"What Is Fentanyl?" by Sherry Norman, RNC, BSN, CCRN, CLNC
FENTANYL SUBLIMAZE
CATEGORY: Analgesic,
Narcotic, General Anesthetic
BRAND NAMES: Actiq®;
Duragesic®; Sublimaze®
USE:
Fentanyl is used for sedation, relief of pain, preoperative medication,
adjunct to general or regional anesthesia, management of chronic pain
(transdermal product)
Actiq® is indicated only for management of breakthrough cancer pain
in patients who are tolerant to and currently receiving opioid therapy
for persistent cancer pain
Patients are considered opioid tolerant if they are receiving at least
60 mg/day of morphine, 50 mcg/hour of transdermal fentanyl, or an
equivalent dose of another opioid for 1 week or longer.
MECHANISM OF ACTION
Fentanyl Binds with stereospecific receptors at many sites within the
CNS, increases pain threshold, alters pain reception, inhibits
ascending pain pathways. Fentanyl binds to brain receptors,
relieving pain. It decreases the feeling of pain and a person's
response to pain
Fentanyl is 50-100 times as potent as morphine; morphine 10 mg I.M. =
fentanyl 0.1-0.2 mg I.M.; fentanyl has less hypotensive effects than
morphine or meperidine due to minimal or no histamine release
PHARMACODYNAMICS – KINETICS:
Respiratory depressant effect may last longer than analgesic effect
Onset of action: Analgesia:
I.M.: 7-15 minutes
I.V.: Almost immediate
Transdermal: 6-8 hours
Transmucosal: 5-15 minutes
Maximum effect:
Transdermal: 24 hours
Transmucosal: 20-30 minutes
Duration:
I.M.: 1-2 hours
I.V.: 30-60 minutes
Transdermal: 72 hours
Transmucosal: 1-2 hours
Absorption: Transmucosal: Rapid, approximately 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
Excretion: Urine (primarily as metabolites, 10% as unchanged drug)
Half-life elimination:
Children 5 months to 4.5 years: Mean: 2.4 hours
Children 0.5-14 years (after long-term continuous
infusion): approximately 21 hours (range: 11-36 hours)
Adults: I.V.: 2-4 hours
Transdermal: 17 hours (range: 13-22); apparent
half-life increased with transdermal due to continued absorption
Transmucosal: 6.6 hours (range: 5-15 hours)
Elimination: In urine primarily as metabolites and less than 10% as
unchanged drug
Clearance: Newborn infants: Clearance may be significantly
correlated to gestational age and birth weight (Saarenmaa, 2000)
STABILITY
Commercially available fentanyl citrate injections should be protected
from light and stored at room temperatures of 15–30°C; brief
exposure to temperatures up to 40°C does not adversely affect the
injection. Fentanyl citrate is hydrolyzed in acidic solutions.
Fentanyl citrate is reportedly physically incompatible with
methohexital sodium, pentobarbital sodium, or thiopental sodium, but
the compatibility depends on several factors (e.g., concentrations of
the drugs, specific diluents used, resulting pH, temperature).
Specialized references should be consulted for specific compatibility
information.
ADMINISTRATION ROUTES:
PARENTERAL:
I.V.: Administer by slow I.V. push over 3-5 minutes or by continuous
infusion; larger bolus doses (>5 mcg/kg) should be given slow I.V.
push over 5-10 minutes
I.V.: Muscular rigidity may occur with rapid I.V. administration.
During prolonged administration, dosage requirements may decrease.
Injection, solution, as citrate [preservative free]: 0.05 mg/mL
available in 2 mL, 5 mL, 10 mL, 20 mL, 30 mL, 50 mL vials
TRANSDERMAL:
Apply to non-irritated and non-irradiated 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).
Transdermal system (Duragesic®) is available in the following
dosages:
25 mcg/hour [10 cm2] (5s); 50 mcg/hour [20 cm2] (5s); 75 mcg/hour [30
cm2]; 100 mcg/hour [40 cm2] (5s)
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.
Lozenge, oral transmucosal, as citrate [mounted on a plastic radiopaque
handle] (Actiq®) is available in the following dosages: 200
mcg, 400 mcg, 600 mcg, 800 mcg, 1200 mcg, 1600 mcg [raspberry flavor]
DOSING FOR ADULTS: —
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.
Pre-medication: 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 oxygen 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: 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
re-dosing 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.
Pain control: Transdermal: Initial: 25 mcg/hour system; if currently
receiving opiates, convert to fentanyl equivalent and administer
equianalgesic dosage titrated to minimize the adverse effects and
provide analgesia. Change patch every 72 hours.
