Optimal Fentanyl Patch Use

There is alot of confusion of what amounts to optimal fentanyl patch use. Many patients contend it only lasts 2 days. How does one adjust the dosage?

1) First thing is that opioids often only give 20-30% relief. Dr. Turk has written an article that contended that only 50% of patients will continue to use opioids as they either have too many side effects or are ineffective.

article here

2) Fentanyl can be dangerous with 2% of patients (I presume novices) subject to respiratory depression.

3) I suspect one of the reasons it appears to only last 2 days is because they were relatively ineffective to start with, and relief is only attained during the peaks. There was a case published of a lady who required Thirty Four 100 ug patches to control her cancer pain:

Bleeker CP, Bremer RC, Dongelmans DA, van Dongen RTM, Crul BJ. Inefficacy of high-dose transdermal fentanyl in a patient with neuropathic pain: a case report. Eur J Pain. 2001;5:325-329

Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58-year-old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 microg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1-2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

4) Now I find this a little confusing because people as supposed to attain steady state after recurrent use:

(from:

Transdermal Fentanyl An Updated Review of its Pharmacological Properties and Therapeutic Efficacy in Chronic Cancer Pain Control
Richard B.R. Muijsers and Antona J. Wagstaff
Drugs 2001; 61 (15): 2289-2307

• It can take between 12-38 hours for a new patch to attain good blood levels”Delays of 34 to 38 hours have been reported between patch application (25 to 100 μg/h) and occurrence of Cmax.”
  Fentanyl half lives are 13- 22 hours – “elimination half-life values of 13 to 22 hours have been reported.”
  A hot bath can cause rapid utilization (and depletion) of the patch. Iwonder about flushes too…
  If one looks at the worst case scenario, someone could eliminate the fentanyl in 13 hours but take 38 hours to reach peak of the new patch – this would result in a 25 hour period of suboptimal control.
  Some people with chronic pain are overweight – just because exercise is too painful. I suspect absorption might be delayed but elimination could be too.

  5) Conclusion is, there are going to be people who are poorly managed between patches. They may say the patches only last 2 days because they can only tolerate the day waiting for the new patch to kick in, when fentanyl levels are at their highest (2 days).One article suggested strongly that if a patch falls off prematurely, one should put the new one on the same spot to maintain blood levels – that begs the question that perhaps these fluctuations are real if applied to a new site.

  6) One patient had a novel way of handling that. She would leave the old patch on for 3 days but apply the new patch on day 2. That way, the new patch has an opportunity to kick in before the old one is removed. I would not try this on a novice as one is asking for trouble but seems like a viable option for patients not well controlled otherwise.

  7) I feel ashamed of our medical community. For decades, they undertreated cancer pain because they thought they knew better. In one study, untrained university students were better judges of pain level than health care professionals (the more trained, the worse at judging). For heavens sake, if a patient says the patch only lasts two days then it probably only last two days despite all one’s pseudo-expertice. Try the above course and see what happens.

  I would be interested in opinions