I received this guest post from Kyle Roberts! It does a really nice job of demonstrating the challenges and potential risks with fentanyl and opioids in general.  If you’d like to share a case with a story, please feel free to contact me!

An elderly female was on a maintenance opioid regimen of Morphine ER 15 mg BID, with breakthrough Norco 10/325mg QID PRN. Needless to say, I was fairly shocked to see a prescription come in for her calling for Fentanyl 100 mcg/hr patches W 72 hours and breakthrough Dilaudid 2 mg Q 2 hours. This is an increase from approximately 70 mg morphine equivalent to 450 mg morphine equivalent. I called the prescriber and they informed me that the patient was on the 100 mcg patch in the hospital with them along with a PCA pump for 2 days and that she had tolerated it fine. “The doctor is not worried about this dose at all” the nurse said to me on the phone. I then spoke with the patients husband when he came to pick up the prescription for fentanyl and I inquired about how she was doing. He then informed me that she had been home for three days, used none of her breakthrough medication and was still very sedated with limited ability to communicate.

I believe this to be a case where the prescriber assumed that 2 days was long enough to see steady state concentrations of the fentanyl, however, it would appear that the fentanyl effects continued to rise after she was released from their care. This was the largest hike in dose I have seen. I had the husband not pick up the fentanyl and had him contact the doctor. He was extremely grateful for my advice as he was concerned about his wife’s mental state since she started the fentanyl.

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