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.