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Fentanyl


Pronunciation

 (FEN ta nil)


U.S. Brand Names

 Actiq®; Duragesic®; Sublimaze®


Synonyms

 Fentanyl Citrate


Generic Available

 Yes: Excludes lozenge


Canadian Brand Names

 Actiq®; Duragesic®


Use

Injection: Sedation, relief of pain, preoperative medication, adjunct to general or regional anesthesia

Transdermal: Management of moderate-to-severe chronic pain

Transmucosal (Actiq®): Management of breakthrough cancer pain


Use - Dental

 Adjunct in preoperative intravenous conscious sedation in patients undergoing dental surgery


Restrictions

 C-II


Pregnancy Risk Factor

 C/D (prolonged use or high doses at term)


Pregnancy Implications

 Fentanyl crosses the placenta and has been used safely during labor. Chronic use during pregnancy has shown detectable serum levels in the newborn with mild opioid withdrawal (case report).


Lactation

 Enters breast milk/not recommended (AAP rates "compatible")


Contraindications

 Hypersensitivity to fentanyl or any component of the formulation; increased intracranial pressure; severe respiratory disease or depression including acute asthma (unless patient is mechanically ventilated); paralytic ileus; severe liver or renal insufficiency; pregnancy (prolonged use or high doses near term)

Transmucosal lozenges (Actiq®) or transdermal patches must not be used in patients who are intolerant to opioids. Patients are considered opioid-tolerant if they are taking at least 60 mg morphine/day, 30 mg oral oxycodone/day, 8 mg oral hydromorphone/day, 50 mcg transdermal fentanyl/hour, or an equivalent dose of another opioid for 1 week. Transdermal patches are not for use in acute pain, mild pain, or postoperative pain management.


Warnings/Precautions

 An opioid-containing analgesic regimen should be tailored to each patient's needs and based upon the type of pain being treated (acute versus chronic), the route of administration, degree of tolerance for opioids (naive versus chronic user), age, weight, and medical condition. The optimal analgesic dose varies widely among patients. Doses should be titrated to pain relief/prevention. Fentanyl shares the toxic potentials of opiate agonists, and precautions of opiate agonist therapy should be observed; use with caution in patients with bradycardia; rapid I.V. infusion may result in skeletal muscle and chest wall rigidity leading to respiratory distress and/or apnea, bronchoconstriction, laryngospasm; inject slowly over 3-5 minutes; nondepolarizing skeletal muscle relaxant may be required. Tolerance or drug dependence may result from extended use. Use caution in patients with a history of drug dependence or abuse. The elderly may be particularly susceptible to the CNS depressant and constipating effects of narcotics.

Actiq® should be used only for the care of cancer patients and is intended for use by specialists who are knowledgeable in treating cancer pain. For patients who have received transmucosal product within 6-12 hours, it is recommended that if other narcotics are required, they should be used at starting doses 1 /4 to 1 /3 those usually recommended. Actiq® preparations contain an amount of medication that can be fatal to children. Keep all units out of the reach of children and discard any open units properly. Patients and caregivers should be counseled on the dangers to children including the risk of exposure to partially-consumed units. Safety and efficacy have not been established in children <16 years of age.

Topical patches: Serious or life-threatening hypoventilation may occur, even in opioid-tolerant patients. Serum fentanyl concentrations may increase approximately one-third for patients with a body temperature of 40°C secondary to a temperature-dependent increase in fentanyl release from the system and increased skin permeability. Patients who experience adverse reactions should be monitored for at least 24 hours after removal of the patch. Transdermal patch may contain conducting metal (eg, aluminum); remove patch prior to MRI. Safety and efficacy of transdermal system have been limited to children >2 years of age who are opioid tolerant.


Adverse Reactions

>10%:

Cardiovascular: Hypotension, bradycardia

Central nervous system: CNS depression, confusion, drowsiness, sedation

Gastrointestinal: Nausea, vomiting, constipation, xerostomia

Neuromuscular & skeletal: Chest wall rigidity (high dose I.V.), weakness

Ocular: Miosis

Respiratory: Respiratory depression

Miscellaneous: Diaphoresis

1% to 10%:

Cardiovascular: Cardiac arrhythmia, edema, orthostatic hypotension, hypertension, syncope

Central nervous system: Abnormal dreams, abnormal thinking, agitation, amnesia, dizziness, euphoria, fatigue, fever, hallucinations, headache, insomnia, nervousness, paranoid reaction

