Pain Management in Hospice Patients: The Fentanyl Patch
Posted by Dr. Jim Joyner
Rational Use of the Fentanyl Patch
Fentanyl patch (Duragesic) has been used for the management of severe pain in the U.S. since the early 1990's. Despite numerous warnings from the FDA, manufacturers, and consumer safety groups, fentanyl patches are still a source of frequent serious medication errors due to inappropriate prescribing, dispensing, and administration errors.
The Institute for Safe Medication Practices (ISMP) has been monitoring fentanyl patch-related medication errors since 2000 and has addressed the issue in several of their past newsletters. ISMP recently expressed ongoing concern about the continued inappropriate use of the fentanyl patch in their June 28, 2007 Alert: "ISMP is deeply troubled and alarmed by what appears to be a steady stream of adverse events with fentanyl patches, including fatalities..."
The ISMP alert describes a multifaceted problem resulting from the following:
♦ Prescribing of fentanyl patches to opioid-naïve patients
♦ Excessive doses either alone or in conjunction with other opioids
♦ Lack of sufficient oversight of dose titration
♦ Lack of patient education
The fentanyl patch should only be used in opioid-tolerant patients with chronic pain that is not well controlled on shorter-acting analgesics. It is not indicated for short-term, acute pain, intermittent pain, or post-surgical pain. Healthcare professionals, patients, and caregivers all must have an understanding that after applying the first patch, it may take 12-16 hours to reach the peak analgesic effect. The need for short-acting analgesics for breakthrough pain should be anticipated during the initial titration phase.
Following the initial patch application, the dose may be titrated upwards based upon the average daily usage of the PRN short-acting opioid, but no more frequently than 3 days after the initial dose. Following this initial titration the ISMP recommends that further dose increases are not done more frequently than every 6 days in order to avoid risks of over-dosing.
One problem associated with the patch is not removing the previous patch before applying another. Even though the patches are intended to provide continuous release of fentanyl over 72 hours, there is a residual amount of drug within the patch that will continue to release for several hours beyond the 72 hour interval if the patch is not removed. This may result in over-dosage and serious toxicity if the previous patch is not removed when applying the next one.
Another potential for toxicity occurs with elevated body temperature. The transit of fentanyl from the patch to the skin will be significantly speeded up when heat is applied or the if the patient has a fever. This increases the risk for over-dosage and toxicity. The ISMP received a report in March 2005 of a 77 yr old female who died after applying a fentanyl patch to her buttock and later used a heating pad in that area. It was also determined that the patient failed to remove the previous patch when applying her next one. Heating pads, electric blankets, heat lamps, saunas, hot tubs, or heated water beds should not be used with the fentanyl patch. Patients with a fever higher than 102F are at risk of increased fentanyl absorption and may have to have their dose decreased until the temperature decreases.
Serious errors have resulted from improper disposal of fentanyl patches. Another ISMP report describes the death of a 4 year old boy after he applied a patch to his skin. His mother found him on the floor near an overturned trash can that contained discarded patches. The manufacturer of Duragesic recommends that used patches be disposed of by folding the adhesive side of the patch together so that it sticks to itself and then flushed down the toilet.
Here are some guidelines for appropriate application of the fentanyl patch for your hospice patients and caregivers:
♦ Apply to chest, back, flank, or upper arm
♦ Apply only to intact skin, avoiding areas that are cut, abraded, very oily, or otherwise irritated
♦ Apply on areas where there is no hair
♦ If patch must be applied to an area with hair, do not shave (shaving irritates skin and may result in increased drug absorption). Instead, clip hair as close to the skin as possible
♦ Clean the skin area with water only & dry completely prior to patch application
♦ Avoid soaps, lotions, oils, and alcohol on the skin prior to application of the patch
♦ Rotate the site of application to avoid local skin irritation
♦ If gel from the patch accidentally contacts skin of the patient or caregiver, wash the area with water only. Soap, alcohol, or other solvents may increase absorption of the drug through the skin
Outcome Resources is dedicated to assisting hospices with the very best information and education related to hospice medication management. Contact Us to learn more about how we can assist your hospice in decreasing costs while increasing the quality of patient care.