Opioid Patch Dosing Guidelines for Pain Management
Transdermal fentanyl patches should only be used for severe and persistent pain in opioid-tolerant patients, never for acute pain, postoperative pain, or in opioid-naïve patients due to the serious risk of respiratory depression. 1, 2
Patient Selection Criteria
Transdermal fentanyl is indicated only for:
- Opioid-tolerant patients (defined as those taking for one week or longer: at least 60 mg oral morphine per day, 25 mcg transdermal fentanyl per hour, 30 mg oral oxycodone per day, 8 mg oral hydromorphone per day, 25 mg oral oxymorphone per day, or 60 mg oral hydrocodone per day) 2
- Patients with stable pain patterns not requiring frequent dose adjustments 3, 1
- Patients who need continuous opioid administration and cannot be managed with other medications 1
Contraindications:
- Opioid-naïve patients
- Acute or intermittent pain
- Postoperative pain
- Mild pain
- Significant respiratory depression
- Known or suspected gastrointestinal obstruction 2
Conversion to Transdermal Fentanyl
- Determine the 24-hour analgesic requirement of current opioid
- Use the following conversion table to select appropriate fentanyl patch strength:
| Transdermal Fentanyl | Oral Morphine | Oral Oxycodone | Oral Hydromorphone |
|---|---|---|---|
| 25 mcg/hr | 60 mg/day | 30 mg/day | 7.5 mg/day |
| 50 mcg/hr | 120 mg/day | 60 mg/day | 15 mg/day |
| 75 mcg/hr | 180 mg/day | 90 mg/day | 22.5 mg/day |
| 100 mcg/hr | 240 mg/day | 120 mg/day | 30 mg/day |
| [3,1] |
- For continuous IV fentanyl to transdermal fentanyl: use 1:1 ratio (μg/hr IV = μg/hr transdermal) 1
Administration Guidelines
- Each patch is intended to be worn for 72 hours (though some patients require replacement every 48 hours) 3, 1
- Apply to clean, dry, non-irritated, flat skin on upper torso
- Rotate application sites
- Prescribe breakthrough medication for the first 24 hours while patch reaches steady state 3
- After 2-3 days, adjust patch dosage based on average amount of breakthrough medication required 3
Special Considerations
- Heat exposure warning: Avoid direct external heat sources (heating pads, electric blankets, hot tubs, fever) as they accelerate absorption and can cause overdose 1, 2, 4
- Dose adjustments: For hepatic or renal impairment, start with half the usual dose and titrate slowly 2
- Discontinuation: Do not abruptly discontinue in physically dependent patients to avoid withdrawal symptoms 2
- Naloxone availability: Consider prescribing naloxone based on patient's risk factors for overdose 2
Safety Precautions
- Monitor for respiratory depression, especially during initiation and dose increases 2
- Patches contain high doses of fentanyl before and after use, requiring proper disposal 4
- High-risk situations for overdose include:
- Confusion between dose strengths
- Forgetting to remove old patch when applying new one
- Applying multiple patches
- Cutting patches (never do this)
- Increased skin temperature 4
Available Strengths
Transdermal fentanyl patches are available in: 12 mcg/hour, 25 mcg/hour, 37.5 mcg/hour, 50 mcg/hour, 62.5 mcg/hour, 75 mcg/hour, and 100 mcg/hour 2
Proper Disposal
- Fold used patches with adhesive sides together and flush down toilet immediately after removal 2
- This prevents accidental exposure to children, pets, or others 4
Following these guidelines ensures appropriate and safe use of transdermal fentanyl patches for pain management, minimizing risks while maximizing benefits for suitable patients.