Indications for Use of Fentanyl Patches
30. What special considerations are necessary for use of fentanyl transdermal patches in patients such as A.J.?
Transdermal fentanyl can be used to effectively manage chronic cancer pain. Because of the nature of the transdermal delivery system, the onset of analgesia may be delayed by 6 to 12 hours after placement of the patch.121,122 On removal of the patch, the fentanyl deposited in the subcutaneous tissue continues to release active drug for approximately another 8 to 12 hours. These delays in onset on application and in offset after removal of the transdermal patch discourage use of the patch except for patients who require a steady maintenance analgesic dose. The transdermal patches do not provide sufficient flexibility in dosing to manage rapidly changing analgesic needs. Even after stabilized on a given drug regimen, patients with cancer pain always should be given an immediate-onset opioid analgesic (e.g., morphine elixir or solution) to take as needed for management of breakthrough pain.123 If the need for breakthrough drugs becomes frequent, the underlying dosage regimen should be reassessed and the doses increased as appropriate. Fentanyl absorption from the patches can be affected by body temperature, and unintentional overdoses can occur with hyperthermia.124
A patient given fentanyl patches must be instructed to dispose of used patches appropriately to prevent inadvertent access by children or household animals. Fentanyl patches were thought to be safe from diversion and abuse, but the drug enclosure membrane can be removed and active drug accessed.125
31. What other delivery system options are available for A.J. to manage his breakthrough pain?
Oral transmucosal delivery of fentanyl offers the advantage of controlling pain relatively quickly without being invasive. Oral transmucosal delivery systems deliver drug with a relatively rapid onset and increased bioavailabillity compared with GI absorption. Because this route delivers medication into the bloodstream so quickly, it is imperative that the relative potency of this agent is understood.126,127
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