INSOMNIACS place to talk in the wee hours

Patty it's done.......................Fentanyl.

I'm including the black box warning in it's entirety. Not sure as yet, how I will annotate it. But will reinforce the last paragraph regarding heat sources since you will be using the heating pads. The statement at the very end is very well written. If you start using Fentanyl, you would have to discontinue the total body warm moist heat. But if the trade off is better pain control, it doesn't matter how you get there as long as you get there.

Not sure what your MO knows about the drug, if he thinks it only works for a small area. All Opiods work by affecting the opiod receptors in the brain which positively affects the whole body. Plus, Fentanyl has a positive serotonergic affect. That means it mimics the positive affect of increasing serotonin availibility( mechanism I'm not sure of). The antidepressants SSRI's & SSNRI's(see fentanyl thread for list if questions) increase serotonin. Fentanyl is the only opiod that has a positive serotonergic affect. It's two for one drug.

What's different about fentanyl from the other opiods is it doesn't space you out unless the dose is too high. My pain was the entire musculoskeletal system. Post polio & fibromyalgia  induced by the Aromatase inhibitors. The day I started, I was a pain scale of 10. Like you the tears were flowing. I was WORN out by pain. It was heaven as the drug started to take effect.+- 18 hours. The pain melted away. Memory on pain scale with it on, is sketchy. I was so used to living my life with a 5-7(predominantly 5). For the duration that I was on Fentanyl, pain control was effective enough that I rarely took meds for breakthrough. I had an OXY script of 120 pills prescribed to be taken every 4-6 hours for breakthrough. If you calculate that out, it was enough for a month. That script lasted 18 months versus 1 month.

The lovely positive serontonergic effect was one of mellow well being for the duration. Not High. Not spacey. With Oxy 10 mg,  I'm spacey without great pain control and a bit spacey on 5 mg. I much preferred Fentanyl over Oxy.

In the Duragesic monograph below you will see the discussion regarding 3A4. All opiods go through 3A4. My 3A4 is a intermediate metabolizer which means I process it slowly. At the time I was using it, we didn't know that. You've read the "Panicking about Pain" thread. I developed a 7 day plan. I won't restate it here. What it means for you is that you should have your genetics done. I'm taking an educated guess here that you are a rapid metabolizer at 3A4, b/c you are taking high dose without relief but are symptomatic with negative s.e.'s. Doesn't matter if I'm wrong or right. Testing of your 3A4 is critical to your pain control. Depending if there is an aberration in the metabolism, dosing of anything going through 3A4 should be adjusted. Likely hood if I hadn't developed my 7 day plan, I would have been overdosed if I had changed the patch every 3 days

With Genelex testing for the panel is as cheap as testing for one.(see Fentanyl thread). For completeness her the panel includes 2D6, 2C9, 2C19, 3A4, 3A5, Vkroc1.

Dosing: Ask for the 25 mcg patch to start.. They come in a box of 5. If after one week of use pain is not in target range and s.e's none to minimal discuss using 50 mcg. But as you go up in dose s.e's will become more prominent as is the case with all drugs. Once they screwed up my script and gave me 50 mcg. I used them , but was spacey.

Skin prep: Wash application site with non oily soap and dry well. Patch will fall off if the skin is oily. Avoid cleaning skin with alcohol before application. Might set you up for skin irritation. Application site should be moved around to avoid skin from becoming irritated from the adhesive. If a patch comes off, it's designed to not be able to be reapplied.

Skin site selection: Most practioners recommend the upper back area. I recommend anterior upper chest. Reason is if you become unconscious for any reason the upper chest area is exposed by EMT's/doc's to evaluate breathing. In an unconscious state the patch would be identified and removed. If the patch is on the back it may be missed.  Long term use, consider a Medic Alert bracelet.

Initiating drug: Ask for a HomeHealth Referral for "Evaluation of Medication" change. There's an ICDM-9 code for it that the HHA will use. It's covered by insurance. The importance of this is that the nurse will evaluate how you are responding to the drug. It's necessary to be done in your surroundings versus going to the docs office. This evaluation is usually done over 1-2 weeks. Should be repeated if there is a dosage change. review the monograph to educate yourself about the drugs workings.

Storage and disposal: Keep in a secure area from children and pets. Dispose of in the trash that is then secured. Disposal is controversial as it is with all drugs now. Drugs used to be recommended to be put done the toilet. Drugs were affecting the environment. In the trash it goes to the landfill. Communities have developed drug disposal plans.

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Drug Monograph 

Black box warning for Fentanyl( black box warnings means that these are serious considerations regarding a drug).