The dosage should not be titrated more frequently than every 3 days
after the initial dose or every 6 days thereafter. The majority of
patients are controlled on every 72-hour administration, however, a
small number of patients require every 48-hour administration.
DOSING THE ELDERLY PATIENT:
Elderly have been found to be twice as sensitive as younger patients to
the effects of fentanyl. A wide range of doses may be used. When
choosing a dose, take into consideration the following patient factors:
age, weight, physical status, underlying disease states, other drugs
used, type of anesthesia used, and the surgical procedure to be
performed.
Transmucosal: Dose should be reduced to 2.5-5 mcg/kg. Suck on lozenge
vigorously approximately 20-40 minutes before the start of procedure.
DOSING THE 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.
DOSING FOR PEDIATRICS: —
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
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.V.: 0.5-1 mcg/kg/dose;
may repeat after 30-60 minutes; or 25-50 mcg, repeat full dose in 5
minutes if needed, may repeat 4-5 times with 25 mcg at 5-minute
intervals if needed. Note: Higher doses are used for major procedures.
Mean required dose: Neonates with gestational age <34 weeks:
0.64 mcg/kg/hour; neonates with gestational age 34 weeks: 0.75
mcg/kg/hour
Continuous sedation/analgesia during ECMO: Initial I.V. bolus: 5-10
mcg/kg slow I.V. push over 10 minutes, then 1-5 mcg/kg/hour; titrate
upward; tolerance may develop; higher doses (up to 20 mcg/kg/hour) may
be needed by day 6 of ECMO
Neonates: Analgesia: International Evidence-Based Group for Neonatal
Pain recommendations (Anand, 2001):
Intermittent doses: Slow I.V. push: 0.5-3 mcg/kg/dose.
Continuous infusion: 0.5-2 mcg/kg/hour
SIGNIFICANT ADVERSE REACTIONS:
LESS THAN 10% OF PATIENTS MAY EXPERIENCE:
Cardiovascular: Bradycardia, hypotension, peripheral
vasodilation
Central nervous system: Drowsiness, sedation, increased
intracranial pressure
Gastrointestinal: Nausea, vomiting
Endocrine & metabolic: Antidiuretic hormone release
Neuromuscular & skeletal: Chest wall rigidity (high
dose I.V.) – ESPECIALLY FOLLOWING RAPID IF ADMINISTRATION
Ocular: Miosis
1% to 10% OF PATIENTS MAY EXPERIENCE:
Cardiovascular: Cardiac arrhythmias, orthostatic
hypotension
Central nervous system: Confusion, CNS depression
Gastrointestinal: Constipation
Ocular: Blurred vision
Respiratory: Apnea, postoperative respiratory depression
LESS THAN 1% (LIMITED TO IMPORTANT OR LIFE-THREATENING): Bronchospasm,
convulsions, hypercarbia, laryngospasm, respiratory depression
OTHER:
Cardiovascular: flushing
Cns - euphoria
Dermatologic: erythema, pruritus, facial pruritus with oral
transmucosal product
Gastrointestinal: biliary tract spasm
Genitourinary: urinary tract spasm
MISCELLANEOUS:
Physical and psychological dependence with prolonged use. Note:
Neonates who receive a total fentanyl dose >1.6 mg/kg or continuous
infusion duration >5 days are more likely to develop narcotic
withdrawal symptoms; children 1 week to 22 months: those who receive a
total dose of 1.5 mg/kg or duration >5 days have a 50% chance of
developing narcotic withdrawal and those receiving a total dose >2.5
mg/kg or duration of infusion >9 days have a 100% chance of
developing withdrawal. Doses should be tapered to prevent withdrawal
symptoms.
Below is a chart of the occurance of adverse reactions from “First
Databank”
Adverse Effects List from First
Databank
More Frequent
BRADYCARDIA
severe
DROWSINESS
HYPOTENSION
severe
NAUSEA
RESPIRATORY DEPRESSION
severe
VOMITING
Less Frequent
CARDIAC ARRHYTHMIAS
severe
Rare or Very Rare
ALLERGIC DERMATITIS
severe
BILIARY SPASM
BLURRED VISION
BRONCHOSPASM, ALLERGIC
severe
CHILLS
CIRCULATORY DEPRESSION
severe
CNS DEPRESSION
CNS EXCITATION
severe
CONFUSION, POSTOPERATIVE
severe
CONSTIPATION
CONVULSIONS
severe
DELIRIUM
severe
DOUBLE VISION
HIVES
severe
ITCHING
severe
LARYNGOSPASM
severe
MENTAL DEPRESSION
severe
ORTHOSTATIC HYPOTENSION
PARESTHESIA
severe
SKIN RASH
severe
URETERAL SPASM
VISION CHANGES
(MEDSCAPE 2004)
CONTRAINDICATIONS:
Hypersensitivity to fentanyl or any component of the formulation;
increased intracranial pressure; severe respiratory depression; severe
liver or renal insufficiency; pregnancy (prolonged use or high doses
near term)
Actiq® 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, 50 mcg transdermal fentanyl/hour, or an equivalent
dose of another opioid for greater than or equal to 1 week.
