How can you inject fentanyl patches

Death due to the intravenous injection of fentanyl extracted from transdermal patches has not been previously reported. We present 4 cases in which the source of fentanyl was transdermal patches and was injected.

In all of these cases, the victim was a white male who died at home. Case 1 was a year-old with no known history of drug use, who was found by his wife on the floor of his workshop. Police recovered a fentanyl patch, needle, and syringe at the scene.

The risk of drug dependence on fentanyl patches is high. Prescribers should carefully establish genuine need before prescribing. Fentanyl misuse is an emerging problem. Use of fentanyl transdermal patches carries a number of risks of overdose, with a small margin between an appropriate therapeutic dose and a toxic dose. Use of fentanyl patches requires care when commencing treatment and is only appropriate in patients in whom opioid analgesic treatment is well established. When fentanyl transdermal patches are used appropriately, plasma levels may take around 24 hours to reach a steady state.

Fentanyl patches are designed to provide a steady release of fentanyl over 72 hours. There is no advantage in prescribing fentanyl patches to be applied daily or every two days.

The pharmacokinetics of fentanyl only add to the danger. Fentanyl is highly lipid-soluble and has a large volume of distribution 60— L. An effective analgesic concentration of fentanyl ranges from 0. The absence of detectable opioid in the urine was consistent with a recent overdose.

Alterations to the formulation or presentation of the patch might make it harder to misuse the drug intravenously, although previous experience with temazepam in several countries has shown that such changes are not necessarily the answer. In response to the ease of misuse of temazepam, the pharmaceutical industry produced a gel-filled formulation that would be as "resistant" as possible to injecting. However, it has since been shown that the gel-filled preparation is readily injectable, 10 and results in more medical complications, including superficial thrombophlebitis, abscesses and deep venous thrombosis.

There are several case reports of ischaemic necrosis of digits resulting from intra-arterial injection of temazepam. To date, all reported deaths from misuse of fentanyl patches have been the result of other than intravenous misuse. Prescribers need to be alert to the potential for misuse and the consequent risk of fatality. They need to impress on patients the importance of secure storage of patches. Stricter regulation of fentanyl patches could be enforced by accounting for patches after they have been dispensed eg, ensuring that, on the death of a patient issued with patches, unused medications are returned.

A more draconian measure would be to require that used patches be returned before more can be issued. However, this would not prevent the theft of patches, and would put the onus of returning used patches on patients already suffering from debilitating pain.

It is clearly necessary to continue to strictly control the availability and prescribing of these patches, which potentially are a highly sought after product on the black market. However, it is also important to avoid widespread public warning of the risk, which might serve only to advertise a novel activity for risk-takers. Fentanyl, dissolved in ethanol a flux enhancer and gelled with hydroxyethyl cellulose, is held in a drug reservoir between a backing layer and a rate-controlling membrane on an adhesive base.

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