 Opioids are required for the management of pain in over 80% of cancer patients.

 Fentanyl is a synthetic phenylpiperidine with mu-receptor agonist activity.

 Its high lipid solubility contributes to high potency, as well as rapid tissue
redistribution after a single dose; its half-life is relatively short.
 Formulation in a transdermal patch has allowed sustained release of drug in a
manner suitable for chronic pain management.
 Paix et al. have reported a retrospective study of 11 advanced cancer patients who
were switched from morphine or codeine to subcutaneous (sc) infusions of
fentanyl due to side effects such as delirium, sedation, nausea, and vomiting.
 In view of the above considerations, Edmonton Palliative Care Programme began
to employ fentanyl by continuous sc infusion in late 1995. The treatment was
offered to selected patients who experienced uncontrolled pain while receiving
transdermal fentanyl, or who experienced toxicity on other opioids.
Methods

 The charts of all patients who had been initiated on subcutaneous fentanyl
infusions during admission to one of the four palliative care units in the city
during an 8-month period were reviewed retrospectively
 Data were collected on patient and pain characteristics; indications for fentanyl sc;
total opioid dose in the 24 hours prior to switchover; stable daily dose of fentanyl
sc (defined as no dose change and no more than 2 breakthrough doses per day for
48 hours); visual analogue scores (VAS) for pain intensity on a 100-mm scale on
the day prior to switchover and on the day of stabilization
Study result

 Twenty-two patients received fentanyl by subcutaneous infusion for 7.4 ± 7.5

days (range 2– 32)
 Seventeen patients were switched from other opioids at a median parenteral
morphine equivalent dose of 135 mg/day (range 15.6–720 mg/ day) to fentanyl sc
due to toxicity. Ten achieved stability after 2.8 ± 1.2 days (range 2–6).
 Five patients were switched from transdermal fentanyl at a median dose of 2400
mg/day (range 1200–4800 mg/day) to sc infusions because of uncontrolled pain.
Three achieved stability after 2.2 and 8 days, respectively.
 data suggest that fentanyl by continuous sc infusion is a useful opioid for the
management of cancer pain.
 Local tolerance is excellent. In patients whose pain is inadequately controlled on
transdermal fentanyl, it allows for more rapid titration than is possible with the
patch.
 While the intravenous route could also be used, it is often more difficult and
uncomfortable to access in advanced cancer patients; moreover, direct comparison
of the two modes of opioid administration has revealed similar efficacy.
 Fentanyl by continuous sc infusion also represents a potential alternative for
patients who are experiencing toxicity on other opioids.
 Ten of seventeen patients switched for this indication achieved stability by dose
criteria, with a trend to improvement in VAS pain and MMSE
 Disadvantages of subcutaneous fentanyl include the need for a continuous
infusion device and higher cost of the drug.