Previous Tips
October Tip
Did you know…
Considerations used for the initiation and administration of fentanyl are:
1. A complete history of opioid use within the last 2 weeks to ensure the patient is fully opioid tolerant. [Tolerance can be assumed if the individual is on a moderate, stable, regularly scheduled dose of a strong opioid (not just a prn dose), i.e., a total daily dose of at least 60-90 mg/day morphine equivalence daily for at least 2 weeks, given at least b.i.d. for CR or q.i.d. for IR)]
2. Do not switch from codeine to fentanyl regardless of the codeine dose, as some codeine users may have little or no opioid tolerance.
3. Use extra caution with patients at higher risk for overdose.
Consider: Have you been including in your assessments regarding pain management your clients, their history of opioid use prior to administration of a new Fentanyl physician order?
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September Tip
Did you know…
Fentanyl is a potent (approximately 100 times more potent than morphine), synthetic opioid analgesic with a rapid onset and short duration of action. Historically it has been used to treat chronic breakthrough pain and is commonly used pre-procedures.
In palliative care we use fentanyl to manage severe incident or breakthrough pain in opioid tolerant clients as it is able to quickly cross the blood/ brain barrier. As a result, fentanyl begins to have its effect almost immediately after it enters the blood. The speed with which it enters the blood depends on the form of Fentanyl that is administered.
In Canada the forms and routes of Fentanyl used for managing pain in adult palliative/ EOL clients are:
Injection (via individual s/c injections; with a s/c butterfly with a CADD pump; IV)
Sublingual (by using the Injection ampoule liquid)
Transdermal patch (Duragesic)
Transmucosa (Bioerrodable oral mucosa adhesive film - Onsolis)
Consider: What would be the most appropriate use and route when Fentanyl is ordered by physician for your clients?
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August Tip:
Did you know…
Lipid Solubility affects drug behavior and therefore is one of the considerations when choosing which opioid is used to manage an individual's pain?
We normally think of Fentanyl as short-acting and Morphine as long-acting. However, the 2 drugs have similar elimination half-lives: 2-4 hours for Morphine and 3-7 hours for Fentanyl. We often think of drug elimination as determining the duration of effect. However, Morphine does not last longer than Fentanyl. Because it is eliminated more slowly from the body it lasts longer because once it enters the central nervous system it has a difficult time exiting the cellular lipid barrier (blood-brain barrier). It is this retention in the central nervous system that makes Morphine longer-acting than Fentanyl. Because Morphine is not very lipid-soluble, it takes a long time to cross the blood-brain barrier both going in and out of the brain. This produces what one might call a "slow-in, slow-out" drug. Indeed, when compared with lipid-soluble drugs, Morphine is noted to be slower in onset. Fentanyl, on the other hand, is lipophilic and crosses the blood-brain barrier rapidly in both directions; it is a "fast-in, fast-out" drug. Therefore, Fentanyl acts quickly and has a short duration of action because of its lipid solubility.
Consider: What does that mean for your clients who are ordered Fentanyl for pain Management?
The Pharmacology of Fentanyl and Its Impact on Pain Management: Lipid Solubility -
Donald R. Taylor, MD, Medical Director, Comprehensive Pain Care in Palliative Care, Georgia, USA; Medscape.
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July Tip:Did you know ...
Nurses often report fear of causing respiratory depression in their client when dosing with opioids to efficacy in a palliative/end-of-life situation.
Consider: Respiratory depression is RARE when opioid doses are titrated up appropriately. If respiratory rate is less than 8/minute, and the client is not actively dying medical intervention is required.
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June Tip:
Did you know ...
A comprehensive pain assessment must include:
Location: include radiation
Intensity: worst, least, average, etc.
Quality: burning, aching, dull, stabbing, tingling, etc.
Pattern: onset and duration, constant or intermittent, etc.
Aggravating factors: posture, movement, activities, etc.
Relieving factors: position, rest, alternative therapies
Effect on quality of life: sleep, activities, etc.
Medication history: efficacy, adverse effects, etc.
Consider: What does that mean for your clients whose pain you are assessing? Has it been assessed completely to be able to manage it well? Please refer to the RNAO Best Practice Guideline for Pain Assessment. For a link to the RNAO website and the practice guidelines, please click here.
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May Tip:
Did you know ...
- Codeine is a WEAK opioid
- Codeine is converted by enzyme to a weak form of morphine
- 10% of the population does not produce the enzyme to convert codeine into morphine for their body to use to control pain
Consider: What does that mean for your clients who are on Tylenol with codeine?
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April Tip:
Did you know...
The consequences of unrelieved pain are:
- Respiratory and cardiac complications
- Decreased gastric and bowl motility
- Depressed immune response
- Increased blood glucose and insulin resistance
- Blunted cognitive function
- Affected mood, activities of daily living and quality of life
Consider: What does that mean for your clients whose pain is not well managed.
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