The adhesive patch is typically prescribed to treat postoperative pain or chronic pain conditions, but in some cases is being misused, often with deadly consequences. Fentanyl is available as a transdermal system for the treatment of chronic pain in opioid-tolerant patients; however, it carries a black box warning due to both the potency of the product and the potential for abuse. Pop superstar Prince, found dead more than a month ago at his estate outside Minneapolis, died from an overdose of the powerful opioid fentanyl, authorities said Thursday. WebMD has the details. Missouri girl Destiny Spitler, 12, was found lifeless in her bed on Saturday morning and investigators called to the scene discovered a fentanyl patch, which is up to 100 times stronger than morphine, on her thigh. Order Minocycline Online - Cheap Prices, Fast Shipping and High Quality. Available 50 mg and 100 mg Doses. Fentanyl: The king of all opiates, and a killer drug crisis. It’s stronger than heroin and more potent than OxyContin. It’s also cheap, ubiquitous, and incredibly deadly. Inside the rise of fentanyl. An Alternative Algorithm for Dosing Transdermal Fentanyl for Cancer- Related Pain. ABSTRACT: Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Intolerable side effects, ineffective pain relief, or a change in the patient’s clinical status can dictate the need for a new pain management regimen. Transdermal fentanyl (Duragesic) is an opioid agonist that has been shown to be safe and effective for the treatment of cancer pain. However, clinicians should realize that the manufacturer’s recommendations for equianalgesic dosing of transdermal fentanyl may result in initial doses that are too low in some patients, and in a titration period that is too long. Under these circumstances, the patient is likely to experience unrelieved pain. An alternative dosing algorithm that considers both a review of the literature and our combined clinical experience with transdermal fentanyl should help clinicians individualize the treatment of pain. The majority of patients (6. Each patient’s plan of care must be individualized, reassessed, and, if necessary, altered regularly to maximize pain control, functionality, and ultimately, quality of life. The patient’s self- report of pain should be the basis of pain management, since both caregivers and health care workers tend to underestimate pain severity. At this point, opioids can be used alone or in combination with nonopioid therapies. Adjuvant agents, such as corticosteroids, tricyclic antidepressants, and anticonvulsants, can be used concurrently to enhance analgesic efficacy, treat opioid- induced symptoms or to alleviate specific types of pain. When this occurs, patients require agents that provide a rapid onset of action and short duration of effect to complement the pain- control regimen. Social and family relationships may suffer as patients avoid interpersonal interaction or experience personality changes as a result of persistent pain. Although initially the “step” approach was recommended. A different opioid may be necessary as a result of intolerable side effects, cost considerations, or the need for an alternative route of administration as the patient’s disease progresses. Of the 4. 2 patients whose medication was unchanged at initial evaluation, 2. Thus, 8. 0 patients required changes in drug or route of administration prior to death or discharge. These 8. 0 patients experienced a total of 1. Conversion tables are often based on the results of single- dose studies in patients receiving low opioid doses for postoperative pain. Although relative analgesic potency is conventionally expressed in comparison with 1. Table 1). Pure agonists are used most commonly in the treatment of cancer pain. Pure agonists bind completely to mu receptors and usually do not have a ceiling dose. The dose is increased as necessary to allow for adequate analgesia unless intolerable or unmanageable side effects occur. Fentanyl is approximately 7. In the transdermal system, fentanyl is released from a cutaneously applied reservoir at a nearly constant amount per unit of time. The amount of fentanyl released per hour is directly proportional to the surface area of the patch in contact with the skin. Commercially available patch sizes provide delivery rates of 2. This allows for a constant level of analgesia. After removal, serum fentanyl levels decrease gradually, about 5. Several nonblinded clinical studies have shown that transdermal fentanyl effectively controls chronic pain associated with cancer. Therapy was converted from stabilized morphine doses to transdermal fentanyl generally without loss of pain relief. In one study of 2. P = . 0. 37). This preference may have been related to the fact that transdermal fentanyl was associated with less constipation (P < . P = . 0. 15), and less disruption to daily life (5. This may have resulted from the significantly lower frequency (P < . P < . 0. 