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Inappropriate Prescribing of Transdermal Fentanyl in Opioid Naïve Nursing Home Residents



by: Eric Widera (@ewidera)

If you had to guess what long acting opioid is most commonly started on in nursing home patients, which one would you guess?    A new study released last week in JAGS shocked me.   The answer to this question was a fentanyl patch.   Even more shocking, many of those started on this medication were never prescribed any opioids prior to being started on a patch.  

Ok, before I get ahead of myself, let me describe the study.   The authors used nursing home data from 22,253 Medicare-enrolled long-stay residents (meaning that they had to have a stay of greater than 90 days).  They combined the Minimum Data Set (MDS) with Medicare enrollment, hospital claims, and prescription drug transaction data from January to December of 2011 to determine the prevalence of new initiation of a long-acting opioid prescriptions.   They excluded residents who were comatose, who did not initiate a long-acting opioid after nursing home admission, or who had less than 3 months of continuous enrollment in Medicare Part D before initiation of a long-acting opioid.

What they found was eye opening:

  • One out of ten nursing home residents (9%) were never on a short acting agent in the previous 60 days prior to starting a long acting opioid.   
  • The most-common initial long-acting opioids was a fentanyl patch, accounting for about half of all long acting opioids for both opioid-naïve and non-naïve patients. 
  • For those opioid-naïve patients put on fentanyl patches, 27% were placed on a 12 mcg/h patch.   38% were placed on a 25mcg/h patch, and the rest were placed on 50mcg/h or more of a patch.   

I have some worry about a blanket statement against the use of long acting opioids without starting a short acting agent first, I do feel that starting a fentanyl patch in an opioid naïve patient is dangerous.   My only hope is that the study didn't capture opioid prescriptions that were outside of the Medicare Part D benefit, which is possible but unlikely to account for all of their findings.


Reference

Comments

Unknown said…
And I know of a physician who routinely orders fentanyl patches on opioid naive, actively dying hospice patients in the hospital...
Mike Steinman said…
This is an important study, and may be a strong case for implementing more decision support into the opioid prescribing process to steer prescribers towards better practices, and put up roadblocks to more dangerous practices. No easy answer about how to do this when everyone is using a different EHR, but prescribing it too complicated now to keep doing things the old way.
Your title is misleading and does not reflect the conclusion of the paper.
Eric Widera said…
That's because the title summarizes the conclusion of my blog post. I'd be happy to hear arguments why fentanyl patches in opioid naive patients is appropriate though.
Mary Lynn McPherson said…
I'm not a fan of transdermal fentanyl (TDF). Not only is it prescribed for opioid-naive patients, but it's also used inappropriately in patients who are very wasted and cachectic, leading to altered absorption and retention. Also, trying to titrate TDF to achieve pain relief in a quickly changing situation (like someone dying) is like trying to adroitly steer a barge. Some practitioners seem to think you can "set and forget" with TDF - slap that puppy on and walk away (does this explain it in nursing homes?) but that's far from true! Definitely not a "one size fits all" opioid formulation!
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Anonymous said…
I have been suffering from Amyotrophic lateral sclerosis (ALS) disease for the last two years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulate all over my body and i have been taking treatment from my doctor, few weeks ago i came on search on the internet if i could get any information concerning the prevention of this disease, on my search i saw a testimony of someone who has been healed from (Hepatitis B and Cancer) by this Man Dr Segun and she also gave the email address of this man and advise we should contact him for any sickness that he would be of help, so i wrote to Dr Segun telling him about my (ALS Virus) he told me not to worry that i was going to be cured!! hmm i never believed it,, well after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me as the Dr assured me that i have cured,after some time i went to my doctor to confirmed if i have be finally healed behold it was TRUE, So friends my advise is if you have such sickness or any other at all you can email Dr Segun on : (dr.segunsplletemple@gmail.com)..... THESE ARE THE THINGS DR Segun CAN ALSO CURE.. GONORRHEA, HIV/AIDS , LOW SPERM COUNT, MENOPAUSE DISEASE, CANCER,KINDS,PREGNANCY PROBLEM, SHORT SIGHTEDNESS PROBLEM, Stroke, Bring back ex lover or wife/husband....sir i am indeed grateful for the help i will forever recommend you to my friends!!!...
Anonymous said…
In an inpatient geriatric psychiatry unit in my community fentanyl is routinely used for management of severe agitation in dementia patients. Can't tell you how many I've weaned upon transfer to our hospice facility but often it's too little too late
muna said…
We do use them at our palliative unit, not in opioid naive of course, mainly as a rotation, in patients who cannot swallow, and based on availability of other long acting opioids.
I think safe titration is a challenge

Would be useful to know others experience with transdermal fentanyl in actively dying patients..do you titrate down, or remove them once patients are unconscious..? Also, do you think that titration up higher than 200mcg is not useful..?
Andrew Kamell said…
Wow. I have started a fentanyl 12mcg/hr on the rare patient after a single dose of IR opioid seemed helpful, but 25mcg? 50mcg? Insane.
One of the problems that this might be identifying is that as soon as people are identified as dying, or comfort measures, some physicians routinely order things like morphine 2mg/hr or even "2-10mg/hr, titrate to effect," or some other outrageous order. They're dying, so of course they need high doses of opioids, right?
No...

PS please remove the spam comments...
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Transcript
Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, I spy someone in our …