What should I know to use fentanyl safely with palliative care patients?

Medications

Safety considerations when using opioids

As health care providers taking care of palliative care patients, we need to educate patients and families about the safe use, handling and storage of opioids. This quick consult looks specifically at the safe handling of fentanyl. For safety considerations when using opioids in general, please see: What is happening with the opioid crisis in Canada? What should I know to use opioids safely with palliative care patients?

In addition to the precautions generally taken with opioids, fentanyl brings unique challenges that must be considered when it is used in the palliative care patient population.

Use of the transdermal fentanyl patch

To reduce and prevent harm, educate patients and families about these important safety points when the long-acting transdermal fentanyl patch is being used.

Ensure patients understand that medications are ONLY to be used by them, not by others.
The long-acting transdermal fentanyl patch formulations are not to be used when a patient is opioid-naïve. Patients need to have consistent pain and be on a stable dose of strong opioids prior to starting a fentanyl transdermal patch. This route of fentanyl medication delivery should not be used for acute or poorly controlled pain.
An increase in body temperature or application of excessive and continual heat directly to a transdermal fentanyl patch could cause an increase in the rate of absorption of the fentanyl and should be avoided. Heat sources include heating pad, electric blanket, sauna, hot tub, heated waterbed, excessive sun exposure or strenuous exercise. Avoid overheating and watch for signs of opioid toxicity. Patients who suddenly develop fever may also be at risk for increased absorption.
Place the transdermal fentanyl patch on an area with adequate subcutaneous tissue. Keep in mind that pharmacokinetics may be altered in cachectic patients whose reduced fat tissue may prevent reliable medication release. They therefore may require a higher fentanyl patch dose.
If you experience any issues with transdermal fentanyl patch adherence, please see: What advice can you offer when patients have difficulty with fentanyl patch adherence?
Wear gloves when handling the placement or removal of the patch on a patient. Follow the fentanyl transdermal product monograph for handling.
Do not place patches into the garbage. To ensure safe disposal of used patches, review your local or organizational policies.

For more detailed information on conversion guidelines and initiation of a fentanyl transdermal patch, please see the product monograph or Fraser Health Hospice Palliative Care Program Symptom Guidelines on opioid management. ^[1]

Use of liquid preparations

The liquid preparation of fentanyl or sufentanil may be delivered by the transmucosal route (intranasal, sublingual, buccal) to manage incident pain or incident dyspnea. Note that this practice is off-label; prescribers should be familiar with this use or seek advice from those who are. Incident symptoms are typically intense, brief and predictable, so the ideal benefits are achieved by the use of such short acting, strong opioids with a fast onset of action. If the transmucosal route is used, caution should be taken as the medication is likely provided in a high concentration formulation. Appropriate education about this route of medication delivery and safe medication handling and storage is essential.