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Ask the Pharmacist: Safe Dosing of Fentanyl Patch Critical

Safe Dosing of Fentanyl Patch is Critical

Q. My long history of unsuccessfully treated headache has prompted my doctor to prescribe a fentanyl patch. I recently read an article in my local newspaper about a patient dying from fentanyl. Should I use this drug?

A. Fentanyl patches are available in five strengths: 12 micrograms, 25 micrograms, 50 micrograms, 75 micrograms, and 100 micrograms. One advantage of fentanyl patches is that they only need to be changed every three days. One significant disadvantage is the need for proper dosing and, unfortunately, problems have arisen due to incorrect dosing.

Fentanyl PatchFor all patients, fentanyl patch should be initiated at either 12 or 25 micrograms, with the dose gradually increased over the span of several days or weeks. The only exception to this rule is patients already consuming high doses of narcotics. Sadly, patients have died after beginning fentanyl at too high of a dose, which stopped their breathing. Additionally, fentanyl patches should be slowly discontinued, with the last dose being either 12 or 25 micrograms. Patients suddenly stopping at higher doses are at risk of developing withdrawal symptoms.

All of these issues highlight an important point any patient considering fentanyl patch should be sure that their physician, nurses, pharmacists, and other healthcare providers are familiar with the proper use of this drug.

Lots of Options for Quitting Smoking

Q. My smoking habit has been affecting my headaches for the worse. I want to quit smoking, but can you tell me what works best?

A. I commend your ambition to stop smoking, which is arguably one of the most beneficial lifestyle changes anyone can make. The single greatest indicator for success is patient motivation, so I encourage you to set realistic, but meaningful goals, then continuously work towards them, even if you have a few relapses.

Several non-drug options are available to help you stop smoking, including ‘cold turkey’ methods and counseling. Regarding medications, the main choice is Nicotine Replacement Therapy (NRT), either as a gum, lozenge, patch, nasal spray, or inhaler. Each form has advantages and disadvantages:

  • Gum can quickly satisfy cravings, has a lower incidence of weight gain, and patients can adjust their dose to manage withdrawal symptoms. On the other hand, gum chewing may not be socially acceptable, can be difficult with dentures, and may cause jaw muscle ache.
  • A lozenge can satisfy oral cravings, is easy to use and conceal, and patients can adjust their dose, but stomach and intestinal side effects (nausea, hiccups, flatulence, and heartburn) are more common than with other forms of NRT.
  • Patches provide consistent nicotine levels, are easy to use and conceal, and have decreased compliance issues, but patients cannot quickly adjust their dose, local skin reactions may occur, and people with dermatologic conditions (i.e., psoriasis, eczema, etc.) should not use the patch. In addition, the 16-hour patch can lead to morning cravings and the 24-hour patch can cause vivid dreams or insomnia.
  • The spray allows for easy dose changes to manage withdrawal symptoms, but nasal and throat irritation can occur and people with chronic nasal disorders or severe airway disease should not use the spray.
  • Lastly, the doses of inhalers are easily changed and the inhaler mimics the hand-to-mouth ritual of smoking. However, initial throat or mouth irritation can be a problem, inhaler cartridges may not be as effective in very cold or very warm temperatures, and patients with underlying bronchospastic disease must use the inhaler with caution.

The only oral tablet that is FDA-approved for smoking cessation is sustained-release buproprion (Zyban), which can be prescribed by itself or combined with NRT. Buproprion may be more expensive for some patients (depending on insurance coverage), must be taken daily (sometimes twice daily), and should be used with caution in patients with seizures or eating disorders.

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