NURSING IMPLICATIONS
An opioid antagonist, resuscitative and intubation equipment, and
oxygen should be available; rapid I.V. injection may result in apnea.
Patients with elevated temperature may have increased fentanyl
absorption transdermally, observe for adverse effects, dosage
adjustment may be needed; pharmacologic and adverse effects can be seen
after discontinuation of transdermal system, observe patients for at
least 12 hours after transdermal product removed; destroy unused
portion of Actiq® according to hospital policy on controlled
substances; partial unused doses of Actiq® can be dissolved under
hot running tap water; dispose of handle properly
PATIENT TEACHING INFORMATION:
Patients should be instructed to Avoid alcohol and the herbal medicine
St John's Wort; may cause drowsiness and impair ability to perform
activities requiring mental alertness or physical coordination;
Fentanyl may be habit-forming; avoid abrupt discontinuation after
prolonged use;
an Actiq® Welcome Kit, containing educational materials and safe
storage containers (to keep medication away from children), as well as
a patient safety video, is available from the manufacturer; these can
be obtained by healthcare professionals who call 1-800-896-5855;
dispose of transmucosal and transdermal products properly; keep all
products (even if used) out of the reach of children; keep
transmucosal and transdermal products (both used and unused) out of the
reach of children; special child-resistant containers are available to
temporarily store partially-consumed units that cannot be disposed of
immediately see Actiq® Patient Leaflet for details on proper
storage, administration, and disposal of Actiq®, as well as,
instructions about overdose management. Frequent use of Actiq® may
increase risk of dental caries; consult dentist for appropriate oral
hygiene. Diabetic patients should note that Actiq® contains 2 grams
of sugar/unit (about 1/2 teaspoon of sugar).
WARNINGS & PRECAUTIONS:
Fentanyl is An opioid-containing analgesic. The dosing 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;
Fentanyl should be used 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; non-depolarizing skeletal muscle
relaxant may be required.
Tolerance of drug dependence may result from extended use. 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: Serum fentanyl concentrations may increase
approximately one-third for patients with a body temperature of
40ºC 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 12 hours after removal of the patch. Safety and efficacy of
transdermal system have been limited to children >2 years of age who
are opioid tolerant.
PRECAUTIONS:
Use with caution in patients with bradycardia, hepatic, renal, or
respiratory disease or those with increased ICP, head injuries, or
impaired consciousness; patients must be monitored until fully
recovered;
Decrease dose in patients with hepatic and/or renal disease; not
recommended if patient received MAO inhibitors within 14 days;
Use of transdermal system is not recommended in children less than 12
years or those less than 18 years who weigh less than 50 kg;
Frequent use of Actiq® may increase risk of dental caries;
Actiq® contains 2 g of sugar/unit; inform diabetic patients of
sugar content WARNINGS:
Physical and psychological dependence may occur with prolonged use;
abrupt discontinuation may result in withdrawal or seizures. Symptoms
of opioid withdrawal may occur in patients after conversion of one
dosage form to another or after dosage adjustment.
DRUG/FOOD INTERACTIONS:
CNS depressants: Increased sedation when used with CNS depressants,
phenothiazines
CYP3A4 inhibitors: May increase the levels/effects of fentanyl. 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). 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")
BREAST-FEEDING CONSIDERATIONS — Fentanyl is excreted in low
concentrations into breast milk. Breast-feeding is considered
acceptable following single doses to the mother; however, no
information is available when used long-term. DIETARY CONSIDERATIONS:
Glucose may cause hyperglycemia; monitor blood glucose concentrations.
Actiq® contains 2 g sugar per unit. MONITORING PARAMETERS:
Respiratory and cardiovascular status, blood pressure, heart rate.
oxygen saturation, bowel sounds and abdominal distention. TOXICOLOGY / OVERDOSE COMPREHENSIVE:
Symptoms include CNS depression, respiratory depression, and miosis.
Overdose treatment includes airway support, establishment of an I.V.
line, and administration of naloxone 2 mg I.V. (0.01 mg/kg for
children), with repeat administration as necessary, up to a total of 10
mg.
