II. Class

  1. Short acting Narcotic (except Transdermal Fentanyl)

IV. Contraindications

  1. Mild pain, acute pain or postoperative pain due to risk of respiratory depression (FDA Black Box warning)
  2. Limit use to Opioid tolerant patients (Morphine Sulfate >60 mg/day for at least one week)

V. Dosing: Procedural Sedation and Analgesia (PSAA)

  1. Nasal: 2 mcg/kg intranasal (1/2 in each nostril)
  2. Nebulized: 4 mcg/kg in breath activated neb
  3. IV (onset in 1-3 min, lasting 30-60 min)
    1. Adult: 50 mcg/dose every 3 minutes, titrating to effect
    2. Child: 1 mcg/kg/dose IV every 3 minutes, titrating to effect
      1. Age 1-3 years old: 2-3 mcg/kg/dose every 30-60 minutes as needed
      2. Age 3-12 years old: 1-2 mcg/kg/dose every 30-60 minutes as needed
      3. Age >12 years old: 0.5-1 mcg/kg/dose every 30-60 minutes as needed
  4. Reversal: Naloxone
  5. Often administered in combination with Midazolam (Procedural Sedation and Analgesia)
    1. Use lower doses in combination with Midazolam (Versed)

VI. Dosing: Adult

  1. Transdermal Fentanyl (Duragesic)
    1. Generic strengths: 25, 50, 75, 100 mcg/hour
    2. Trade name strengths: 37.5, 62.5, 87.5 mcg/hour (released in 2015 at 3x the cost of generic)
    3. Onset of full effect only after 24 hours (steady state may not be reached for 1 week)
    4. Change patch ever 72 hours
      1. In atypical cases may need to be changed every 48 hours for end-of-dose pain
      2. Should not be changed more often than every 48 hours
    5. Conversions from prior Morphine (total per 24 hours)
      1. Start with 25 mcg/h Fentanyl Patch for those on Morphine Sulfate 60-134 mg/day
      2. Fentanyl 25 mcg/h: MS 37.5 mg PO or 12.5 mg IV
      3. Fentanyl 50 mcg/h: MS 75 mg PO or 25 mg IV
      4. Fentanyl 75 mcg/h: MS 112 mg PO or 37.5 mg IV
      5. Fentanyl 100 mcg/h: MS 150 mg PO or 50 mg IV
  2. Transmucosal Lozenge (Actiq)
    1. Available strengths: 200, 400, 800, 1200, 1600 ug
    2. Maximum: 4 lozenges per day
  3. Other transmucosal forms
    1. Sublingual tab (Abstral) 100 mcg
    2. Sublingual spray (Subsys) 100 mcg
    3. Nasal spray (Lazanda) 100 mcg

VII. Pharmacokinetics

  1. Intramuscular
    1. Onset: 7 to 15 minutes
    2. Peak: 15 minutes
    3. Duration: 1 to 2 hours
  2. Intravenous
    1. Onset: minutes
    2. Peak: minutes
    3. Duration: 30 to 60 minutes

VIII. Adverse Effects: Chronic Pain (Transdermal)

  1. Respiratory Depression (FDA Black Box Warning)
    1. Limit transdermal use to Opioid tolerant patients (>60 mg Morphine Sulfate per day for at least one week)
    2. Start at low dose
  2. Oversedation
    1. Antagonist: Naloxone (Narcan)

IX. Adverse Effects: Procedural Sedation (IV)

  1. Less histamine release than with Morphine
  2. Respiratory depression
    1. Supplemental Oxygen, Jaw Thrust maneuver, bag-valve mask
    2. Use lower doses in combination with Midazolam (Versed)

X. Efficacy: Non-Cancer Chronic Pain

  1. Transdermal Fentanyl preferred over oral Morphine
    1. Better pain relief
    2. Improved quality of life
  2. Reference
    1. Allan (2001) BMJ 322:1154-8 [PubMed]

XI. References

  1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
  2. (2015) Presc Lett 22(7): 42
  3. Miner (2012) APLS Lecture, HCMC, Minneapolis
  4. Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
  5. Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
  6. Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
  7. University Minnesota Childrens - Pediatric Emergency Drug Card
  8. Becker (2012) Anesth Prog 59:28-42 [PubMed]
  9. Brown (2005) Am Fam Physician 71:85-90 [PubMed]

