AUDIENCE: Family Practice, Psychiatry, Pain Management, Nursing, Endocrinology
ISSUE: FDA is warning about several safety issues with the entire class of opioid pain medicines. See the http://www.fda.gov/Drugs/DrugSafety/ucm489676.htm for a complete listing. These safety risks are potentially harmful interactions with numerous other medications, problems with the adrenal glands, and decreased sex hormone levels. We are requiring changes to the labels of all opioid drugs to warn about these risks.
BACKGROUND: Opioids are powerful prescription medicines that can help manage pain when other treatments and medicines are not able to provide enough pain relief (see List of Opioid Medicines in the http://www.fda.gov/Drugs/DrugSafety/ucm489676.htm). However, opioids also carry serious risks, including of misuse and abuse, addiction, overdose, and death.
Prescription opioids are divided into two main categories – immediate-release (IR) products, usually intended for use every 4 to 6 hours; and extended release/long acting (ER/LA) products, intended to be taken once or twice a day, depending on the individual product and patient.
See the http://www.fda.gov/Drugs/DrugSafety/ucm489676.htm for additional information, including a listing of opioids, serotonergic medicines, and a data summary.
Health care professionals should discontinue opioid treatment and/or use of the other medicine if serotonin syndrome is suspected.
Health care professionals should perform diagnostic testing if adrenal insufficiency is suspected. If diagnosed, treat with corticosteroids and wean the patient off of the opioid, if appropriate. If the opioid can be discontinued, follow-up assessment of adrenal function should be performed to determine if treatment with corticosteroids can be discontinued.
Decreased sex hormone levels:
Health care professionals should conduct laboratory evaluation in patients presenting with such signs or symptoms.
For more information visit the FDA website at: http://www.fda.gov/Safety/MedWatch/SafetyInformation and http://www.fda.gov/Drugs/DrugSafety.
Fentanyl patches may cause serious or life-threatening breathing problems, especially during the first 72 hours of your treatment and any time your dose is increased. Your doctor will monitor you carefully during your treatment. Because of this serious risk, fentanyl patches should only be used to treat people who are tolerant (used to the effects of the medication) to opioid medications because they have taken this type of medication for at least one week and should not be used to treat mild or moderate pain, short-term pain, pain after an operation or medical or dental procedure, or pain that can be controlled by medication that is taken as needed. Tell your doctor if you have or have ever had slowed breathing or asthma. Your doctor will probably tell you not to use fentanyl patches. Also tell your doctor if you have or have ever had lung disease such as chronic obstructive pulmonary disease (COPD; a group of diseases that affect the lungs and airways), a head injury, or any condition that increases the amount of pressure in your brain. The risk that you will develop breathing problems may be higher if you are an older adult or are weak or malnourished due to disease. If you experience any of the following symptoms, call your doctor immediately or get emergency medical treatment: slowed breathing, long pauses between breaths, or shortness of breath.
Taking certain medications with fentanyl may increase the risk of serious or life-threatening breathing problems. Tell your doctor and pharmacist if you are taking or plan to take any of the following medications: amiodarone (Cordarone, Pacerone); aprepitant (Emend); carbamazepine (Carbatrol, Epitol, Equetro, Tegretol, Teril); certain antifungals such as fluconazole (Diflucan), itraconazole (Onmel, Sporanox), and ketoconazole (Nizoral); clarithromycin (Biaxin, in Prevpac); diltiazem (Cardizem, Cartia, Dilacor, Dilt-CD, Diltzac, Taztia); erythromycin (E-Mycin, Erythrocin); fosamprenavir (Lexiva); nefazodone; nelfinavir (Viracept); phenytoin (Dilantin, Phenytek); rifampin (Rifadin, Rimactane, in Rifamate); ritonavir (Norvir, in Kaletra); troleandomycin (TAO) (not available in the United States); and verapamil (Calan, Covera, Verelan). Your doctor may need to change the dosages of your medications and will monitor you carefully.
Fentanyl patches may be habit-forming. Do not apply more patches, apply the patches more often, or use the patches in a different way than prescribed by your doctor. Tell your doctor if you or anyone in your family drinks or has ever drunk large amounts of alcohol; uses or has overused prescription medications; uses or has ever used street drugs; or has or has ever had depression or another mental illness. There is a greater risk that you will overuse fentanyl patches if you have or have ever had any of these conditions.
Do not allow anyone else to use your medication. Fentanyl patches may harm or cause death to other adults and children who use them. Store fentanyl patches in a safe place so that no one else can use them accidentally or on purpose. Be especially careful to keep fentanyl patches out of the reach of children. Keep track of how many patches are left so you will know if any are missing.
People who are not being treated with fentanyl patches may be seriously harmed or may die if the sticky side of a patch touches their skin. Be careful not to allow the sticky side of the patch to touch anyone else's skin. If you are holding or caring for children, make sure that they do not touch your patch. If the patch accidentally comes off of your body and sticks to another person's skin, immediately remove the patch, wash the area with clear water, and get emergency medical attention.
