MedicalResearch.com Interview with:
Shawn Bugden B.Sc. (Pharm), M.Sc., Pharm.D.
College of Pharmacy, Faculty of Health Sciences
University of Manitoba
Winnipeg, Manitoba, Canada
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Bugden: Fentanyl is 100 times more potent than morphine. While there has been a great deal of attention to fentanyl deaths associated with substance abuse, our study focused on the safety of fentanyl use in standard medical practice. Fentanyl is most commonly prescribed as a transdermal (skin) patch that delivers the medication over 3 days. The product monograph and numerous safety warnings (FDA, Health Canada…) make it clear that fentanyl patches should not be used unless the patient has had considerable previous opioid exposure (more than 60mg morphine per day for more than 1 week). Failure to heed these warnings may result in opioid overdose, respiratory depression and death.
This study examined over 11 000 first prescriptions for fentanyl patches over a 12-year period to determine if patients had received adequate exposure to opioids. Overall 74.1% of first prescriptions were filled by patients who had not received adequate prior opioid exposure. An improvement was seen over the study period but even at the end of the study, 50% of prescriptions would be classed as unsafe. More than a quarter (26.3%) of fentanyl prescriptions were given to patients who were completely opioid naïve and had no exposure to opioids of any kind in the previous 60 days. Older adults, who may be more sensitive to the effects of fentanyl overdose, were more likely to receive unsafe prescriptions than younger adults.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Bugden: There are many challenges associated with opioid prescribing and many of these are difficult for healthcare professionals to fully control. Ensuring adequate opioid exposure prior to prescribing a fentanyl patch is fully in the control of prescribers and an important way to improve the safety of opioid prescribing. This study was conducted in a jurisdiction with a fully-linked population database that allows physicians and pharmacists to review all previous prescriptions in real-time. Jurisdictions with less readily available prescribing histories may have even more difficulty ensuring safe prescribing of fentanyl patches. It is hoped that the study will attract the attention of prescribers and accelerate improvements in prescribing practices.
Patients should also be aware of the need for previous opioid exposure before starting a fentanyl patch. Health care professionals need to work with the public to ensure adequate education for safe use of fentanyl patches. This can include but is not limited to:
- Need for previous opioid exposure
- Awareness of signs of overdose (small pupils, slowed breathing, unconsciousness)
- Ability of heat (heating pads etc.) to dramatically increase absorption of fentanyl form patch
- Need for proper disposal of patch after use. Used patches still contain a considerable amount of fentanyl and can be dangerous.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Bugden: The study showed considerable improvement in the safety of fentanyl prescribing over the 12-year study period. However, with the number of previous warnings that have been issued it is surprising that half of all fentanyl prescriptions are still being written for patients without adequate opioid exposure. Future research should explore intervention strategies that could eliminate or minimize this unsafe practice.
MedicalResearch.com: Is there anything else you would like to add?
Dr. Bugden: Fentanyl patches play an important role in treating relatively severe, stable pain. Their use in cancer and palliative care has been an important advance to allow patients to be treated at home without resorting to injectable therapy. Physicians, pharmacists and patients all have a role in ensuring that fentanyl patches are used safely. The Centre for Disease Control and Prevention, released on March 15, 2016, perhaps says it best, “ Dosing effects of transdermal fentanyl are often misunderstood by clinicians and patients, only clinicians who are familiar with the dosing and absorption properties of transdermal fentanyl and are prepared to educate their patients about its use should consider prescribing it.”
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
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Safety of fentanyl initiation according to past opioid exposure among patients newly prescribed fentanyl patchesCMAJ cmaj.150961; published ahead of print April 4, 2016,doi:10.1503/cmaj.150961
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