II. Class
- Short acting Opioid (except Transdermal Fentanyl)
III. Indications
- Intravenous
- Acute ParenteralOpioid analgesia (short acting, preferred in Renal Insufficiency)
- Less cardiovascular depression (e.g. Hypotension) than with Morphine or Hydromorphone
- Short-acting Labor Analgesia
- Procedural Sedation and Analgesia (PSAA)
- Acute ParenteralOpioid analgesia (short acting, preferred in Renal Insufficiency)
- Transdermal
- Chronic Pain (especially Cancer Pain Management)
IV. Contraindications: Fentanyl Patch
- Mild pain, acute pain or postoperative pain due to risk of respiratory depression (FDA Black Box warning)
- Limit use to Opioid tolerant patients (Morphine Sulfate >60 mg/day for at least one week)
V. Precautions: Transdermal and Transmucosal Fentanyl
- Fentanyl Patches are only indicated for Chronic Pain in patients that are Opioid tolerant
- Up to half of Fentanyl Patch prescriptions are written for acute pain despite contraindication and risk
- Serious respiratory depression and death has occurred with Fentanyl Patches
- Only use in patients on at least equivalent of 60 mg Morphine per day (see below)
- (2018) Presc Lett 25(4)
- Risk Evaluation and Mitigation Strategies (REMS)
VI. Dosing: Procedural Sedation and Analgesia (PSAA)
- Nasal: 2 mcg/kg intranasal (1/2 in each nostril)
- Nebulized: 4 mcg/kg in breath activated neb
- IV (onset in 1-3 min, lasting 30-60 min)
- Adult: 50 mcg/dose every 3 minutes, titrating to effect
- Child: 1 mcg/kg/dose IV every 3 minutes, titrating to effect
- Age 1-3 years old: 2-3 mcg/kg/dose every 30-60 minutes as needed
- Age 3-12 years old: 1-2 mcg/kg/dose every 30-60 minutes as needed
- Age >12 years old: 0.5-1 mcg/kg/dose every 30-60 minutes as needed
- Reversal: Naloxone
- Often administered in combination with Midazolam (Procedural Sedation and Analgesia)
VII. Dosing: Cancer Pain in the Adult
- Transdermal Fentanyl (Duragesic)
- Generic strengths: 25, 50, 75, 100 mcg/hour
- Trade name strengths: 37.5, 62.5, 87.5 mcg/hour (released in 2015 at 3x the cost of generic)
- Onset of full effect only after 24 hours (steady state may not be reached for 1 week)
- Change patch ever 72 hours
- In atypical cases may need to be changed every 48 hours for end-of-dose pain
- Should not be changed more often than every 48 hours
- Conversions from prior Morphine (total per 24 hours)
- Start with 25 mcg/h Fentanyl Patch for those on Morphine Sulfate 60-134 mg/day
- Slowly titrate doses at no more often than every 3 days
- Fentanyl 25 mcg/h: MS 37.5 mg PO or 12.5 mg IV
- Fentanyl 50 mcg/h: MS 75 mg PO or 25 mg IV
- Fentanyl 75 mcg/h: MS 112 mg PO or 37.5 mg IV
- Fentanyl 100 mcg/h: MS 150 mg PO or 50 mg IV
- Start with 25 mcg/h Fentanyl Patch for those on Morphine Sulfate 60-134 mg/day
- Transmucosal Fentanyl
- Sublingual tab (Abstral) 100 mcg
- Sublingual spray (Subsys) 100 mcg
- Nasal spray (Lazanda) 100 mcg
- Buccal Tablets (Fentora)
- Transmucosal Lozenge (Actiq)
- Available strengths: 200, 400, 800, 1200, 1600 ug
- Maximum: 4 lozenges per day
VIII. Pharmacokinetics
- Intramuscular
- Onset: 7 to 15 minutes
- Peak: 15 minutes
- Duration: 1 to 2 hours
- Intravenous
- Duration: 30 to 60 minutes
- Onset <1 minute
- Peaks 2 to 5 minutes
IX. Adverse Effects: Procedural Sedation or Analgesia (IV)
- Less Histamine release than with Morphine
- Chest wall rigidity (with high doses)
- Respiratory depression
- Supplemental Oxygen, Jaw Thrust maneuver, bag-valve mask
- Use lower doses in combination with Midazolam (Versed)
X. Adverse Effects: Chronic Pain (Transdermal)
- Respiratory Depression (FDA Black Box Warning)
- Limit transdermal use to Opioid tolerant patients (>60 mg Morphine Sulfate per day for at least one week)
- Start at low dose
- Oversedation
XI. Efficacy: Non-Cancer Chronic Pain
- Transdermal Fentanyl preferred over oral Morphine
- Better pain relief
- Improved quality of life
- Reference
XII. Resources
- Fentanyl Injection (DailyMed)
- Fentanyl Patch (DailyMed)
- Fentanyl Lozenge (DailyMed)
XIII. References
- Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
- (2015) Presc Lett 22(7): 42
- (2021) Presc Lett 28(3): 15-6
- Miner (2012) APLS Lecture, HCMC, Minneapolis
- Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
- Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
- Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
- University Minnesota Childrens - Pediatric Emergency Drug Card
- Velasco and Kiel (2023) Crit Dec Emerg Med 37(1): 4-9
- Becker (2012) Anesth Prog 59:28-42 [PubMed]
- Brown (2005) Am Fam Physician 71:85-90 [PubMed]
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Related Studies
| fentanyl (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| FENTANYL 100 MCG/2 ML VIAL | Generic | $0.63 per ml |
| FENTANYL 100 MCG/HR PATCH | Generic | $8.35 each |
| FENTANYL 12 MCG/HR PATCH | Generic | $9.16 each |
| FENTANYL 2,500 MCG/50 ML VIAL | Generic | $0.63 per ml |
| FENTANYL 25 MCG/HR PATCH | Generic | $3.29 each |
| FENTANYL 37.5 MCG/HR PATCH | Generic | $41.06 each |
| FENTANYL 50 MCG/HR PATCH | Generic | $5.55 each |
| FENTANYL 75 MCG/HR PATCH | Generic | $7.06 each |
| fentora (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| FENTORA 400 MCG BUCCAL TABLET | $123.17 each | |
| FENTORA 600 MCG BUCCAL TABLET | $159.45 each | |
| FENTORA 800 MCG BUCCAL TABLET | $195.15 each | |