Avoiding Fatal Overdoses With Fentanyl Patches (Oct. 2005)

FDA has issued a public health advisory about deaths and serious injuries that have occurred when pain-relieving transdermal patches containing fentanyl, such as Duragesic, were misused. This has caused fatal overdoses of the drug. The Institute for Safe Medication Practices describes an incident where a patient’s caregiver placed the fentanyl patch on the patient’s buttock, which was the site of her pain. When the patient went to bed, she also used a heating pad at the same place. The patient was discovered dead two days later. According to ISMP, neither the prescribing physician nor the pharmacist had counseled her on how to use the patch properly, and they hadn’t told her to avoid applying heat over the patch. There have also been cases where children have gotten hold of the patches, with tragic results. In one case, a mother found her 4-year old son dead next to an overturned trash can that held torn wrappers and used patches. The boy had applied a patch to his body, either a discarded one from the trash, or one he opened from a box of new patches. ISMP also describes a case where a child was accidentally exposed to a patch that fell off a family member, and another one where a child removed his grandmother’s patch and applied it to himself. It’s important to instruct patients how to safely store and dispose of the patches. Used patches, or those that are no longer needed, should be folded in half so that the sticky side of the patch sticks to itself, then flushed …
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