Fentanyl patches that have been worn for 3 days still contain enough medication to cause serious harm or death to adults or children who are not being treated with the medication. Never throw used or unused patches in a trash can or leave them in a place where they may be found by others, especially children. Dispose of used and unwanted patches properly according to instructions. (See STORAGE and DISPOSAL.)
If your fentanyl patch is exposed to extreme heat, it may release too much medication into your body at once. This can cause serious or life-threatening symptoms. Do not expose your patch or the skin around it to direct heat such as heating pads, electric blankets, heat lamps, saunas, hot tubs, and heated water beds. Do not take long, hot baths or sunbathe while you are wearing the patch. Your patch may also release too much medication if you have a fever or if you get very hot after physical activity. Avoid physical activity that might cause you to get very hot. Call your doctor right away if you have a fever. Your doctor may need to adjust your dose.
Tell your doctor if you are pregnant or plan to become pregnant. If you use fentanyl patches regularly during your pregnancy, your baby may experience life-threatening withdrawal symptoms after birth. Tell your baby's doctor right away if your baby experiences any of the following symptoms: irritability, hyperactivity, abnormal sleep, high-pitched cry, uncontrollable shaking of a part of the body, vomiting, diarrhea, or failure to gain weight.
Your doctor or pharmacist will give you the manufacturer's patient information sheet (Medication Guide) when you begin treatment with fentanyl patches and each time you fill your prescription. Read the information carefully and ask your doctor or pharmacist if you have any questions. You can also visit the Food and Drug Administration (FDA) website (http://www.fda.gov/Drugs/DrugSafety/ucm085729.htm) or the manufacturer's website to obtain the Medication Guide.
Talk to your doctor about the risks of using this medication.
Why is this medication prescribed?
Fentanyl patches are used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. Fentanyl is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain.
How should this medicine be used?
Transdermal fentanyl comes as a patch to apply to the skin. The patch is usually applied to the skin once every 72 hours. Change your patch at about the same time of day every time you change it. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Apply fentanyl patches exactly as directed.
Your doctor may start you on a low dose fentanyl patch and gradually increase your dose, not more often than once every 3 days at first, and then not more often than once every 6 days. Your doctor may decrease your dose if you experience side effects. Talk to your doctor about how you are feeling during your treatment with fentanyl patches.
Fentanyl patches are only for use on the skin. Do not place patches in your mouth or chew or swallow the patches.
Do not stop using fentanyl patches without talking to your doctor. Your doctor will probably decrease your dose gradually. If you suddenly stop using fentanyl patches you may have symptoms of withdrawal. Call your doctor if you experience any of these symptoms of withdrawal: restlessness, teary eyes, runny nose, yawning, sweating, chills, muscle pain, large pupils (black circles in the center of the eyes), irritability, anxiety, backache, pain in the joints, weakness, stomach cramps, difficulty falling asleep or staying asleep, nausea, loss of appetite, vomiting, diarrhea, fast heartbeat, or rapid breathing.
Do not use a fentanyl patch that is cut, damaged, or changed in any way. If you use cut or damaged patches, you may receive most or all of the medication at once, instead of slowly over 3 days. This may cause serious problems, including overdose and death.
You may bathe, swim, or shower while you are wearing a fentanyl patch. If the patch falls off during these activities, dispose of it properly. Then dry your skin completely and apply a new patch. Leave the new patch in place for 72 hours after you apply it.
You can apply a fentanyl patch to your chest, back, upper arms, or the sides of your waist. If you are applying the patch to a child or to a person who is unable to think clearly, choose an area on the upper back to make it more difficult for the person to remove the patch and place it in his or her mouth. Choose an area of skin that is flat and hairless. Do not apply the patch to parts of the body that move a lot or to skin that has been exposed to radiation or that is sensitive, very oily, broken out, irritated, broken, cut or damaged. If there is hair on the skin, use scissors to clip the hair as close to the skin as possible. Do not shave the area.
To apply the patch, follow these steps:
- Clean the area where you plan to apply the patch with clear water and pat completely dry. Do not use any soaps, lotions, alcohols, or oils.
- Tear open the pouch containing the fentanyl patch along the dotted line, starting at the slit. Remove the patch from the pouch and peel off both parts of the protective liner from the back of the patch. Try not to touch the sticky side of the patch.
- Immediately press the sticky side of the patch onto the chosen area of skin with the palm of your hand.
- Press the patch firmly for at least 30 seconds. Be sure that the patch sticks well to your skin, especially around the edges.
- If the patch does not stick well or comes loose after it is applied, tape the edges to your skin with first aid tape. If the patch still does not stick well, you may cover it with Bioclusive or Tegaderm brand see-through dressings. Do not cover the patch with any other type of bandage or tape.