Dermatologic: Erythema, papules, pruritus, rash

Gastrointestinal: Abdominal pain, anorexia, biliary tract spasm, diarrhea, dyspepsia, flatulence

Local: Application site reaction

Neuromuscular & skeletal: Abnormal coordination, abnormal gait, back pain, paresthesia, rigors, tremor

Respiratory: Apnea, bronchitis, dyspnea, hemoptysis, pharyngitis, rhinitis, sinusitis, upper respiratory infection

Miscellaneous: Hiccups, flu-like syndrome, speech disorder

<1%: Abdominal distention, ADH release, amblyopia, aphasia, bladder pain, bradycardia, bronchospasm, circulatory depression, CNS excitation or delirium, cold/clammy skin, convulsions, depersonalization, dysesthesia, exfoliative dermatitis, hyper-/hypotonia, hostility, laryngospasm, oliguria, paradoxical dizziness, physical and psychological dependence with prolonged use, polyuria, pustules, stertorous breathing, stupor, urinary tract spasm, urticaria, vertigo

Postmarketing and/or case reports: Anorgasmia, blurred vision, dental caries (Actiq®), ejaculatory difficulty, gum line erosion (Actiq®), libido decreased, tachycardia, tooth loss (Actiq®), weight loss


Overdosage/Toxicology

 Symptoms of overdose include CNS depression, respiratory depression, and miosis. Treatment is supportive. Naloxone, 2 mg I.V. with repeat administration as necessary up to a total of 10 mg, can also be used to reverse toxic effects of the opiate. Patients who experience adverse reactions during use of transdermal fentanyl should be monitored for at least 24 hours after removal of the patch.


Drug Interactions

 Substrate of CYP3A4 (major); Inhibits CYP3A4 (weak)

CNS depressants: Increased sedation with CNS depressants, phenothiazines

CYP3A4 inhibitors: May increase the levels/effects of fentanyl. Potentially fatal respiratory depression may occur when a potent inhibitor is used in a patient receiving chronic fentanyl (eg, transdermal). Example inhibitors include azole antifungals, ciprofloxacin, clarithromycin, diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, protease inhibitors, quinidine, and verapamil.

MAO inhibitors: Not recommended to use Actiq® within 14 days. Severe and unpredictable potentiation by MAO inhibitors has been reported with opioid analgesics.


Ethanol/Nutrition/Herb Interactions

Ethanol: Avoid ethanol (may increase CNS depression).

Food: Glucose may cause hyperglycemia.

Herb/Nutraceutical: St John's wort may decrease fentanyl levels. Avoid valerian, St John's wort, kava kava, gotu kola (may increase CNS depression).


Stability

Injection formulation: Store at controlled room temperature of 15°C to 25°C (59°F to 86°F); protect from light

Transdermal: Do not store above 25°C (77°F)

Transmucosal: Store at controlled room temperature of 15°C to 30°C (59°F to 86°F)


Compatibility

 Stable in D5W, NS

Y-site administration: Compatible: Alatrofloxacin, amphotericin B cholesteryl sulfate complex, atracurium, cisatracurium, diltiazem, dobutamine, dopamine, enalaprilat, epinephrine, esmolol, etomidate, furosemide, gatifloxacin, heparin, hydrocortisone sodium succinate, hydromorphone, labetalol, levofloxacin, linezolid, lorazepam, midazolam, milrinone, morphine, nafcillin, nicardipine, nitroglycerin, norepinephrine, pancuronium, potassium chloride, propofol, ranitidine, remifentanil, sargramostim, thiopental, vecuronium, vitamin B complex with C

Compatibility in syringe: Compatible: Atracurium, atropine, bupivacaine with ketamine, butorphanol, chlorpromazine, cimetidine, clonidine with lidocaine, dimenhydrinate, diphenhydramine, droperidol, heparin, hydromorphone, hydroxyzine, meperidine, metoclopramide, midazolam, morphine, ondansetron, pentazocine, perphenazine, prochlorperazine edisylate, promazine, promethazine, ranitidine, scopolamine. Incompatible: Pentobarbital

Compatibility when admixed: Compatible: Bupivacaine. Incompatible: Fluorouracil, methohexital, pentobarbital, thiopental


Mechanism of Action

 Binds with stereospecific receptors at many sites within the CNS, increases pain threshold, alters pain reception, inhibits ascending pain pathways


Pharmacodynamics/Kinetics

Onset of action: Analgesic: I.M.: 7-15 minutes; I.V.: Almost immediate; Transmucosal: 5-15 minutes

