Dr Pauline Kane

Registrar in Palliative Medicine

Beaumont Hospital
17th Sept 2009
 Overview
Transdermal opioid patches
Used for stable chronic pain
Frequently cancer pain is not stable pain
Transmucosal opioids
Short acting opioids
Breakthrough cancer pain
New drugs
Indications for Transdermal Opioid
Patch
Indication: Chronic pain
Cannot take oral medications
Nausea, Vomiting
Mucositis
Mouth ulcers
Dysphagia
Difficulty taking tablets
Poor compliance
Cognitive impairment
Elderly
 Transdermal route
Avoidance of hepatic first pass metabolism
Continuous pain relief
Improves patient compliance with treatment
Constant drug delivery providing a more stable
plasma concentration without peaks
Ease of administration despite nausea, vomiting and
difficulties swallowing
Absorption independent of food or fluid intake
Transdermal Patches
Fentanyl patch
Durogesic

Matrifen

Replace patch every 72 hours

Why fentanyl?
Fentanyl citrate
Absorbed easily through skin
Low risk for skin irritation
100 times more potent than morphine
Less constipating
Less nausea and vomiting
 Using Fentanyl Patch
Apply patch to dry, flat, non-hairy skin on torso or
upper arm
Press firmly in place with the hand for 30 seconds to
ensure good contact
Replace patch every 72 hours
Rotate patch sites
Avoid same site for several days
Wait 24 hours before evaluating pain relief
Fentanyl transdermal patch
Fentanyl transdermal patch
Equivalence chart – Lasts 72 hours

Fentanyl transdermal patch Morphine oral equivalent in 24

hours
12mcg/hr 45mg oral morphine in 24 hours

25mcg/hr 90mg oral morphine in 24 hours

50mcg/hr 180mg oral morphine in 24 hours

75mcg/hr 270mg oral morphine in 24 hours

100mcg/hr 360mg oral morphine in 24 hours

Other users of fentanyl patches
Buprenorphine Transdermal Patch
Butrans – lower strength opioid patch
Replace patch every 7 days

Transtec – higher strength opioid patch

Replace patch every 3 days
Butrans Transdermal Patch
Indication:
Moderate pain unresponsive to non-opioid analgesics
Apply to dry, non-hairy skin on torso or upper arm
Replace patch every 7 days
Rotate patch site
Avoid using same area for 3 weeks
Level of pain relief should not be assessed until patch
is on for 3 days
Buprenorphine transdermal patch
Equivalence chart: Lasts 7 days
Buprenorphine transdermal patch
Butrans
5mcg/hr
Morphine oral equivalent in 24
hours
7mg oral morphine in 24 hours

10mcg/hr 14mg oral morphine in 24 hours

15mcg/hr 21mg oral morphine in 24 hours

20mcg/hr 28mg oral morphine in 24 hours

Transtec transdermal patch
Indication:
Moderate to severe pain
Severe pain unresponsive to non-opioid analgesics
Apply patch every 3 days
Rotate patches
Avoid same area for at least 6 days
Only evaluate pain relief after patch is on for at least
24 hours
Buprenorphine transdermal patch
Equivalence chart:Lasts 72 hours/3
days
Buprenorphine transdermal patch Morphine oral equivalent in 24
Transtec hours

35mcg/hr 30-60mg oral morphine in 24 hours

52.5mcg/hr 60-90mg oral morphine in 24 hours

70mcg/hr 90-120mg oral morphine in 24 hours

Buprenorphine transdermal patch
Rates of absorption increase if skin is warm and
dilated
Safe to use in patients with renal impairment
Not removed in haemodialysis
Smaller starting doses are advised in hepatic
impairment – highly protein bound drug
More persistent erythema than with fentanyl patches
Can cause pruritus
 Transdermal Opioid Patches
Important to remember that the patches contain a
significant dose of morphine
In patients who are opioid naïve
Commence at lowest dose
Remember buprenorphine 5mcg/hr patch =
morphine 7mg/24 hours orally
Remember fentanyl 12mcg/hr patch = morphine
40mg/24 hours orally
Important to check daily that patch is still in place
 Cautionary Use of Opioid
Transdermal Patches
COPD or other medical conditions predisposing to
respiratory depression eg. Myasthenia gravis
Elderly
Cachetic
Debilitated
Susceptibility to hypercapnia – CO2 retention
 Raised intracranial pressure
 Impaired consciousness
 Coma
 Brain tumour
Caution in bradyarrhythmias
 Precautions
Lack of appreciation that fentanyl is a strong opioid
analgesic
Inappropriate use for short-term, intermittent or
post-operative pain in opioid naive patients
Lack of patient education re safe use, storage &
disposal
Lack of awareness of signs of overdose
Lack of awareness of increased absorption of opioid if
skin under patch becomes vasodilated eg. Febrile
patients, or by an external heat source eg. Electric
blankets, sauna
Breakthrough Cancer Pain
Incident pain – predictable
Voluntary – onset with activity such as walking
Involuntary – onset with activity such as coughing
Procedural – onset related to intervention such as
wound dressing
Spontaneous pain - unpredictable
Breakthrough Cancer Pain

Rapid onset
Short duration
1 min to 2-3 hours
Fentanyl for breakthrough pain
Indication: Patient has been on long acting opioid
medication of the following strength for chronic
cancer pain for at least a week;
Oral morphine ≥ 60mg/day
Transdermal fentanyl ≥ 25mcg/hr
Oxycodone ≥ 30mg/day
Oral hydromorphone ≥ 6mg/day
An equianalgesic dose of another opioid
Can commence on short acting opioid for
breakthrough pain
 Buccal Fentanyl: Actiq
First transmucosal fentanyl preparation
‘Lozenge on a stick’
Fentanyl in hard sweet matrix
Lozenge placed inside cheek and moved constantly
up and down, and changed at intervals to other cheek
Aim to consume lozenge in 15 mins
 Transmucosal routes
Buccal
Effentora
Place tablet in upper portion of buccal cavity above
upper rear molar between cheek and gum
Less permeable
75% is actually swallowed, reducing bioavailability
Prolonged contact with mucosa and lozenge –
problematic if inflamed mucosa
Transmucosal routes
Sublingual
Abstral
Place tablet under tongue
Rapid absorption
Highly vascularised under the tongue
Highly permeable
High bioavailability
Transmucosal:Nasal route
Nose has surface area of 150-180cm2
Continuous mucus in nose limits drug uptake to
about 15mins
Rhinitis does not affect it
Convenient to use in those with nausea, vomiting, dry
mouth syndrome or mucositis
Nasalfent
Not reimbursed on GMS
Directions for Use
Wait 4 hours between doses
No food/drink while tablet in mouth
Tablet disintegration takes 15-30 mins
 Buccal and Sublingual
Medication
Do not suck/chew/swallow as this decreases plasma
concentration
Xerostomia – drink water prior to tablet placement
Mouth ulcers
Mucositis
Transmucosal fentanyl citrate
25% of dose is absorbed rapidly into systemic
circulation
Pain relief in 5-10 mins
Remainder is swallowed or absorbed more slowly
This is subject to hepatic first pass metabolism
Only 1/3 of this amount is available systemically,
25% of the total dose
Fentanyl for Breakthrough Pain

Use with caution

Highly addictive
Irish Medicines Board have 6 recorded cases of
addiction to Actiq
Only use for breakthrough pain caused by cancer
 Conclusion
Transdermal patches
Indication:
 Chronic pain poorly controlled on non-opioid analgesics
Start on lowest dose in opioid naïve patients
Transmucosal route
Indication:
 Only used for breakthrough pain secondary to cancer
Highly addictive