From the Guidelines
When initiating a fentanyl 12 mcg patch for chronic pain in a patient previously on scheduled hydromorphone, it is recommended to give the final dose of hydromorphone as scheduled and then apply the fentanyl patch at that time, rather than overlapping the medications, to prevent opioid stacking and reduce the risk of respiratory depression or other adverse effects from excessive opioid levels. This approach is supported by the CDC clinical practice guideline for prescribing opioids for pain, which emphasizes the importance of careful dosing and monitoring when transitioning between opioid medications 1.
Key Considerations
- The fentanyl patch takes approximately 12-24 hours to reach therapeutic blood levels, making timing crucial in this transition 1.
- Giving the last dose of hydromorphone when starting the patch provides pain coverage during the initial period while fentanyl levels are building in the system.
- After applying the patch, the patient should discontinue the regular hydromorphone schedule, though they may still use breakthrough pain medication if prescribed.
- This transition method balances the need for continuous pain control while minimizing the risk of opioid overdose during medication changes, as highlighted in the guideline 1.
Rationale
The rationale behind this recommendation is to ensure a safe and effective transition from one opioid medication to another, minimizing the risk of adverse effects such as respiratory depression, which is a major concern with opioid therapy 1. The CDC guideline notes that ER/LA opioids, including fentanyl patches, should be reserved for severe, continuous pain and should be considered only for patients who have received certain dosages of immediate-release opioids daily for at least 1 week 1.
Clinical Implications
Clinicians should use caution when prescribing ER/LA opioids and consider the potential for increased overdose risk, especially when combining them with immediate-release opioids 1. The guideline recommends using ER/LA opioids with predictable pharmacokinetics and pharmacodynamics to minimize unintentional overdose risk, and it advises against initiating opioid treatment with ER/LA opioids for subacute or chronic pain 1.
Patient Safety
Patient safety is paramount, and clinicians should educate patients about the safe use of opioid medications, including the risks of overdose and the importance of adhering to the prescribed dosage regimen 1. By following the recommended transition method and carefully monitoring patients, clinicians can help ensure safe and effective pain management while minimizing the risks associated with opioid therapy.
From the FDA Drug Label
Fentanyl transdermal system is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. The efficacy of fentanyl transdermal system 12 mcg/hr as an initiating dose has not been determined In addition, patients who are not opioid-tolerant have experienced hypoventilation and death during use of fentanyl transdermal system. To convert patients from oral or parenteral opioids to fentanyl transdermal system, use Table C: TABLE C* DOSE CONVERSION GUIDELINES Current AnalgesicDaily Dosage (mg/d) Oral hydromorphone 8-17 17.1-28 28.1-39 39.1-51 IV hydromorphone 1.5-3.4 3.5-5.6 5.7-7. 9 8-10 Recommended Fentanyl Transdermal System Dose 25 mcg/hr50 mcg/hr75 mcg/hr100 mcg/hr
Giving the last dose of scheduled hydromorphone in place of the fentanyl 12 microgram (mcg) patch when initiating fentanyl patch therapy for chronic pain management is not directly addressed in the provided drug label.
- The label provides guidelines for converting patients from other opioids, including hydromorphone, to fentanyl transdermal system using Table C.
- However, it does not explicitly state what it means to give the last dose of scheduled hydromorphone in place of the fentanyl 12 mcg patch.
- The label emphasizes the importance of using fentanyl transdermal system only in patients who are opioid-tolerant and provides guidelines for dose conversion and titration.
- It is essential to follow the recommended guidelines and consult the label or a healthcare professional for specific guidance on initiating fentanyl patch therapy 2.
From the Research
Initiating Fentanyl Patch Therapy
When initiating fentanyl patch therapy for chronic pain management, giving the last dose of scheduled hydromorphone in place of the fentanyl 12 microgram (mcg) patch is a strategy that may be considered to minimize the risks associated with fentanyl.
Risks Associated with Fentanyl
- Fentanyl has a high risk of causing respiratory depression and reduced cerebral circulation, as noted in 3.
- The risk of respiratory depression is particularly concerning when fentanyl is combined with other substances, such as illicit opioids 3.
- Fentanyl overdose deaths have reached "epidemic" levels in North America, with death invariably resulting from respiratory depression 4.
Comparison with Other Opioids
- Fentanyl has been compared to other opioids, such as heroin and morphine, in terms of its ability to depress respiration 4.
- Fentanyl was found to produce more rapid depression of respiration than equipotent doses of heroin or morphine 4.
- Atypical opioids, such as buprenorphine, tramadol, and tapentadol, may be safer than conventional opioids like fentanyl due to their unique mechanisms of action 5.
Risk Factors for Opioid-Induced Respiratory Depression
- Certain risk factors, such as renal failure, concomitant central nervous system (CNS) depressants, and increasing age, have been identified as contributing to severe opioid-induced respiratory depression (OIRD) 6.
- The first 24 hours of opioid administration have also been found to be a high-risk period for OIRD 6.