01) of side effects. There were no significant differences between treatment groups with respect to measures of pain intensity, sleep adequacy, or symptoms. Transdermal fentanyl is noninvasive, and analgesia is sustained for long durations. This therapy can be administered to patients who cannot take oral analgesic medications because of such cancer- related side effects as nausea, vomiting, and dysphagia. The most serious reactions were deaths due to hypoventilation resulting from inappropriate use. Hypotension and hypertension were observed in opioid- nave patients. However, an open multicenter study of 4. A Case Report and Literature Review. Department of Pharmacy Services, University Health System, 4. Medical Drive, San Antonio, TX 7. USA2. Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX 7. USA3. Pharmacotherapy Education and Research Center, The University of Texas Health Science Center at San Antonio,San Antonio, TX 7. USA4. Division of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 7. USACopyright . This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose. Fentanyl is available as a transdermal system for the treatment of chronic pain in opioid- tolerant patients; however, it carries a black box warning due to both the potency of the product and the potential for abuse. A 3. 2- year- old man was brought to the emergency department (ED) via emergency medical services for toxic ingestion and suicide attempt. The patient was treated with whole bowel irrigation and continuous intravenous naloxone infusion for approximately 4. Despite numerous case reports describing oral ingestion of fentanyl patches, information on the management of such intoxication is lacking. Introduction. Fentanyl, a potent phenylpiperidine opioid agonist available as a transdermal patch, carries a black box warning cautioning health care providers on both the potency of the product and the potential for abuse and diversion . Numerous consumer Internet websites describe means for abusing fentanyl patches, such as smoking, chewing, freezing, or intravenous injection of the gel reservoir . In 2. 00. 5, Goldberger and colleagues presented data from the state of Florida which found fentanyl as the cause of 1. Although anecdotal reports exist, there is little published in medical literature regarding oral intoxication of fentanyl patches . We describe both the presentation and management of a patient who ingested two fentanyl patches. Case Report. A 3. ED) via emergency medical services (EMS) for a toxic ingestion. The patient was in a verbal altercation around 0. After discovering law enforcement was en route, his ex- wife witnessed the patient chewing and ingesting two illegally purchased 5. EMS found the patient to be nonresponsive to verbal or physical stimuli, bradycardic, and with miotic pupils. Two milligrams of intravenous naloxone were administered by EMS, which resulted in opioid reversal and arousal of the patient. The patient was subsequently transferred to our ED with findings of altered mental status, obtundation, and drowsiness. On arrival, law enforcement corroborated the ex- wife’s description of the patient ingesting the two fentanyl patches and gave an account of the event to the ED physician and pharmacists. The patient admitted to regular use of methamphetamine, opioids, and benzodiazepines and had a past medical history bipolar disorder for which he took no medications. His review of systems was negative, except for the dizziness, drowsiness, and altered mental status, and admission physical examination was unremarkable. The patient’s initial set of vitals after 2 milligrams of intravenous naloxone were as follows: afebrile, blood pressure 1. A urine drug screen was negative for opioids, but positive for amphetamines and benzodiazepines. Serum ethanol, acetaminophen, and salicylate levels were all negative. A serum fentanyl level was not obtained. Upon arrival, the patient was stabilized and assessed. At 1. 00. 0, a naloxone drip (8 micrograms per milliliter in 0. Additionally, whole bowel irrigation with polyethylene glycol 3. The patient had one bowel movement in the ED (no documentation that patches or remnants were passed) and remained hemodynamically and neurologically stable until transfer to the medical intensive care unit at approximately 2. He did not receive any additional naloxone after this point. In total, he received approximately 1. He remained cardiovascularly and neurologically stable throughout his stay in the medical ICU, was subsequently downgraded to the medical floor on hospital day 3 (4. Discussion. Multiple ingestions of fentanyl patches have been reported, with outcomes ranging from transient symptoms of overdose (e. Van Rijswijk and Van Guldener described the case of an 8. His nurse promptly removed the patch from the patient’s mouth; however, thirty minutes later, the patient became less arousable and hypotensive. After administration of naloxone 0. Thomas and colleagues published a case report of a 4. Upon autopsy, the decedent had three pieces of fentanyl patches in his stomach. Further history reveals that the decedent commonly chewed, sucked on, and swallowed fentanyl patches to obtain a high. Lastly, Woodall and colleagues reported a case series of seven deceased patients in whom oral administration