Therapeutic Handbook - GGC Prescribing

Good prescribing points for transdermal fentanylIndications for using fentanyl patches:• Stable pain only, not suitable for acute pain.• Oral route not viable due to e.g. poor absorption or swallowing difficulties e.g. ileostomy, headand neck cancer, etc.• Morphine and other oral strong opioids cannot be tolerated due to side effects e.g. confusion,excessive ongoing drowsiness, intractable constipation.• Compliance issues – a supervised patch change will assist this.Remember:• Pain must be stable:- It takes 6 - 12 hours for the patch to begin to work and will take 36 - 48 hours to reach stableplasma levels (do not increase patch before 72 hours have passed).- Any subsequent dose increase will take 48 hours to see full therapeutic effect.• Fentanyl is a potent opioid, 100 - 150 times more potent than oral morphine.• Fentanyl patches are not normally appropriate in opioid naive patients and great care is requiredin this situation. Seek specialist advice.Note: Durogesic DTrans ® 12 micrograms/hour is only licensed for fine titration between 25 and75 micrograms/hour. Initiating a patient on a 12 microgram/hour patch will be an ‘off-label’ use.There will be clinical situations when this may be justified.• As patches vary considerably in their appearance and to avoid the risk of patient confusion,patients should not be changed from one formulation or make to another without adequatecounselling.• If the patient, on a fentanyl patch, is dying and/or pain control becomes unstable and additionalanalgesia is required, do not take the patch off. Leave the patch on (continuing to replace every72 hours) and add a continuous subcutaneous infusion.• There is a very wide range in equivalency between transdermal fentanyl and oral morphine.Palliative CarePage 320