(215) Experience with Oral Transmucosal Fentanyl Citrate Opioid-Tolerant Patients at a Large Cancer Institution

Abstract

Background: Oral transmucosal fentanyl citrate (OTFC) is approved for the control of cancer breakthrough pain. Patients at our institution were noted to be using OTFC for around-the-clock dosing, (2) IV opioid supplementation, (3) “when water was unavailable to swallow pills”, (4) wound care (5) anxiety and insomnia, and (6) gastrointestinal obstruction. Objective: To evaluate the use and barriers for OTFC. Methods: We attempted to contact 67 consecutive cancer patients by telephone 5 months after they were prescribed OTFC at our institution and asked the following: (a) Are you still using OTFC?; (b) If “yes”, for what reasons?; and (c) If “no”, why not? Results: 22 now deceased, 14 not available, 3 with no recollection of OTFC use, 1 never filled the prescription due to concern regarding potential hazards to children and pets. Thirteen patients were using OTFC for cancer breakthrough pain. 14 discontinued OTFC for the following reasons: 5 due to resolution of pain (post-operative pain and radiation-induced odynophagia); 7 due to suboptimal pain relief; 1 due to conversion to a continuous IV opioid infusion; 2 due to excessive sedation; and 1 due to self-consciousness during public use. Discussion: Although OTFC is approved for cancer breakthrough pain, we have identified other uses in our patients, including the following: around-the-clock dosing; as a “more convenient” substitute for pills; as an anxiolytic or hypnotic; for procedure-related pain; for radiation-induced odynophagia; and in patients with gastrointestinal obstruction. Reasons given for discontinuing OTFC include: ineffective pain relief; side effects; stigmata associated with public use; conversion to continuous parenteral opioids; and concern of accidental intoxication by others. Closer monitoring of compliance and appropriate dose titration may improve the therapeutic use of OTFC.