Peak effect: Transmucosal: Analgesic: 20-30 minutes

Duration: I.M.: 1-2 hours; I.V.: 0.5-1 hour; Transmucosal: Related to blood level; respiratory depressant effect may last longer than analgesic effect

Absorption: Transmucosal: Rapid, ~25% from the buccal mucosa; 75% swallowed with saliva and slowly absorbed from GI tract

Distribution: Highly lipophilic, redistributes into muscle and fat

Metabolism: Hepatic, primarily via CYP3A4

Bioavailability: Transmucosal: ~50% (range: 36% to 71%)

Half-life elimination: 2-4 hours; Transmucosal: 6.6 hours (range: 5-15 hours); Transdermal: 17 hours (half-life is influenced by absorption rate)

Excretion: Urine (primarily as metabolites, 10% as unchanged drug)


Dosage

 Note: These are guidelines and do not represent the maximum doses that may be required in all patients. Doses should be titrated to pain relief/prevention. Monitor vital signs routinely. Single I.M. doses have a duration of 1-2 hours, single I.V. doses last 0.5-1 hour.

Children 1-12 years:

Sedation for minor procedures/analgesia: I.M., I.V.: 1-2 mcg/kg/dose; may repeat at 30- to 60-minute intervals. Note: Children 18-36 months of age may require 2-3 mcg/kg/dose

Continuous sedation/analgesia: Initial I.V. bolus: 1-2 mcg/kg then 1 mcg/kg/hour; titrate upward; usual: 1-3 mcg/kg/hour

Pain management: Transdermal (limited to children >2 years who are opioid tolerant): Initial dose: 25 mcg/hour system (higher doses have been used based on equianalgesic conversion); change patch every 72 hours

Children >12 years and Adults:

Sedation for minor procedures/analgesia: I.M., I.V.: 0.5-1 mcg/kg/dose; higher doses are used for major procedures

Pain management: Transdermal:

Initial: To convert patients from oral or parenteral opioids to transdermal formulation, a 24-hour analgesic requirement should be calculated (based on prior opiate use). This analgesic requirement should be converted to the equianalgesic oral morphine dose (see equianalgesic dosage table). The initial fentanyl dosage may be approximated from the 24-hour morphine dosage (see table) and titrated to minimize adverse effects and provide analgesia. Change patch every 72 hours.

Titration: Short-acting agents may be required until analgesic efficacy is established and/or as supplements for "breakthrough" pain. The amount of supplemental doses should be closely monitored. Appropriate dosage increases may be based on daily supplemental dosage using the ratio of 45 mg/24 hours of oral morphine to a 12.5 mcg/hour increase in fentanyl dosage.

Frequency of adjustment: The dosage should not be titrated more frequently than every 3 days after the initial dose or every 6 days thereafter. Patients should wear a consistent fentanyl dosage through two applications (6 days) before dosage increase based on supplemental opiate dosages can be estimated.

Frequency of application: The majority of patients may be controlled on every 72-hour administration; however, a small number of patients require every 48-hour administration.

Adults:

Premedication: I.M., slow I.V.: 50-100 mcg/dose 30-60 minutes prior to surgery

Adjunct to regional anesthesia: I.M., slow I.V.: 50-100 mcg/dose; if I.V. used, give over 1-2 minutes

Severe pain: I.M.: 50-100 mcg/dose every 1-2 hours as needed; patients with prior opiate exposure may tolerate higher initial doses

Adjunct to general anesthesia: Slow I.V.:

Low dose: Initial: 2 mcg/kg/dose; Maintenance: Additional doses infrequently needed

Moderate dose: Initial: 2-20 mcg/kg/dose; Maintenance: 25-100 mcg/dose may be given slow I.V. or I.M. as needed

High dose: Initial: 20-50 mcg/kg/dose; Maintenance: 25 mcg to one-half the initial loading dose may be given as needed

General anesthesia without additional anesthetic agents: Slow I.V.: 50-100 mcg/kg with O2 and skeletal muscle relaxant

Mechanically-ventilated patients (based on 70 kg patient): Slow I.V.: 0.35-1.5 mcg/kg every 30-60 minutes as needed; infusion: 0.7-10 mcg/kg/hour

