to days once applied, a patient can be in pain for a long period of time before the drug begins having an effect.
4. Delayed withdrawal. Fentanyl patches basically create a deposit of drug being slowly absorbed through the skin. I remember a case where a patient was on a chronic higher dose (100 mcg) and the patch was discontinued in the ED without any follow up or supplemental opioids. Long story short, they ended up having withdrawal symptoms, but not until hours after they were discharged. (Remember slow onset as well as slow elimination and offset)
5. Drug diversion. Whether at home, or in healthcare settings, I’ve dealt with numerous cases of drug diversion. These cases even go to the point of diverters removing used patches from dementia patients.
Looking for more real world clinical pearls? Check out the 30 medication mistakes I see in my everyday practice as a clinical pharmacist – a free resource for subscribers.
I totally agree with your post and the dangers of fentanyl. I would like to add one more concern. If a patient has a fever, uses an electric blanket or sits in a warm bath, the drug will be released from the patch much quicker and the patient may be at risk of toxicity. Patients need to be well educated on the patch before they use it.
Thanks for the addition!
Actually the bath or shower need to be really long before it does a difference thats noticable ….from my side,the worst ennemie of fentanyl patch ,its the sun …i dont get out in summer when its really hot ….if you can,just dont take fentanyl…if i could restart all over i would start it …im now on 130mcg/2days teva/ratio patch and i was on 170/2days before…i was able to go down by myself to 130 but its really hard…
I would add two other problems. Sometimes, the patches do not stick to the skin and then they will NOT WORK. In a very hot climate when sweating is problem, I found the patches did not adhere well.
I saw some patients when the duration of the patch was about 48 hours. They were coming back sooner and in a lot of pain. talking to the patients it was clear the duration of analgesia was a lot shorter than everyone THINKS it should be.
Bill, you have “Hit the Nail Right on the Head” as it were! Many GP, FP’s have bought into the idea that a patient can receive 72 hours of analgesic activity from the application of one patch. This is not necessarily the correct interpretation across the board and each patient should be monitored individually for actual response vs time curve.
Having had 6 lumbar fusions and a “ProDisc” replacement at L3-L4 in addition to double cervical fusions at C6-C7 then C5-C6, the 72 hour action in the sales brochure leaves much room for inadequate pain control! My most recent time under the knife, of one of the most outstanding Neurosurgeons in my area, performed a revision and fusion of C5-C6-C7 (with hardware), then in 3 weeks a laminectomy at my Pro-Disc level, L3-L4. The laminectomy failed to produce relief and resulted in another entry at that level to stabilize the joint (10 days after the initial procedure). Thankfully, my local physician managed my pain therapy and correctly titrated me down from 125 mcg fentanyl patch Q48hr to a maintainenance dose of 50 mcg Q48hr over a period of 5 months with terrific pain control (also supplemented with oxycodone 10/325 QID prn breakthru pain.
I also had the concern of the patches coming off in the shower or by sweating during rehab, but being a pharmacist I knew that “coverderm patches were available over the counter, so I used the larger size over the top of the fentanyl patch and never had one come off in the shower or while walking. I changed to the smaller coverderm patch as I titrated down to 50 mcg fentanyl with the same, excellent results. And having nieces, nephews and grandchildren around a lot I STRONGLY ENCOURAGE following the above advice and FLUSH the old patch immediately after removal. Wash your hands with soap and water to remove any potential residue on your fingers. NEVER apply any form of alcohol gel hand wash as that will just push the drug into your skin tissue.
In cases where it’s wearing off, they should be increasing the strength. I really don’t like Q48H directions. With the new 37.5, 62.5, and 87.5 strengths it’s a smaller jump too. I really like having more options.
As an RPh, I always include in the directions to “remove old patch.” If they forget, which can be more common than you might think with rotating application sites, it can significantly increase the risk of toxicity.
Regarding the ISMP’s guidelines for disposal of used patches, does anyone know if it is safe to flush them into a septic system?
For septic systems…will never dissolve or fall apart – so depending on how many get “flushed” – will eventually block the system. We advise our patients to fold in half and take to the drug disposal site. It’s beyond my imagination that flushing is an option – our water systems were not created for non-dissolving items. People keep medications from animals and children all the time. Kind of seems like telling someone to flush their insulin syringe in the trash versus properly storing in container for disposal. I think someone needs to rethink the method of disposal for patches.
Can I add some more?
I definitely agree about there needing to be good contact between the patch and the skin, and the comment about sweating.
CLinically I have found that if people are very thin or cachectic, fentanyl patches dont’ work well. I imagine it’s to do with the fentanyl being lipophilic. Has any one else noticed this?
