Friday, May 08, 2009

Fentanyl Transdermal Patches for Severe, Chronic Pain

A few days ago an elderly cancer patient was admitted to one of my rooms directly from the doctor's office for management of severe, chronic cancer-related pain. She rated her pain at "more than 10 of 10" on the pain scale. I'm always quick to give pain medication, but in this case we had no doctor's orders for one thing, and the supplies to access the patient's IV port-a-cath site (that's the same thing as an infus-a-port) hadn't arrived yet from the distant central supply department. Despite her pain, it was reassuring to review her home medication list and see that she had listed the Fentanyl transdermal pain patch among her medications. (Duragesic is a well-known brand-name for the Fentanyl patch.) The strong medication released from the patch on a slow, continuous basis is absorbed through the skin and provides great pain relief to most patients. Later in my admission assessment I asked her specific questions about the last time she took her home medications in order to complete the medication reconciliation process. It turned out that although the patient had filled the Fentanyl patch prescription, she had never used any of them.

My patient told me that after filling the Fentanyl patch prescription, she happened to catch an attorney's television commercial which warned about using Fentanyl patches. "The lawyer said those patches are 80 times more powerful than morphine, and they can kill a person." Unfortunately, my patient suffered quite a bit of intense pain and ended up admitted to the hospital due to that frightening television commercial. It's true that the Fentanyl is a MUCH stronger pain medication than morphine (about 100 times stronger), and certain circumstances related to this medication have come under well-deserved scrutiny in recent years--see FDA's 2007 Fentanyl Advisory--but with proper safeguards, this medication is both safe and very effective.

Some generic versions of the Fentanyl patch of the dosage 25 mcg/hr were recalled in 2008; check this list to learn more about the affected lots. The damaged patches released the pain medication too quickly, therefore putting patients at risk for an accidental overdose which could have caused them to breathe way too slowly--or not at all--due to oversedation.

I'll probably come back to tweak this blog entry later. For now, I want to point the reader to the patient information guide, instructions for use, and the "black box warning" for the Duragesic Fentanyl Patch.

The following "Important Safety Information" can be read in its entirety at the Duragesic site.

Here are some of the key points you need to know about using the (Fentanyl transdermal system) with my own bold/italics added to emphasize certain points.
  • It is used to manage constant moderate to severe chronic pain that needs to be treated around the clock which cannot be treated by: combination narcotic, short-acting, or non-narcotic pain treatment products.
  • It should only be used by people who are receiving or have developed a tolerance to pain therapy with products known as opioids. It should not be used if you have pain that will go away in a few days, such as pain from surgery, medical or dental procedures, or short-lasting conditions.
  • One serious important side effect is slow, shallow, and/or difficulty in breathing, if the dose is too high. This sometimes happens the first time someone uses the product, so they should be watched more closely during the first 3 days of treatment.
  • It can be abused in ways similar to other legal or illegal pain products. Care should be taken in storing this medication.
  • It is a thin, adhesive, rectangular patch that is worn on your skin and delivers a strong pain-relieving medicine called Fentanyl through the skin and into the bloodstream. Using damaged patches can change the amount that is absorbed and cause too much medicine to be absorbed through the skin that can cause serious and sometimes fatal breathing problems.
  • Do not combine with alcohol or other CNS depressants (e.g., sleep medications, tranquilizers) because dangerous additive effects may occur, resulting in serious injury or death.
  • Avoid exposing the Fentanyl application site and surrounding area to direct external heat sources, such as heating pads or electric blankets, heat or tanning lamps, saunas, hot tubs, and heated water beds, while wearing the system. Avoid taking hot baths or sunbathing. There is a potential for temperature-dependent increases in Fentanyl released from the system resulting in possible overdose and death.
  • Keep patches (new and used) out of the reach of children and others for whom Fentanyl was not prescribed. A considerable amount of active Fentanyl remains in the patch even after it has been used as directed. Accidental or deliberate application or ingestion by a child or adolescent will cause respiratory depression that could result in death.
  • For more information about DURAGESIC® Fentanyl patches, talk to your doctor or call 1-800-526-7736, 9:00 AM - 5:00 PM (EST), Monday through Friday.

For additional information, here's a link to an FDA article, Proper Use of Fentanyl Pain Patches.

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