- If a patch falls off before it is time to remove it, dispose of the patch properly and apply a new patch. Leave the new patch in place for 72 hours.
- When you are finished applying the patch, wash your hands with water right away.
- When it is time to change your patch, peel off the old patch and apply a new patch to a different skin area.
- After you remove your patch, fold it in half with the sticky sides together and flush it down a toilet.
Other uses for this medicine
This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.
What special precautions should I follow?
Before using fentanyl patches,
- tell your doctor and pharmacist if you are allergic to fentanyl, or any other medications, or any of the ingredients in fentanyl patches. Ask your doctor or pharmacist or check the Medication Guide for a list of the ingredients.
- tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, and nutritional supplements you are taking or plan to take. Be sure to mention the medications listed in the IMPORTANT WARNING and any of the following medications: antidepressants; antihistamines (found in cough, cold, and allergy medications); buprenorphine (Zubsolv); butorphanol; medications for anxiety; medications for nausea; muscle relaxants; nalbuphine; other medications for pain;pentazocine (Talwin); sedatives; sleeping pills; and tranquilizers. Also tell your doctor or pharmacist if you are taking the following medications or have stopped taking them within the past 2 weeks: monoamine oxidase (MAO) inhibitors including isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Eldepryl, Emsam, Zelapar), and tranylcypromine (Parnate). Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
- tell your doctor what herbal products you are taking, especially St. John's wort.
- tell your doctor if you have or have ever had paralytic ileus (condition in which digested food does not move through the intestines). Your doctor may tell you not to use fentanyl patches.
- tell your doctor if you have or have ever had seizures; slowed heartbeat; difficulty urinating; low blood pressure; or thyroid, heart, liver, pancreas, gallbladder, or kidney disease.
- tell your doctor if you are breast-feeding.
- if you are having surgery, including dental surgery, tell the doctor or dentist that you are using fentanyl patches.
- you should know that this medication may make you drowsy. Do not drive a car, operate machinery, or do other possibly dangerous activities until you know how this medication affects you.
- you should know that fentanyl patches may cause dizziness, lightheadedness, and fainting when you get up too quickly from a lying position. This is more common when you first start using fentanyl patches. To avoid this problem, get out of bed slowly, resting your feet on the floor for a few minutes before standing up.
- do not drink alcohol or take prescription or nonprescription medications that contain alcohol while you are using fentanyl patches. Alcohol increases the chance that you will experience serious side effects of this medication.
- you should know that fentanyl patches may cause constipation. Talk to your doctor about changing your diet or using other medications to prevent or treat constipation while you are using fentanyl patches.
What special dietary instructions should I follow?
Talk to your doctor about eating grapefruit and drinking grapefruit juice while using this medication.
What should I do if I forget a dose?
If you forget to apply or change a fentanyl patch, apply the patch as soon as you remember it. Be sure to remove your used patch before applying a new patch. Wear the new patch for the period of time prescribed by your doctor (usually 3 days) and then replace it. Do not wear two patches at once unless your doctor has told you that you should.
What side effects can this medication cause?
Fentanyl patches may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:
- mood changes
- feeling cold
- hallucinations (seeing things or hearing voices that do not exist)
- difficulty falling asleep or staying asleep
- uncontrollable shaking of a part of the body
- pain, burning, tingling, or numbness in the hands or feet
- dry mouth
- stomach pain
- loss of appetite
- back pain
- difficulty urinating
- skin irritation, redness, itching, or swelling in the area where you wore the patch
Some side effects can be serious. If you experience any of these symptoms or those listed in the IMPORTANT WARNING section, call your doctor immediately:
- fast or pounding heartbeat
- chest pain
- swelling of the eyes, face, mouth, tongue, throat, arms, hands, feet, ankles, or lower legs
- difficulty breathing or swallowing
Fentanyl patches may cause other side effects. Call your doctor if you have any unusual problems while you are using fentanyl patches.
If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online (http://www.fda.gov/Safety/MedWatch) or by phone (1-800-332-1088).
What should I know about storage and disposal of this medication?
Store the fentanyl patches at room temperature and away from excess heat and moisture (not in the bathroom).
Throw away any patches that are used, outdated, or no longer needed by carefully removing the adhesive backing, folding the sticky sides of each patch together so that it sticks to itself, and flushing the patches down the toilet. Throw away the pouches and protective liners in the trash. Wash your hands well with water after throwing away fentanyl patches. Do not put unneeded or used fentanyl patches in a garbage can.
In case of emergency/overdose
In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.
Symptoms of overdose may include:
- difficulty breathing
- extreme sleepiness or tiredness
- difficulty thinking, talking, or walking normally
- small, pinpoint pupils (black circles in the center of the eye)
- coma (loss of consciousness for a period of time)
What other information should I know?
Keep all appointments with your doctor.
This prescription is not refillable. Be sure to schedule appointments with your doctor on a regular basis so that you do not run out of medication if your doctor wants you to continue using fentanyl patches.
It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.