Patient-controlled analgesia (PCA): I.V.: Usual concentration: 50 mcg/mL

Demand dose: Usual: 10 mcg; range: 10-50 mcg

Lockout interval: 5-8 minutes

Breakthrough cancer pain: Adults: Transmucosal: Actiq® dosing should be individually titrated to provide adequate analgesia with minimal side effects. It is indicated only for management of breakthrough cancer pain in patients who are tolerant to and currently receiving opioid therapy for persistent cancer pain. An initial starting dose of 200 mcg should be used for the treatment of breakthrough cancer pain. Patients should be monitored closely in order to determine the proper dose. If redosing for the same episode is necessary, the second dose may be started 15 minutes after completion of the first dose. Dosing should be titrated so that the patient's pain can be treated with one single dose. Generally, 1-2 days is required to determine the proper dose of analgesia with limited side effects. Once the dose has been determined, consumption should be limited to 4 units/day or less. Patients needing more than 4 units/day should have the dose of their long-term opioid re-evaluated. If signs of excessive opioid effects occur before a dose is complete, the unit should be removed from the patient's mouth immediately, and subsequent doses decreased.

Elderly >65 years: Transmucosal: Actiq®: Dose should be reduced to 2.5-5 mcg/kg; elderly have been found to be twice as sensitive as younger patients to the effects of fentanyl. Patients in this age group generally require smaller doses of Actiq® than younger patients.


Dosing adjustment in hepatic impairment:

Recommended Initial Duragesic Dose Based Upon Daily Oral Morphine Dose1

Oral
24-Hour Morphine
(mg/d)		 Duragesic® Dose
(mcg/h)
60-134 2 25
135-224 50
225-314 75
315-404 100
405-494 125
495-584 150
585-674 175
675-764 200
765-854 225
855-944 250
945-1034 275
1035-1124 300
Product information, Duragesic® - Janssen Pharmaceutica
1 Should not be used to convert from Duragesic® to other therapies because this conversion to Duragesic® is conservative. Use of this table for conversion to other analgesic therapies can overestimate the dose of the new agent; overdosage of the new analgesic agent is possible (see dosage for discontinuation of Duragesic® ).
2 Pediatric patients initiating therapy on a 25 mcg/hour Duragesic® system should be opioid-tolerant and receiving at least 60 mg oral morphine equivalents per day.

Dosing adjustment in hepatic impairment:

Opioid Analgesics Initial Oral Dosing Commonly Used for Severe Pain

Drug Equianalgesic Dose
(mg)		 Initial Oral Dose
Oral 1 Parenteral 2 Children
(mg/kg)		 Adults
(mg)
Buprenorphine - 0.4 - -
Butorphanol - 2 - -
Hydromorphone 7.5 1.5 0.06 4-8
Levorphanol 4 (acute)
1 (chronic)		 2 (acute)
1 (chronic)		 0.04 2-4
Meperidine 300 75 Not Recommended
Methadone 10 5 0.2 0.2
Morphine 30 10 0.3 15-30
Nalbuphine - 10 - -
Pentazocine 50 30 - -
Oxycodone 20 - 0.3 10.20
Oxymorphone 1 - - -
From "Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain," Am Pain Soc , Fifth Ed.
1 Elderly: Starting doese should be lower for this population group
2 Standard parenteral doses for acute pain in adults; can be used to doses for I.V. infusions and repeateed small I.V. boluese. Single I.V. boluses, use half the I.M. dose.
Children >6 months: I.V. dose = parenteral equianalgesic dose x weight (kg)/100

Dosing adjustment in hepatic impairment: Actiq®: Although fentanyl kinetics may be altered in hepatic disease, Actiq® can be used successfully in the management of breakthrough cancer pain. Doses should be titrated to reach clinical effect with careful monitoring of patients with severe hepatic disease.


Administration

I.V.: Muscular rigidity may occur with rapid I.V. administration. During prolonged administration, dosage requirements may decrease.

Transdermal: Apply to nonirritated and nonirradiated skin, such as chest, back, flank, or upper arm. Upper back is preferred location in children. Do not shave skin; hair at application site should be clipped. Prior to application, clean site with clear water and allow to dry completely. Do not cut patch. Apply patch immediately after removing from package. Firmly press in place and hold for 30 seconds. Change patch every 72 hours. Keep transdermal product (both used and unused) out of the reach of children. Do not use soap, alcohol, or other solvents to remove transdermal gel if it accidentally touches skin, as they may increase transdermal absorption; use copious amounts of water. Avoid exposing application site to external heat sources (eg, heating pad, electric blanket, heat lamp, hot tub).

