Fentanyl / Duragesic Pain Patch Overprescription Becoming A Full-Blown Crisis

There’s an old saying that, “two is a coincidence, three is a pattern.” Last week, the fentanyl pain patch (technically the “DURAGESIC^® fentanyl transdermal system”) came up three times for me:

• First, my office received a call from someone who had recently lost a family member through a rather inexplicable course of malpractice, and while talking to our nurse paralegal briefly mentioned the patient had “pain patches.”
• Second, a lively discussion came together on one of the many plaintiff’s lawyer e-mail lists I follow, talking about the types of wrongful death claims that can be brought after a Fentanyl death.
• Third, WHYY reported that Pennsylvania health officials were warning about how “Overdoses from the opiate fentanyl have already led to at least 50 confirmed deaths in the state this year, according to Pennsylvania’s department of drug and alcohol programs.”

That seemed like a pattern, so I figured it was time for a blog post.

The idea of the fentanyl pain patch sounds crazy: why would you ever give someone a drug that is prone to abuse, prone to theft and drug trafficking, and has, as the warning label says, a “risk of fatal overdose due to respiratory depression?” Once you have seen a loved one go through weeks of agony caused by irreparable nerve or muscle damage, or bone degeneration or the like, then it makes sense, and it’s no stretch to say that these patches have given some people their lives back.

But there’s a dark side. As the prescribing information for the Duragesic patch says:

Respiratory depression is the chief hazard of DURAGESIC. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death.

DURAGESIC has a narrow indication and should be prescribed only by healthcare professionals who are knowledgeable in the administration of potent opioids and management of chronic pain [see Indications and Usage (1)]. DURAGESIC is contraindicated for use in conditions in which the risk of lifethreatening respiratory depression is significantly increased, including use as an as-needed analgesic, use in non-opioid tolerant patients, acute pain, and postoperative pain [see Contraindications (4)]. Proper dosing and titration of DURAGESIC are essential [see Dosage and Administration (2.3)]. Overestimating the DURAGESIC dose when converting patients from another opioid medication, can result in fatal overdose with the first dose. However, respiratory depression has also been reported with use of DURAGESIC in patients who are opioidtolerant, even when DURAGESIC has been used as recommended and not misused or abused.

Read that a couple times, particularly the last sentence, and let it sink in: the pain patch can cause fatal respiratory depression even when used correctly.

Yet, the biggest problem may not be misuse of Duragesic by patients, but overprescription by doctors. Importantly, the prescribing label warns that the fentanyl pain patch should not be used:

• 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])

Shockingly, however, some doctors routinely prescribe the fentanyl pain patch for short-term pain, for recovery after surgery, and for patients whose could be more than adequately managed by other available painkillers, including oral morphine, oral oxycodone, or oral hydromorphone. Some patients could even be treated by less-dangerous therapies like NSAIDs or the like, if done properly in conjunction with non-medication therapies like cold and hot therapy or physical therapy. Many times, doctors prescribe the pain patch in lieu of sending the patient to a specialist pain management doctor.

Frankly, I think the problem needs to stop at the source: doctors need to stop giving out fentanyl soeasily. But while there’s money to be made by the drug companies, and while the medical societies refuse to clamp down on the surgeons and family physicians that shouldn’t ever prescribe fentanyl to anyone, it doesn’t seem like anything’s going to change.