As I work with different physicians to help their patients taper off the high dose Fentanyl patches before Jan 1 (as they will no longer be covered by the Ontario Drug Benefits Program), I do find it both amusing and frustrating throughout the process. Many patients are titrated to the high strength Fentanyl patches because of inadequate pain control. Yet many don’t realize these Fentanyl patches don’t work very well.
It takes patience and time which I find we often lack in our health care system.
It takes patience because it has a very slow onset of action. So don’t expect it to work right away. But if the patient has been on the patch for a good period of time (e.g at least 4 weeks) and is still complaining of pain, everyone should question first if there is any issue with the Fentanyl absorption transdermally before increasing the dose. For more info on the intricacies of working with Fentanyl patch, please refer to this post.
I find it amusing because as I explain to the various physicians how the Ontario Drug Benefits Program will no longer pay for the high dose Fentanyl patches as of Jan 1 2017, many of their first question or reaction is that whether we can substitute with two lower strength patches. For example, if an individual is currently on Fentanyl patch 75mcg/hr which will not be covered soon, can we substitute with Fentanyl patch 50mcg/hr and Fentanyl patch 25mcg/hr together?
This is an easy and a lazy way out but the pharmacy may be at risk for crawl back later if there is an audit to be done. There is also safety concern with handling multiple patches leading to more medication incidents (e.g. forgetting to remove all the patches)
By asking this question, we have essentially skipped the fundamental question to consider the risk with keeping the patients on the high dose fentanyl patches. We are delisting the high dose Fentanyl patches because there is strong evidence to show that they are more harmful than helpful for pain management. Not only are they probably ineffective, there are serious issues that we are trying to manage such as the Fentanyl patch diversion and opioid overdose crisis across the country.
By asking the question, we have dismissed the very important point that we should try to evaluate if our patients can be on a different opioid, taper off to the lower strength patch or simply take a moment to assess and review.
By asking the question, we have simply ignored out duties to practice safe medicine.
So if this is the attitude that we tend to take in our health care system, we will not be able to move forward to improve, to sustain and to survive.
To be quite honest, many of the my patients who have successfully tapered to a lower strength Fentanyl patch have experienced no withdrawal symptoms and no increase of pain at all. It was like they were switched to a lower strength patch and no one noticed. This essentially supports my hypothesis that many can’t absorb the fentanyl patches in the first place.
I hate to state the obvious – these Fentanyl patches don’t work well at all.