Transmucosal: Foil overwrap should be removed just prior to administration. Once removed, patient should place the unit in mouth and allow it to dissolve. Do not chew. Actiq® units may be occasionally moved from one side of the mouth to the other. The unit should be consumed over a period of 15 minutes. Unit should be removed after it is consumed or if patient has achieved an adequate response and/or shows signs of respiratory depression. For patients who have received transmucosal product within 6-12 hours, it is recommended that if other narcotics are required, they should be used at starting doses 1 /4 to 1 /3 those usually recommended.


Monitoring Parameters

 Respiratory and cardiovascular status, blood pressure, heart rate

Transdermal: Monitor for 24 hours after application of first dose


Dietary Considerations

 Actiq® contains 2 g sugar per unit.


Patient Education

 While using this medication, do not use alcohol and other prescription or OTC medications (especially sedatives, tranquilizers, antihistamines, or pain medications) without consulting prescriber. If using Actiq® Oral Transmucosal, you may be at risk for dental carries due to the sugar content. Maintain good oral hygiene. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. May cause hypotension, dizziness, drowsiness, impaired coordination, or blurred vision (use caution when driving, climbing stairs, or changing position - rising from sitting or lying to standing, or when engaging in tasks requiring alertness until response to drug is known); nausea or vomiting (frequent mouth care, small, frequent meals, chewing gum, or sucking lozenges may help); or constipation (increased exercise, fluids, fruit, or fiber may help; if unresolved, consult prescriber about use of stool softeners). Report acute dizziness, chest pain, slow or rapid heartbeat, acute headache; confusion or changes in mentation; changes in voiding frequency or amount; swelling of extremities or unusual weight gain; shortness of breath or respiratory difficulty; or vision changes. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.

Administration:

Transdermal: Apply to clean, dry skin, immediately after removing from package. Firmly press in place and hold for 30 seconds.

Actiq® transmucosal: Actiq® preparations contain an amount of medication that can be fatal to children. Keep all units out of the reach of children and discard any open units properly. Actiq® Welcome Kits are available which contain educational materials, safe storage and disposal instructions.


Additional Information

 Fentanyl is 50-100 times as potent as morphine; morphine 10 mg I.M. is equivalent to fentanyl 0.1-0.2 mg I.M.; fentanyl has less hypotensive effects than morphine due to lack of histamine release. However, fentanyl may cause rigidity with high doses. If the patient has required high-dose analgesia or has used for a prolonged period (~7 days), taper dose to prevent withdrawal; monitor for signs and symptoms of withdrawal.

Transmucosal (oral lozenge): Disposal of Actiq® units: After consumption of a complete unit, the handle may be disposed of in a trash container that is out of the reach of children. For a partially-consumed unit, or a unit that still has any drug matrix remaining on the handle, the handle should be placed under hot running tap water until the drug matrix has dissolved. Special child-resistant containers are available to temporarily store partially consumed units that cannot be disposed of immediately.

Transdermal system (Duragesic®): Upon removal of the patch, ~17 hours are required before serum concentrations fall to 50% of their original values. Opioid withdrawal symptoms are possible. Gradual downward titration (potentially by the sequential use of lower-dose patches) is recommended. Keep transdermal product (both used and unused) out of the reach of children. Do not use soap, alcohol, or other solvents to remove transdermal gel if it accidentally touches skin as they may increase transdermal absorption, use copious amounts of water.


Anesthesia and Critical Care Concerns/Other Considerations

 When developing a therapeutic plan for pain control, scheduled, intermittent opioid dosing or continuous infusion is preferred over the "as needed" regimen. The 2002 ACCM/SCCM guidelines for analgesia (critically-ill adult) recommend fentanyl in patients who need immediate pain relief because of its rapid onset of action. Repeated doses or a continuous infusion of fentanyl may cause accumulation. Fentanyl or hydromorphone is preferred in patients who are hypotensive or have renal dysfunction. Morphine or hydromorphone is recommended for intermittent, scheduled therapy. Both have a longer duration of action requiring less frequent administration. Fentanyl is great to prevent pain during a procedure and can be dosed intermittently for such an application. Prolonged analgesia requires an infusion.

Fentanyl is 50-100 times as potent as morphine; morphine 10 mg I.M. is equivalent to fentanyl 0.1-0.2 mg I.M.; fentanyl has less hypotensive effects than morphine due to lack of histamine release. However, fentanyl may cause rigidity with high doses. If the patient has required high-dose analgesia or has used for a prolonged period (~7 days), taper dose to prevent withdrawal; monitor for signs and symptoms of withdrawal.


Cardiovascular Considerations

 May precipitate bradycardia, hypotension, and peripheral vasodilation. These properties necessitate close hemodynamic monitoring.