DURAGESIC^® (fentanyl transdermal system) CII contains a high concentration of a potent Schedule II opioid agonist, fentanyl. Schedule II opioid substances which include fentanyl, hydromorphone, methadone, morphine, oxycodone, and oxymorphone have the highest potential for abuse and associated risk of fatal overdose due to respiratory depression. Fentanyl can be abused and is subject to criminal diversion. The high content of fentanyl in the patches (DURAGESIC^®) may be a particular target for abuse and diversion.

DURAGESIC^® is indicated for management of persistent, moderate to severe chronic pain that:

• Requires continuous, around-the-clock opioid administration for an extended period of time, and
• Cannot be managed by other means such as nonsteroidal analgesics, opioid combination products, or immediate-release opioids

DURAGESIC^® should ONLY be used in patients who are already receiving opioid therapy, who have demonstrated opioid tolerance, and who require a total daily dose at least equivalent to DURAGESIC^® 25 mcg/hr. Patients who are considered opioid-tolerant are those who have been taking, for a week or longer, at least 60 mg of morphine daily, or at least 30 mg of oral oxycodone daily, or at least 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid.

Because serious or life-threatening hypoventilation could occur, DURAGESIC^®is contraindicated:

• In patients who are not opioid-tolerant
• In the management of acute pain or in patients who require opioid analgesia for a short period of time
• In the management of post-operative pain, including use after out-patient or day surgeries (e.g., tonsillectomies)
•    In the management of mild pain
• In the management of intermittent pain (e.g., use on an as needed basis [prn])

(See CONTRAINDICATIONS section of the full Prescribing Information for further information.)

Since the peak fentanyl concentrations generally occur between 20 and 72 hours of treatment, prescribers should be aware that serious or life-threatening hypoventilation may occur, even in opioid-tolerant patients, during the initial application period.

The concomitant use of DURAGESIC^®with all cytochrome P450 3A4 inhibitors (such as ritonavir, ketoconazole, itraconazole, troleandomycin, clarithromycin, nelfinavir, nefazodone, amiodarone, amprenavir, aprepitant, diltiazem, erythromycin, fluconazole, fosamprenavir, grapefruit juice, and verapamil) may result in an increase in fentanyl plasma concentrations, which could increase or prolong adverse drug effects and may cause potentially fatal respiratory depression. Patients receiving DURAGESIC^®and any CYP3A4 inhibitors should be carefully monitored for an extended period of time and dosage adjustments should be made if warranted. (See CLINICAL PHARMACOLOGY-Drug Interactions, WARNINGS, PRECAUTIONS, and DOSAGE AND ADMINISTRATION sections of the full Prescribing Information for further information.)

The safety of DURAGESIC^®has not been established in children under 2 years of age. DURAGESIC^®should be administered to children only if they are opioid-tolerant and 2 years of age or older. (See PRECAUTIONS - Pediatric Use section of the full Prescribing Information.)

DURAGESIC^® is ONLY for use in patients who are already tolerant to opioid therapy of comparable potency. Use in non-opioid tolerant patients may lead to fatal respiratory depression. Overestimating the DURAGESIC^® dose when converting patients from another opioid medication can result in fatal overdose with the first dose (see DOSAGE and ADMINISTRATION – Initial DURAGESIC^® Dose Selection - section of full Prescribing Information for further information). Due to the mean elimination half-life of approximately 20-27 hours, patients who are thought to have had a serious adverse event, including overdose, will require monitoring and treatment for at least 24 hours.

DURAGESIC^® can be abused in a manner similar to other opioid agonists, legal or illicit. This risk should be considered when administering, prescribing, or dispensing DURAGESIC^® in situations where the healthcare professional is concerned about increased risk of misuse, abuse, or diversion.

Persons at increased risk for opioid abuse include those with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). Patients should be assessed for their clinical risks for opioid abuse or addiction prior to being prescribed opioids. All patients receiving opioids should be routinely monitored for signs of misuse, abuse, and addiction. Patients at increased risk of opioid abuse may still be appropriately treated with modified-release opioid formulations; however, these patients will require intensive monitoring for signs of misuse, abuse, or addiction.

DURAGESIC^® patches are intended for transdermal use (on intact skin) only. Do not use a DURAGESIC^® patch if the seal is broken or the patch is cut, damaged, or changed in any way.

Avoid exposing the DURAGESIC^® application site and surrounding area to direct external heat sources, such as heating pads or electric blankets, heat or tanning lamps, saunas, hot tubs and heated water beds, while wearing the system. Avoid taking hot baths or sunbathing. There is a potential for temperature-dependant increases in fentanyl released from the system resulting in possible overdose and death. Patients wearing DURAGESIC^® systems who develop fever or increased core body temperature due to strenuous exertion should be monitored for opioid side effects and the DURAGESIC^® dose should be adjusted if necessary.

teka hmmm I think it wouldn't fit there either. Thanks