© The Medical-Legal News, 2007
• The Gist: Look for use of these patches in medical cases you litigate, defend or review.
By Margaret S. Wacker
Pain medication patches are being used more frequently, especially after the Joint Commission has required more aggressive attention to, and treatment of, patients’ complaints of pain.
The downside of this increased use is that some medical professionals are unfamiliar with prescribing the patches and the medications they contain. There also are problems with a lack of monitoring, and patients often are not given clear instructions in how to use the patches.
Transdermal drug delivery systems are patches that are applied to the skin. They provide continuous drug delivery and maintain a steady drug concentration in the blood. Scopolamine patches are frequently used for seasickness, as are nitroglycerin patches for angina, and nicotine patches for smoking. Such common usage has created risks. This is especially evident when Fentanyl patches are prescribed for pain management. Fentanyl is a pain medicine about 80 times stronger than morphine.
Examples of life threatening events with fentanyl (Duragesic) pain relief patches fall into three categories:
1) Improper prescribing: A 26-year-old post-op bone-removal patient was prescribed a 100 microgram Duragesic patch on discharge. The nurse who arrived on the next shift, one hour after the patch was applied, caught the high-dosage error. The patch was removed before depot (the “puddle” of medicine on the skin) formation. An opiate-naïve 86-year-old woman under hospice care complained of a stiff neck. The LPN assumed the standard hospice orders applied and administered a 25 microgram patch. Her pharmacist soon found her cyanotic and barely responsive — another overdose.
2) Failure to monitor: A 32-year-old post c-section woman was prescribed a 100 microgram Duragesic patch for post section pain. She coded in her room that evening. After resuscitation it was discovered that her obstetrician asked another physician how to manage pain when a patient was allergic to morphine. The colleague recommended Fentanyl but never considered that it would be prescribed in the form of a high dose patch.
3) Improper patient instructions: An elderly patient with chronic pain was prescribed six Percocets daily. When she required more relief, her physician changed her analgesia to a 25 microgram Duragesic patch. She phoned him to complain about feeling dizzy and sleepy. He told her to cut the patch in half (which would release a huge and dangerous amount of medicine — the opposite of what the doctor wanted). Her daughter intervened and confronted the physician. A patient receiving a 50 microgram Duragesic patch asked for a heating pad for muscle pain. The nurse failed to warn her about placing heat over the patch. The heat intensified the release of the fentanyl from the depot and increased her continuous dose.
These scenarios are real and common. Fentanyl patches are excellent formulations for pain management in specific populations, but improper understanding of them and the potency of their narcotic has led to many life-threatening near misses.
Fentanyl patches are constructed differently from other transdermal delivery systems. They require eight to ten hours for the skin under the drug reservoir to create a drug depot. Once formed, fentanyl is released from the depot into the body at a constant rate for 72 hours.
The reversal agent for an overdose, usually Naloxone, has an effect for only 45-60 minutes, so the patient will require intravenous naloxone and intensive care monitoring until the drug is eliminated from the depot.
Fentanyl is one of the most potent narcotics available. When reviewing a medical record of a patient receiving transdermal Fentanyl you must be sure to note documentation regarding time, site and date of application. •
Margaret S. Wacker, RN, PhD, CLNC is based in Florida; firstname.lastname@example.org.