Inappropriate use of Fentanyl Patches

76 year old male had recently had a hip fracture with surgery and was in a substantial amount of pain. Upon discharge from the hospital, he was admitted to a long term care facility for rehab. Acute pain management was the highest on the priority list and the provider started Fentanyl patch 25 mcg as needed every three days. You could imagine my surprise when I saw this order 🙂 – So what’s wrong with a fentanyl patch as needed? Two major points: 1. Fentanyl patches are not meant for acute pain to begin with, they are meant for chronic pain. 2. Even more importantly, here’s a prime example why knowing and learning pharmacokinetics matters. The onset of a Fentanyl patch takes at least about 6 hours (per Lexicomp) to start having an effect which flies in the face of the premise of an as needed medication. As needed medications are meant to help treat a condition quickly. Would you want your patient in pain for at least 6 hours(probably much longer) before they started feeling any relief at all? The patient did request to use it as it was meant for their pain control, did not get any pain relief and the patch was discontinued. Substantial waste of money and time as well as not helping the patient!

6 Comments

Luka Tehovnik on May 26, 2014 at 4:04 pm

Short and educating! Please, more! Thank you!!
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Alka Bhalla on February 8, 2015 at 4:37 pm

Were there no short-acting oral opioids on the order? Hard to believe the patient was sent off without having his pain managed adequately! How did the MD come up with the conversion to Fentanyl 25? *puzzled*
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Kelly on April 12, 2015 at 6:46 am

Another important lesson in this gentleman’s care is that while not extremely elderly (i.e. age > 85) he is 76 yo and his body is showing signs of aging (he is in the hospital for surgical repair of a hip Fx …true we don’t know if he got this Fx jumping and playing with his grandkids or just getting out of his easy chair).
We must be very careful when giving pain medication to the elderly. We surely want and have to Tx their pain adequately but the elderly respond to opioids much more dramatically and a change in mental status could further c/o his recovery. Fentanyl patch, even though the references say that it takes 6 hrs for onset of pain relief, I am a chronic pain Pt as well as a physician and I got relief on my RSD skin within 20 minutes using the patches Q 48°. I think it varies with the Pt. Max is 6 hrs. As the article so well stated, Fentanyl patches are not for acute pain, only chronic.
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- Jbb on November 11, 2015 at 6:30 am
  
  Not necessarily 6 hours max onset time. Depends on tour of patch and person -I am a chronic pain patient and pharmacist and use duragesic 75mcg/hr patch and takes a good 8-12 hours for patch to kick in in I’ve mistaken change day or time.
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  - Kelly on November 13, 2015 at 4:52 am
    
    jbb You are correct. I was not intending for the ‘6 hr max’ to apply to anyone but me I have RSD also called CRPS and the ionic flux of my skin may be dramatically different than nl. It was an anecdotal comment. I am so sorry that you too suffer from chronic pain. Have you ever considered a pain pump?
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Asma on April 28, 2016 at 3:18 pm

Thats right! Fentanyl not the first option for naive patients, and of course of chronic. Even if used in chronic, its not used as prn, cus of difficulty with dose adjustments, right??
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