SAMPLE PATIENT EDUCATION SHEET
PATIENT EDUCATION — 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
PATIENT WARNING: This warning is for Actiq® only. It is for
cancer pain that is poorly treated by other pain medicines. It is not
to be used for pain caused by surgery. Keep away from children. REASONS PATIENTS SHOULD NOT TAKE THIS
MEDICINE
If you have an allergy to fentanyl or any other part
of this medicine.
Tell healthcare provider if you are allergic to any
medicine. Make sure to tell about the allergy and how it affected you.
This includes telling about rash; hives; itching; shortness of breath;
wheezing; cough; swelling of face, lips, tongue, or throat; or any
other symptoms involved.
If you have any of the following conditions:
Increased pressure in your brain, kidney disease, liver disease, or
severe lung disease. PURPOSE OF THIS MEDICINE:
This medicine is used to relieve pain. HOW TO TAKE THIS MEDICINE:
All forms:
Drink plenty of non-caffeine containing liquid
unless told to drink less liquid by healthcare provider.
Skin patch:
Apply patch to clean, dry, healthy skin on the
chest, back, upper leg, or upper arm.
Clip hair at site before putting patch on. Do not
shave.
Move patch site with each patch.
Lollipop:
Place lollipop in your mouth between the cheek and
lower gum.
Suck lollipop. Do not chew, break, or crush. IF YOU MISS A DOSE:
Use a missed dose as soon as possible.
If it is almost time for the next dose, skip the
missed dose and return to your regular schedule.
Many times this medicine is taken on an as needed
basis. PRECAUTIONS WHEN TAKING THIS MEDICINE:
This medicine may be habit-forming with long-term
use.
If you are 65 or older, use this medicine with
caution. You could have more side effects.
Check medicines with healthcare provider. This
medicine may not mix well with other medicines.
You may not be alert. Avoid driving, doing other
tasks or activities until you see how this medicine affects you.
Avoid alcohol (includes wine, beer, and liquor) or
other medicines and natural products that slow your actions and
reactions. These include sedatives, tranquilizers, mood stabilizers,
antihistamines, and other pain medicine.
Tell healthcare provider if you are pregnant or plan
on getting pregnant.
Tell healthcare provider if you are breast-feeding. THE COMMON SIDE EFFECTS OF THIS
MEDICINE INCLUDE:
Feeling lightheaded, sleepy, having blurred vision,
or a change in thinking clearly. Avoid driving, doing other tasks or
activities that require you to be alert or have clear vision until you
see how this medicine affects you.
Nausea or vomiting. Small frequent meals, frequent
mouth care, sucking hard candy, or chewing gum may help.
Constipation. More liquids, regular exercise, or a
fiber-containing diet may help. Talk with healthcare provider about a
stool softener or laxative. THE FOLLOWING ARE THINGS YOU SHOULD
MONITOR AND REPORT TO YOUR HEALTHCARE PROVIDER
Change in condition being treated. Is it better,
worse, or about the same?
Keep a diary of pain control.
Bowel movements. REASONS TO CALL HEALTHCARE PROVIDER
IMMEDIATELY
If you suspect an overdose, call your
local poison control center immediately or dial 911.
Signs of a life-threatening reaction. These include
wheezing; chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat.
Severe dizziness or passing out.
Difficulty breathing.
Significant change in thinking clearly and logically.
Poor pain control.
Severe nausea or vomiting.
Severe constipation.
Feeling extremely tired or weak.
Any rash.
No improvement in condition or feeling worse. HOW TO STORE THIS MEDICINE:
Store at room temperature. Do not freeze.
Throw away any unused lollipops in a sealed
container away from children and pets. GENERAL STATEMENTS
If you have a life-threatening allergy,
wear an allergy identification bracelet at all times.
Do not share your medicine with others and do not
take anyone else's medicine.
Keep all medicine out of the reach of children and
pets.
Keep a list of all your medicines (prescription,
natural products, supplements, vitamins, over-the-counter) with you.
Give this list to healthcare provider (doctor, nurse, nurse
practitioner, pharmacist, physician assistant).
Talk with healthcare provider before starting any
new medicine, including over-the-counter, natural products, or vitamins.
REFERENCES:
1. AHFS – American Society of Health Systems Pharmacists Drug
Information, 2004; p 2036 – 2041.
2. Medscape: First Databank – Adverse effects list
Fentanyl, 2004
3. Skidmore – Roth, Mosby’s Nursing Drug Reference, 2004, p 438 –
442.