Patients and family members are reluctant, of course, to change therapy if the patient is receiving adequate pain control. Therefore a patient who may tolerate oral opiates is maintained on Duragesic unnecessarily. It can be very helpful to counsel the patient that any nausea experienced with oral opiates should diminish in less than a week because there is a tolerance effect to the nausea. In addition to the incredible cost of this medication, there are other clinical drawbacks to the use of Duragesic in hospice patients. This fact will usually lead to under dosing when converting from oral morphine to a fentanyl patch and overdosing when switching from a fentanyl patch to oral morphine.
Additional drawbacks are absorption problems and practical issues regarding the patch formulation.
The use of the transdermal system is limited by the difficulties involved in delivering high doses AND the need for an alternative route to provide supplemental doses for breakthrough pain. There is an alarming variability in the absorption of fentanyl from Duragesic patches. Also, many clinicians caring for hospice patients will attest that many patients have inadequate pain relief on the 3rd day of wearing a Duragesic patch. Patients should be advised to avoid exposing the transdermal application site to direct external heat sources such as heating pads, electric blankets, heat lamps, saunas, etc. A relative contraindication for Duragesic would be any patient who is febrile or diaphoretic.