Abstract
Background
For opioid-tolerant patients with persistent pain from a serious illness like advanced cancer, fentanyl transdermal patches are an appropriate analgesic option. In fact, they are a preferred long-acting opioid option for patients with dysphagia, an obstructing tumor in the upper gastrointestinal tract, intolerance to other opioids, or renal failure.1,2 Concerns regarding fentanyl patches, particularly public health concerns with fentanyl overdoses, compel many patients to feel trepidation regarding their prescribed use for pain. Furthermore, practical concerns regarding transdermal fentanyl (i.e., bathing with the patch, effectiveness in cachexia) arise frequently in clinical care. 3 This Fast Fact offers guidance on commonly expressed concerns regarding the fentanyl patch. See Fast Fact #2 for more on dosing.
Public Health Concerns with Fentanyl
Fentanyl’s potency is much higher than most opioids. 4 Because of this, mixing of illicit fentanyl with other illicit substances is dangerous.4,5 In a medical setting, the dosing is highly regulated and calibrated in the transdermal patches.6–8 While many patients and families may agree intellectually that the prescribed use of transdermal fentanyl is appropriate, emotionally they may fear the medication because illicit fentanyl use is a leading cause of opioid-related deaths in the United States. 9 Furthermore, fentanyl-related deaths occur disproportionately in certain populations (e.g., males, urban areas, individuals with lower education, black Americans), which may contribute to distrust of the medication. 9 A public campaign promoting a “Fentanyl Free America” with a call to action to disrupt fentanyl’s supply chain adds more public concerns about its safety. 10
Responding to Patients and Families About Public Health Concerns
Be curious and explore their emotional responses towards fentanyl. Many families have had personal experiences with opioid use disorder and overdose. Strong feelings towards a medication with negative connotations are common, with some even feeling like they are betraying their recovery or their loved ones by taking prescribed fentanyl for their pain control. Create safety for patients to explore these feelings because they may not do so spontaneously. If the feelings are not acknowledged proactively, future adherence will likely be affected. To start the conversation, inquire about what they have heard about fentanyl and what concerns they may have. Validate their concerns and if appropriate, refer to mental health professionals if necessary. After validating their concerns, offer clinical reasoning on why you recommend it for them and distinguish the supervised/prescribed/indicated use of fentanyl from the dangers of illicit use. Make sure they know how important their safety is to you. Provide standard safe opioid counseling, such as keeping the medication in a secure place (e.g., locked box), best handling practices (see below), disposing of unused patches, and normalizing the co-prescription of intranasal naloxone in case of an accidental overdose of a patient or bystander (see Fast Fact #328). Note, the half-life of naloxone is quite short compared to the patch, so if naloxone is given, notify emergency medical services (or the hospice team if appropriate) immediately even if the person temporarily recovers. Collaborate with clinical pharmacists and nursing to help with this patient education and counseling. Ultimately, respect patient autonomy and offer alternative analgesic options if they decline.
Other Counseling for Patients and Families Regarding Fentanyl Patches
MRI machines: While many fentanyl patch manufacturers do not require removal for MRI testing, patients may be asked to remove their patch if it will be in the radiofrequency field due to the risk of burns.
11
If this is recommended, discard the old patch and apply a new one to a different skin site following the MRI study. Since the half-life of the fentanyl patch is 13–25 hours, patients should be reassured that they will continue to have adequate pain relief during the procedure.
12
Disposal: consult your institutional/county/state policies and restrictions. Many police stations have take-back policies and will help dispose of them. If not, used patches should be folded in half and flushed down the toilet. This is often preferred to keeping unused fentanyl patches in the house. Safe handling: Bystanders should wear gloves if touching the patch, then wash their hands. If it falls off prior to the scheduled next dose, dispose of it and place a new one.13,14 Patches should not be cut or torn.13,14 Avoid direct external heat (i.e., sauna use, heating pad) to the patch, as blood circulation can increase systemic intake and raise the risk of overdose.15,16 Patients can bathe, shower, and swim while wearing a fentanyl patch.
14
Avoid skin areas that are oily, burned, or irritated. Wipe away residue from soaps, lotions, etc., before applying patch. Patients prone to excessive sweating: patch placement on the inner upper arm or thigh may help, as may fixing it with a nonocclusive film dressing.2,13 Site reactions: mild pruritus, swelling, or erythema is common. Instruct patients to tell the clinician about it so they can evaluate and ensure it is not an allergic reaction. Typically, the site reactions are manageable by rotating sites, cleaning the area with water, and/or applying hydrocortisone.
2
Cachexia—subcutaneous fat provides a reservoir for the medication to be slowly released. Thus, response to fentanyl patches may be less reliable in patients with cachexia.17,18 Still, imminently dying patients often cannot tolerate oral medications, making transdermal routes a viable option to for long-acting opioids at the end of life. Bottom line—monitor patients and dosing carefully.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.