of a fentanyl patch was suspected to have contributed to their death . Decedents ranged in age from 2. Postmortem fentanyl serum concentrations ranged from 7 to 9. L, whereas typical serum concentrations from single dose studies with fentanyl transbuccal tablets (1. L . More recently, Carson and colleagues presented a case of a 2. ED after chewing and aspirating a transdermal fentanyl patch. On autopsy, the decedent had a beige foreign body (later identified as the transdermal device) lodged in the mainstem bronchus, and postmortem toxicological analysis revealed a serum fentanyl level of 8. L . Fentanyl serum levels are not performed in our facility’s laboratory, and determining them would require sending them to an outside laboratory. Due to the typical return time on these types of labs, we felt an admission fentanyl level would be of little benefit to the medical team three days later. Fentanyl is 5. 0–6. However, when ingested orally, fentanyl undergoes extensive first- pass metabolism, resulting in 2. Therefore, as alluded to in published case reports, the time fentanyl stays in contact with the oral mucosa directly translates to the systemic absorption and the severity of the overdose. Case reports describe either chewing or sucking on the fentanyl patch, leading to extensive contact time between the oral mucosa and the inner gel matrix. Additionally, the reservoir of a fentanyl patch houses a large dose of fentanyl. In the case of our patient, a 5. If the entire reservoir contents of one fentanyl patch were ingested, approximately 1. Assuming a 2. 5% reduction for cross- tolerance, this fentanyl dose is equivalent to 1. However, ingesting an intact patch would not necessarily result in significant gastrointestinal absorption (i. If the entire contents of one patch were removed and administered transbuccally, this systemic level would be approximately three times that achieved with gastrointestinal absorption (i. Thus, chewing or sucking on a fentanyl patch increases contact time with the buccal membrane and liberates drug from the transdermal system, greatly increasing systemic absorption. Our patient’s ED urine drug screen for opioids was negative; however, this does not necessarily exclude an opioid ingestion. A urine drug screen’s ability to detect substances is based on the assay, the drug (and metabolites, if applicable) the screen is designed for, and a drug’s pharmacokinetics . To be detected in a urine drug screen, the substance must be absorbed, metabolized, and then renally excreted. In general, most standard urine screens for opioids detect codeine, morphine, and metabolites of the two. Fentanyl is a fully synthetic opiate that is structurally dissimilar from morphine and codeine; therefore, the metabolites of fentanyl are also dissimilar . Fentanyl is primarily hepatically metabolized, and the inactive metabolites (primarily norfentanyl) are excreted in the urine. Only 1. 0% of the parent drug is excreted unchanged in the urine . In order to detect a fentanyl- related opioid intoxication, a urine drug screen would need to assay exclusively for fentanyl or the predominant metabolite norfentanyl. Naloxone, a pure opioid antagonist at all opioid receptor sites, has long been utilized in the ED and intensive care unit for the treatment of opioid intoxication . Whole bowel irrigation using polyethylene glycol or a similar osmotic laxative has been used successfully in the treatment of other intoxications, such as lithium or ingestion of extended release products . While activated charcoal is often a first choice for oral intoxications, we chose to utilize a different approach for two reasons. First, the efficacy of single- dose- activated charcoal decreases over time. In a 2. 00. 5 position paper, Chyka and Seger demonstrated decreased efficacy as the time from poisoning is increased from 3. These authors questioned the utility of charcoal use after one hour postingestion. Secondly, drug must be available in the gastrointestinal tract and must be bound by charcoal for this treatment modality to be effective . Since the time from ingestion to presentation to our ED was over 2 hours, the drug was, at least partially, housed within the transdermal system, and there are no data on adsorption of fentanyl to activated charcoal, we opted away from this therapeutic option. Our approach was to utilize a continuous infusion of naloxone until the patient passed the patches in his stool and returned to his baseline mental status. Unfortunately, the patches were never recovered in the patient’s stool and were later presumed to have passed prior to transfer to the intensive care unit, although it is possible that the patient extracted the fentanyl from the patches and disposed them in a conventional means prior to law enforcement and EMS arrival. Fentanyl absorbed across the buccal membrane has an elimination half- life of up to 1. While a specific antidote for benzodiazepine ingestion exists (i. Flumazenil), we did not utilize it because of the unknown duration of alprazolam (or other benzodiazepine) use.
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