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Cost: Medications

fentanyl (on 4/20/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
FENTANYL 0.05 MG/ML AMPUL Generic $0.61 per ml
FENTANYL 1,000 MCG/20 ML AMPUL Generic $0.61 per ml
FENTANYL 100 MCG/2 ML AMPUL Generic $0.61 per ml
FENTANYL 100 MCG/2 ML VIAL Generic $0.50 per ml
FENTANYL 100 MCG/HR PATCH Generic $10.43 each
FENTANYL 12 MCG/HR PATCH Generic $13.09 each
FENTANYL 2,500 MCG/50 ML VIAL Generic $0.50 per ml
FENTANYL 25 MCG/HR PATCH Generic $3.91 each
FENTANYL 37.5 MCG/HR PATCH Generic $43.75 each
FENTANYL 50 MCG/HR PATCH Generic $6.03 each
FENTANYL 75 MCG/HR PATCH Generic $8.97 each
FENTANYL CIT OTFC 1,200 MCG Generic $17.24 each
FENTANYL CITRATE OTFC 400 MCG Generic $9.90 each
FENTANYL CITRATE OTFC 800 MCG Generic $13.83 each
duragesic (on 1/6/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
DURAGESIC 100 MCG/HR PATCH Generic $10.43 each
DURAGESIC 12 MCG/HR PATCH Generic $13.09 each
DURAGESIC 25 MCG/HR PATCH Generic $3.91 each
DURAGESIC 50 MCG/HR PATCH Generic $6.03 each
DURAGESIC 75 MCG/HR PATCH Generic $8.97 each

Ontology: Sublimaze (C0015845)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005283
English sublimaze, Sublimaze

Ontology: Fentanyl (C0015846)

Definition (CHV) a kind of narcotic pain relieving drug
Definition (CHV) a kind of narcotic pain relieving drug
Definition (CHV) a kind of narcotic pain relieving drug
Definition (NCI) A synthetic, lipophilic phenylpiperidine opioid agonist with analgesic and anesthetic properties. Fentanyl selectively binds to the mu-receptor in the central nervous system (CNS) thereby mimicking the effects of endogenous opiates. Stimulation of the mu-subtype opioid receptor stimulates the exchange of GTP for GDP on the G-protein complex and subsequently inhibits adenylate cyclase. This results in a decrease in intracellular cAMP and leads to a reduction in the release of neurotransmitters such as substance P, GABA, dopamine, acetylcholine and noradrenaline. The analgesic effect of fentanyl is likely due to its metabolite morphine, which induces opening of G-protein-coupled inwardly rectifying potassium (GIRK) channels and blocks the opening of N-type voltage-gated calcium channels, thereby resulting in hyperpolarization and reduced neuronal excitability.
Definition (MSH) A potent narcotic analgesic, abuse of which leads to habituation or addiction. It is primarily a mu-opioid agonist. Fentanyl is also used as an adjunct to general anesthetics, and as an anesthetic for induction and maintenance. (From Martindale, The Extra Pharmacopoeia, 30th ed, p1078)
Definition (PSY) Synthetic opiate frequently used illicitly.
Definition (CSP) potent narcotic analgesic, abuse of which leads to habituation or addiction; primarily a mu-opioid agonist, used as an adjunct to general anesthetics, and as an anesthetic for induction and maintenance.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005283
SnomedCT 373492002, 40648001
LNC LP15167-7, MTHU002556
English Fentanyl, Phentanyl, Propanamide, N-phenyl-N-(1-(2-phenylethyl)-4-piperidinyl)-, Fentyl, fentanyl, fentanyl (medication), FENTANYL, Fentanyl [Chemical/Ingredient], fentanyls, phentanyl, fentaNYL, FentaNYL, N-(1-phenethylpiperidin-4-yl)-N-phenylpropionamide, local anesthetic fentanyl (medication), local anesthetic fentanyl, Fentanyl product, Fentanyl (product), Fentanyl (substance)
Swedish Fentanyl
Czech fentanyl
Finnish Fentanyyli
Russian TSITRAT FENTANILA, FENTANEST, LEPTANAL, SENTONIL, SUBLIMAZ, FENTANIL, FENTANILA TSITRAT, ЛЕПТАНАЛ, СЕНТОНИЛ, СУБЛИМАЗ, ФЕНТАНЕСТ, ФЕНТАНИЛ, ФЕНТАНИЛА ЦИТРАТ, ЦИТРАТ ФЕНТАНИЛА
Japanese フェンタニル, フェンタニール
Croatian FENTANIL
Polish Fentanyl
Spanish fentanilo (producto), fentanilo (sustancia), fentanilo, Fentanilo
French Fentanyl
German Fentanyl, Phentanyl
Italian Fentanil
Portuguese Fentanila

Ontology: Duragesic (C0591423)

Concepts Organic Chemical (T109) , Pharmacologic Substance (T121)
MSH D005283
English Janssen Pharmaceutica Brand of Fentanyl, Duragesic, Durogesic, durogesic, duragesic