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Guide to Analgesic Transdermal Patches

Introduction
There are two different analgesic transdermal patches available; fentanyl and buprenorphine. These
provide an alternative method of drug administration but are generally not recommended as a first
line analgesic and should not be used for unstable pain. Analgesic patches are considerably more
expensive than oral therapy. Consider using patches only when the person:

Has difficulty/inability to swallow or the oral route is inappropriate

Is intolerant of morphine or is experiencing unacceptable side effects with oral morphine

Has poor absorption from the GI tract

Has renal impairment

Has pain that is stable and therefore their analgesic requirement is stable

Has compliance problems supervised patch changes will assist this

General patch care

Apply to intact, non-hairy skin on the upper trunk or upper area (any hairs should be cut with
scissors rather than shaved). Avoid areas treated with radiotherapy, scar tissue or oedematous
areas

If needed clean the skin with water only and make sure the skin is dry (soap products can alter
absorption)

Remove the protective layer and apply the patch by firmly pressing with the palm of the hand for
30 seconds to ensure good contact. If patch adherence is poor, adhesive dressing or tape can be
used

Check the patch daily to ensure it is still in place

Bathing, showering or swimming should not affect the patch. If a patch falls off, a new one can be
applied

Used patches still contain active drug. To discard a patch, fold it in half so it sticks together and
dispose of it safely in a sharps bin

Heat /pyrexia increases the rate of transdermal drug absorption and can cause toxicity - avoid
direct contact with heat (e.g. hot water bottle, heat pad)

Showering is possible as the patches are waterproof but avoid soaking in a hot bath, saunas or
sunbathing

If the patient has a persistent temperature of 39oc, the patch dose may need review

Microgram to milligram converter


Key: mcg = micrograms,

mg = milligrams

1000 micrograms (mcg) = 1 milligram (mg)


100 micrograms (mcg) = 0.1 milligrams (mg)
10 micrograms (mcg) = 0.01 milligrams (mg)

Fentanyl patches
These are available as a matrix patch and a reservoir patch. You should not switch between the
different formulations/brands. Fentanyl is a potent opioid; a fentanyl 50mcg/hr patch is equivalent to
90mg twice a day of oral morphine! Therefore fentanyl patches must be prescribed carefully. A
12mcg/hr patch is available for sensitive patients and incremental dose increases.

Brand

Available strengths
(in mcg/hr)

Durogesic D-Trans, Matrifen , Mezolar


Fentalis, Tilofyl

12, 25, 50, 75, 100


25, 50, 75, 100

Patch type
Matrix patch (can cut)
Reservoir patch (cant cut)

Transdermal fentanyl: Approximate equivalence with oral morphine


(This is a guide only and patients should always be titrated individually for pain control)

Oral morphine equivalent


(milligrams/24hrs)
Transdermal Fentanyl
(micrograms/hr)

10

15

30

45

60

90

120

180

270

360

12

25

50

75

100

Starting a fentanyl patch


It usually takes 36-48 hours to reach therapeutic levels, so ensure the person takes another regular
opioid for the first 12 hours after the patch is first applied. The table below shows how to convert to a
fentanyl patch from a previous opioid.

Previous opioid

Switching to fentanyl patch

Immediate release (quick acting) morphine or


oxycodone

Apply patch, continue the immediate release


opioid 4-hourly for the next 12 hours*

Modified-release (long-acting) 12-hourly


morphine or oxycodone

Apply patch when the last dose of a 12-hourly


modified release opioid is given*

Sub-cutaneous infusion of morphine,


diamorphine, oxycodone or alfentanil

Apply the patch and continue the infusion for the


next 12 hours, then stop the infusion*

* Caution look out for breakthrough pain and side effects such as drowsiness

Change the patch every third day (72 hours) at about the same time, avoiding the same skin site
for several days

Once a patch has been removed, the drug is eliminated from the body slowly, and significant
blood levels persist for at least 24 hours. Side effects should be monitored for up to 24 hours after
patch removal

Regular laxatives should be prescribed for patients taking opioids for moderate to severe pain.
Regular fluid intake should be encouraged. Fentanyl is often less constipating than morphine, so
monitor stools and adjust laxative dose if necessary

Ensure that breakthrough pain analgesia is available at all times

Buprenorphine patches
These are available in two formulations and may be a useful option for patients with chronic pain who have
already tried weak opiates such as codeine or dihydrocodeine. Buprenorphine is over 100 times more potent
than oral morphine (refer to equivalence guide below).
Patch type

Available strength release rates (in mcg per hour)

BuTrans (7-day patch)


Transtec (4-day patch)

5, 10, 20
35, 52.5, 70

The table below shows approximate dose equivalents of buprenorphine patches and other opioid analgesics:
Pre-treatment opioid (in mg per 24 hrs)
(This is a guide only and patients should always be titrated individually for pain control)

Weak opioids
Buprenorphine
patch (in mcg
per hour)
5 mcg/hr
10 mcg/hr
20 mcg/hr
35 mcg/hr
52.5 mcg/hr
70 mcg/hr

Strong opioids

Codeine

Dihydrocodeine

Tramadol

Oral
morphine

Fentanyl
patch

30-60 mg
60-120 mg
120-180 mg
-

60 mg
60-120 mg
120-180 mg
-

50 mg
50-100 mg
100-150 mg
-

30-60 mg
90 mg
120 mg

25 mcg/hr
-

Comparisons between BuTrans and Transtec


FAQs
Indication?
When initiating the patch
how long does it take to
reach therapeutic levels?
How many patches can
be applied at a time?
How often is the patch
changed?
Where to apply the
patch?

Duration of action?

BuTrans (7-day patch)

Transtec (4-day patch)

Treatment of non-malignant
moderate pain unresponsive to
non-opioid analgesics

Moderate to severe cancer pain and


severe pain unresponsive to non-opioid
analgesics

72 hours - review analgesic effect


after 72 hours

24 hours - review analgesic effect after 24


hours

Maximum of 2 patches (apply at


same time to avoid confusion)
Every 7 days at about the same
time each day
Upper torso - avoid using the
same patch site for at least 3
weeks
Do not administer other opiates
within 24 hours of patch removal.
If the patient is still in pain, an
immediate release when required
analgesic should be prescribed

Maximum of 2 patches (apply at same


time to avoid confusion)
Every 4 days at about the same time
each day
Upper torso - avoid using the same patch
site for at least 6 days
Do not administer other opiates within 24
hours of patch removal. Patients may still
have side-effects for up to 30 hours

References
1. J Reason, Transdermal patch guidance. BCAP, Nov 09
2. http://www.palliativecareguidelines.scot.nhs.uk/pain%5Fmanagement/ accessed 4.3.11
3. http://www.palliativedrugs.com/advanced-search. Accessed 4.3.11
th
4. Mims, Handbook of pain management, 5 edition, 2009
5. The British pain societys Opiates for persistent pain: good practice, January 2010
http://www.britishpainsociety.org/book_opioid_main.pdf
6. BNF 61, March 2011
7. SIGN 106; Control of pain in adults with cancer, November 2008 http://www.sign.ac.uk/pdf/SIGN106.pdf
Bethan Lewis/Jenny Gibbs - Medicines Management Department NHS Bristol. 03/2011