Dental Health: Effects on Dental Treatment

 Key adverse event(s) related to dental treatment: Xerostomia, changes in salivation (normal salivary flow resumes upon discontinuation), and orthostatic hypotension. Actiq® may contribute to dental carries due to sugar content of oral lozenge; advise patients to maintain good oral hygiene.


Dental Health: Vasoconstrictor/Local Anesthetic Precautions

 No information available to require special precautions


Dental Comment

 Transdermal fentanyl should not be used as a pain reliever in dentistry due to danger of hypoventilation


Mental Health: Effects on Mental Status

 Drowsiness, sedation, and depression are common; may rarely cause paradoxical CNS excitement or delirium


Mental Health: Effects on Psychiatric Treatment

 Concurrent use with low potency antipsychotics and TCAs may produce additive hypotension


Oncology: Vesicant

 No


Dosage Forms

Infusion [premixed in NS]: 0.05 mg (10 mL); 1 mg (100 mL); 1.25 mg (250 mL); 2 mg (100 mL); 2.5 mg (250 mL)

Injection, solution, as citrate [preservative free]: 0.05 mg/mL (2 mL, 5 mL, 10 mL, 20 mL, 30 mL, 50 mL)

Sublimaze®: 0.05 mg/mL (2 mL, 5 mL, 10 mL, 20 mL)

Lozenge, oral transmucosal, as citrate (Actiq®): 200 mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg [mounted on a plastic radiopaque handle; raspberry flavor]

Transdermal system: 25 mcg/hour [6.25 cm 2 ] (5s); 50 mcg/hour [12.5 cm 2 ] (5s); 75 mcg/hour [18.75 cm 2 ]; 100 mcg/hour [25 cm 2 ] (5s)

Duragesic®: 12 mcg/hour [5 cm 2 ] (5s); 25 mcg/hour [10 cm 2 ] (5s); 50 mcg/hour [20 cm 2 ] (5s); 75 mcg/hour [30 cm 2 ]; 100 mcg/hour [40 cm 2 ] (5s)


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International Brand Names

 AB-Fentanyl® (DE); Actiq® (CA, DE, DK, ES, FI, FR, GB, IE, NO, PT, SE); Beatryl® (IL); Duragesic® (CA); Durogesic® (AR, AT, AU, BE, BG, BR, CL, CZ, DE, DK, ES, FI, FR, GB, HR, HU, ID, IE, IL, IT, MX, NL, NO, NZ, PL, PT, RO, RU, SE, SG, SI, TH, TR, ZA); Durogesic TTS® (CH); Fenta-hameln® (DE); Fentanest® (ES, IT, JP, MX); Fentanila Citrato® (CL); Fentanil® (BR, YU); Fentanilo Citrato® (AR); Fentanilo® (CL, CO); Fentanilo Fabra® (AR); Fentanilo Gemepe® (AR); Fentanilo Gray® (AR); Fentanilo Northia® (AR); Fentanyl Alpharma® (FI, SE); Fentanyl Antigen® (TH); Fentanyl® (AU, BE, BG, CR, DO, EC, FI, GT, HN, HR, HU, ID, IL, LU, NO, NZ, PA, PL, RO, RU, SI, SV, TR, YU); Fentanyl B.Braun® (DE, FI, SE); Fentanyl Citrate-Antigen® (LU); Fentanyl Citrate® (AU, SG, TR); Fentanyl-Curamed® (CH); Fentanyl curasan® (DE); Fentanyl DeltaSelect® (DE); Fentanyl Dumex-Alpharma® (DK); Fentanyl-Fresenius® (ZA); Fentanyl Hameln® (DK); Fentanyl-hameln® (FI, SE); Fentanyl Hexal® (DE); Fentanyl Inresa® (DE); Fentanyl Janssen® (AT, CH); Fentanyl-Janssen® (CZ); Fentanyl Janssen® (DE); Fentanyl-Janssen® (FR); Fentanyl Janssen® (NL, PL); Fentanyl Nycomed® (AT); Fentanyl Pharmalink® (SE); Fentanyl-ratiopharm® (DE); Fentanyl Renaudin® (FR); Fentanyl Torrex® (AT, CZ); Haldid® (DK); Hefanil® (YU); Leptanal® (NO, SE); Nafluvent® (AR); Nilperidol® (BR); Q-Med Fentanyl® (ZA); Sintenyl® (CH); Sublimaze® (AR, AU, GB, NZ, ZA); Tanyl® (IL, ZA)


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