Why I Don’t Like Fentanyl Patches in Long Term Care

Fentanyl patches in long term care are an extremely convenient way to deliver continuous opioid therapy.  So what’s not to like and why I do I have concerns about them?  In no particular order:

1. Fentanyl patches are extremely potent.  Many healthcare professionals don’t realize how strong a fentanyl patch is.  Opioid conversions are never perfect, but conservatively, a total daily dose of oral morphine 45-60 mg is approximately equivalent to fentanyl 25 mcg patch.  Because of this, I’ve seen numerous cases of inappropriately high starting doses, especially in the elderly population.  Even used patches have enough medication left in them to provide a lethal dose if taken all at one time.

2.  Lost or missing patches should scare you.  Fentanyl as mentioned above, is extremely potent.  There is significant risk of children/pets getting access to a used patch.  Take a lost or missing patch very seriously.  Simply do a google search of fentanyl patch deaths and you’ll understand what I’m talking about.  Flushing of used patches is recommended per ISMP. More likely with fentanyl patches is the potential for drug diversion. These cases even go to the point of diverters removing used patches from dementia patients.

3.  Fentanyl patches are meant for CHRONIC pain.  I’ve seen orders numerous times for fentanyl patches from the ED or primary providers for the treatment of ACUTE pain.  You are not helping patients relieve their acute pain with a fentanyl patch.  With an onset of action that takes hours to days once applied, a patient can be in pain for a long period of time before the drug begins having an effect.

4.  Delayed withdrawal.  Fentanyl patches basically create a deposit of drug being slowly absorbed through the skin.  I remember a case where a patient was on a chronic higher dose (100 mcg) and the patch was discontinued in the ED without any follow up or supplemental opioids.  Long story short, they ended up having withdrawal symptoms, but not until hours after they were discharged.  (Remember slow onset as well as slow elimination and offset)

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