There has been so much media attention on fentanyl patch recently. From the escalating drug diversion concern to the recipes that turn fentanyl into some exotic concoction, it has captured everyone’s attention including the medical community, the law enforcement and the curious public.
The worrisome fact with Fentanyl abuse is that it is now found to be synthesized in a foreign lab, apparently in China. So drug traffickers are not only relying on drug diversion from our own health care system.
So I start to ponder, what does Fentanyl patch offer that other opioids lack?
Perhaps it offers an alternate route of administration (via transdermal patch) for the treatment of chronic pain when neither the oral nor the injectable route is safe or desirable (e.g. dysphagia, injection site infection,heavy pill burden).
Here are some other key facts to keep in mind when prescribing fentanyl patch:
- Very potent. Fentanyl is an opioid that is 100 times more potent than morphine. So taking a small amount can lead to opioid overdose very quickly if unintended.
- Not for acute pain. As a patch, fentanyl is designed to provide slow but continuous relief of pain, usually in people with complex or cancer pain.
- Be patient, it doesn’t work right away. Fentanyl has a slow onset of action and takes at least 24 hours to kick in.
- Have a Plan B for Pain control. Slow onset of fentanyl also mean an alternative method of pain control will be needed initially.
- Wait to Evaluate Pain. Because it takes time for the drug to reach a steady state concentration in the body, any pain control evaluation should NOT be hastily done. Ideally, pain evaluation should occur in 1-2 weeks after starting the patch or any dose changes.
- Need some Fat to work. Optimal absorption of fentanyl patch occurs when there are adequate subcutaneous fat tissues and thus absorption may be compromised in cachetic or frail individuals, rendering the patch ineffective.
- Not for opioid naive people. Because it is so potent, fentanyl is also not indicated for opioid naive individuals. It is recommended that the individual should be on at least 60mg of morphine (orally) for the last 2 weeks before any attempt of patch conversion.
- Don’t cut the patch. The patch is sophisticated and is designed to release the medication slowly, so cutting the patch or tampering it will destroy the structure and alter the delivery rate of the medication. It may drastically increase absorption initially (leading to oversedation) and does not have enough to last for the duration intended (worsening pain at set intervals).
- Heat is not good for Fentanyl absorption. Any increased heat exposure to the body can increase Fentanyl absorption resulting in oversedation…. so no hot packs or lounging in the hot tube…and also watch for the high fever too.
- Don’t abruptly stop the patch but stop if it ain’t working. Never stop the patch abruptly as it may lead to opioid withdrawal – consider to cross taper with another opioid. But slowly stop if it is not helping with the pain.
I know many physicians are responsible prescribers. But I also know some who can do better. I have seen Fentanyl works wonderfully for individuals with complicated chronic pain. But I have also seen it misused or used in individuals where they clearly have not benefited from the patch. We can’t fix everything but we should fix what’s within our power. Fentanyl patch can be very effective for pain control when we understand how to use it properly. But it can be a bad business when landed in the wrong hands.