Regular transdermal opioids for background pain in palliative care
If opioid therapy is indicated, see Choice of opioid for pain in palliative care and Starting an opioid for pain in palliative care for guidance on opioid choice and considerations when starting opioid therapy.
Transdermal opioid formulations have a slow onset of action and cannot be used for acute pain or rapid dosage adjustment.
Ensure patients starting a transdermal opioid have an immediate-release opioid prescribed for breakthrough pain or incident pain.
Transdermal fentanyl can be considered for patients who have persistent pain and are stabilised on an oral opioid dose equivalent to oral morphine 30 mg per 24 hours, or more. For advice on switching to transdermal fentanyl from another opioid, including approximate equianalgesic doses, see Switching opioids in palliative care. Exercise caution when considering a dose increase of transdermal fentanyl; wait until at least 3 days after the patch was applied before assessing the effectiveness and increasing the dose. A small number of patients find the analgesic effect of a transdermal fentanyl patch wears off early, necessitating a change of patch every second day rather than every third day. Transdermal fentanyl absorption can be variable in some patients (eg those with cachexia).
Transdermal buprenorphineSchmidt-Hansen, 2015 is useful for patients who require a patch but do not meet the criteria for a fentanyl patch (eg the lowest strength fentanyl patch is too high for their opioid requirements) or who prefer less frequent patch replacement (ie every 7 days, rather than every 3 days as with fentanyl). An initial transdermal buprenorphine regimen for pain in patients with palliative care needs who have not been taking an opioid is:
buprenorphine 5 micrograms/hour transdermally, replaced every 7 days. Review response after 3 to 7 days; see Monitoring analgesic therapy in palliative care. If analgesia is inadequate, increase the dose. Maximum dose 40 micrograms/hour. For patients who are older, frail or cachectic, slowly titrate the dose. buprenorphine
For initial regular therapy with transdermal buprenorphine for pain in patients who have been taking opioid therapy, see Switching opioids in palliative care for advice on switching opioids and approximate equianalgesic doses.