II put a bandaid over my patch so it wont fall off. It stays on in the shower and outside, doesnt get sun.medical tape/bandaid work pretty well. I am on 25 mcg/ daily or every 2 days
As with all skin patches, I have found that washing and scrubbing the app site, then rinsing with hot water, patting dry with towel then applying immediately before the natural oil of skin returns works best. While some brands stick better than others, it will not fall off if the “skin oil” is washed off first. I also use and recommend a white board calendar screwed to wall posted the date, time and location of each patch, erase when removed, for myself, family or worst case, the medics to know. I also think the flushing is stupid. I fold it over in half, then wrap with a strong duct tape for the trash bag, then wash hand immediately after touching the stuff. Take it very serious folks. esp if you have children and or pets. Also true with sun, be careful in the heat, it will change the effects. Don’t be a dead hero tell your family to watch you when outside, notify them about the use of & whereabouts naloxone nasal spray. EVERY house should have a batch.
Ive been diagnosed w/intractable pain & as i type this the pain is unbearable. I cant even approach my male pain dr about using low dose pain patches. Yet im going to have to bite the bullet & ask. Im presently on 10mg of oxycodone? It took over 2 yrs to finally put me back on 4 pills every 24 hrs after a new dr took me off one of my pills b4 i had met w/her. The pain drs here n my town of about 40,000 ppl r some of the most uncaring drs ive seen. I have 6 tumors growing on my vertebrae, when i asked my PA if they cause pain she told me to ask my primary dr. This is called playing w/the patient! U should have seen the look on my primary drs face! The PA worked @ the pain clinic i went to each month to get my refills. I took every shot n my coccyx The dr recommended but nothing changed. One day my feet n thin cotton socks went out from under me & i slammed on my butt bones & jammed my spine. I hurt almost as bad as i do writing this. I was writhing all over the wood floor trying to get away from the pain. My husband hurried up the stairs & reached out for me to take his hand & because i hurt so badly & couldnt stop writhing, he told me to f_ck off & walked away. But called the EMS & they brought something like a tarp to get me downstairs across the street to the hospital. Im so sick & tired of being n pain off & on for 48yrs. I cant visit family because sitting on their furniture hurts so much i lay on the floor. That hurts when u have the bones that the only thing covering them is skin that i wear a Lidocaine patch 24/7 Just to keep my spine from rubbing a whole n my skin. My primary dr just finds my bonie bottom so unbelievable she constantly sticks her hand down my pants & does it 2-3 times n a row. She finds it unbelievable. Id rather have a dr feel what i have to live w/then not want to feel @ all. Ive told my pain dr would u like to feel my bones & see why i hurt so bad? He ignores me. Some of these drs either hate their jobs or just cant stand me. Ive had 3 heart drs tell me the reason for having diastolic dysfunction is normal @ my age yet i have an article from a heart specialist who is trying to get Drs to change their mind about how dangerous having a stellar dysfunction really is and that it can kill a person but nope the three heart doctors I saw here in my city all walked out on me & told me I don’t know what I’m talking about and that I can go to the Cleveland clinic and see them if I want to. U would not believe what ive had to deal with! I was prescribed 2 pain patches 7 yrs ago. I used 1 but started getting sick & luckily told my husband that i was wearing a patch. He told me to take it off & throw it away. Has anyone been on a plane & had the person behind u dry heave? By the time we found our hotel i was vomiting & sweating profusely for 12 hrs. I only wore the patch about half an hr.by the time my tired husband woke up i told him find anti vomiting pills or Rectal suppositories. It was the 1 medication i 4got to pack from home. Luckily n germany a person can buy anti vomiting med over the counter & found out the hotel had a dr on site. I vomited so hard for so long i told my family dr i think i vomited the lining of my stomach. She agreed. The pain patch was fentanyl the lowest prescribed dose. I still have the other prescribed patch from 7 yrs ago but hid it somewhere that i cant find it. As per my pain dr. Who insisted I hide it even though our grandkids wont even drive the 15 miles to see us. No pets. I wish there was a way to find out if it was the fentanyl patch that made me so sick or the five days going without any sleep and traveling so far W/out food & water that made me so sick, I’ll never know.
The dr who prescribed the fentanyl Patch 7 yrs ago refuses to prescribe them now & Told me intractable pain is the same as chronic pain, its not! Hence the 2 different words for pain. I dont like nor want to b n the position im n having unbearable pain most of my life. I cant stand the pain. Yet my pain dr agreed to let me have the 4th pill that was taken from me but he informed me he will never increase the 10mg per pill! Boy am i lucky to b in such incredible pain. In the article written about intractable pain the MD PHD said that some ppl have to spend their life n bed or be n a hospital the rest of their lives. Really! Try that 1 where i live. I cant even get a dr to believe i have Gullian barre syndrome & was paralyzed 4-5 weeks unable to move. nobody believes that one either.