Editing Fentanyl (section)

=== Pain management ===
[[File:PecFent 100mcg.jpg|thumb|A fentanyl nasal spray with a strength of 100{{nbsp}}[[Microgram|μg]] per use]]
The bioavailability of intranasal fentanyl is about 70–90% but with some imprecision due to clotted nostrils, pharyngeal swallow, and incorrect administration. For both emergency and palliative use, intranasal fentanyl is available in doses of 50, 100, 200, 400(PecFent){{nbsp}}μg. In emergency medicine, safe administration of intranasal fentanyl with a low rate of side effects and a promising pain-reducing effect was demonstrated in a prospective observational study in about 900{{nbsp}}out-of-hospital patients.<ref>{{cite journal | vauthors = Karlsen AP, Pedersen DM, Trautner S, Dahl JB, Hansen MS | title = Safety of intranasal fentanyl in the out-of-hospital setting: a prospective observational study | journal = Annals of Emergency Medicine | volume = 63 | issue = 6 | pages = 699–703 | date = June 2014 | pmid = 24268523 | doi = 10.1016/j.annemergmed.2013.10.025 }}</ref>

In children, intranasal fentanyl is useful for the treatment of moderate and severe pain and is well tolerated.<ref name="ReferenceA">{{cite journal | vauthors = Murphy A, O'Sullivan R, Wakai A, Grant TS, Barrett MJ, Cronin J, McCoy SC, Hom J, Kandamany N | title = Intranasal fentanyl for the management of acute pain in children | journal = The Cochrane Database of Systematic Reviews | volume = 10 | issue = 10 | page = CD009942 | date = October 2014 | pmid = 25300594 | pmc = 6544782 | doi = 10.1002/14651858.CD009942.pub2 }}</ref> Furthermore, a 2017 study suggested the efficacy of fentanyl lozenges in children as young as five, weighing as little as 13{{nbsp}}kg. Lozenges are more inclined to be used as the child is in control of sufficient dosage, in contrast to buccal tablets.<ref>{{cite journal | vauthors = Coombes L, Burke K, Anderson AK | title = The use of rapid onset fentanyl in children and young people for breakthrough cancer pain | journal = Scandinavian Journal of Pain | volume = 17 | issue = 1 | pages = 256–259 | date = October 2017 | pmid = 29229211 | doi = 10.1016/j.sjpain.2017.07.010 | s2cid = 8577873 }}</ref>

==== Chronic pain ====
It is also used in the [[Pain management|management]] of [[chronic pain]].<ref>{{cite journal | vauthors = Plante GE, VanItallie TB | title = Opioids for cancer pain: the challenge of optimizing treatment | journal = Metabolism | volume = 59 | issue = Suppl 1 | pages = S47–S52 | date = October 2010 | pmid = 20837194 | doi = 10.1016/j.metabol.2010.07.010 }}</ref> Often, [[transdermal patch]]es are used.<ref name="www.dea.gov">{{cite web |title=Fentanyl |type=factsheet |publisher=[[Drug Enforcement Administration]] |url=https://www.dea.gov/factsheets/fentanyl |access-date=4 December 2018 |archive-date=4 December 2018 |archive-url=https://web.archive.org/web/20181204053826/https://www.dea.gov/factsheets/fentanyl |url-status=live }}</ref> The patches work by slowly releasing fentanyl through the skin into the bloodstream over 48 to 72{{nbsp}}hours, allowing for long-lasting pain management.<ref name="AC-Durogesic2">{{cite book | veditors = Jasek W |year=2007 |title=Austria-Codex |edition=62nd |publisher=Österreichischer Apothekerverlag |isbn=978-3-85200-181-4 |location=Vienna |pages=2621{{nbsp}}ff |language=de}}</ref> Dosage is based on the size of the patch, since, in general, the transdermal absorption rate is constant at a constant skin temperature.<ref name="AC-Durogesic2" /> Each patch should be changed every 72{{nbsp}}hours.<ref>{{cite web |title=Fentanyl patches (Durogesic) for chronic pain |website=NPS Medicinewise |date=August 2006 |url=https://www.nps.org.au/radar/articles/fentanyl-patches-durogesic-for-chronic-pain#:~:text=The%20patch%20should%20be%20changed,and%20100%20micrograms%20per%20hour. |access-date=7 December 2021 |archive-date=7 December 2021 |archive-url=https://web.archive.org/web/20211207205934/https://www.nps.org.au/radar/articles/fentanyl-patches-durogesic-for-chronic-pain#:~:text=The%20patch%20should%20be%20changed,and%20100%20micrograms%20per%20hour. |url-status=live }}</ref> Rate of absorption is dependent on a number of factors. Body temperature, skin type, amount of body fat, and placement of the patch can have major effects. The different delivery systems used by different makers will also affect individual rates of absorption, and route of administration. Under normal circumstances, the patch will reach its full effect within 12 to 24{{nbsp}}hours; thus, fentanyl patches are often prescribed with a fast-acting opioid (such as morphine or oxycodone) to handle breakthrough pain.<ref name="AC-Durogesic2" /> It is unclear if fentanyl gives long-term pain relief to people with [[neuropathic pain]].<ref>{{cite journal | vauthors = Derry S, Stannard C, Cole P, Wiffen PJ, Knaggs R, Aldington D, Moore RA | title = Fentanyl for neuropathic pain in adults | journal = The Cochrane Database of Systematic Reviews | volume = 10 | issue = 5 | page = CD011605 | date = October 2016 | pmid = 27727431 | pmc = 6457928 | doi = 10.1002/14651858.CD011605.pub2 }}</ref>

==== Breakthrough pain ====
Sublingual fentanyl dissolves quickly and is absorbed through the [[sublingual]] mucosa to provide rapid analgesia.<ref name="trib">{{cite web |title=Abstral sublingual tablets |date=May 2016 |publisher=UK Electronic Medicines Compendium |url=http://www.medicines.org.uk/emc/medicine/21371/SPC/Abstral+Sublingual+Tablets/ |url-status=live |access-date=1 May 2017 |archive-url=https://web.archive.org/web/20170323181204/http://www.medicines.org.uk/emc/medicine/21371/SPC/Abstral+Sublingual+Tablets/ |archive-date=23 March 2017 }}</ref> Fentanyl is a highly lipophilic compound,<ref name="trib" /><ref>{{cite journal | vauthors = | title = Abstral (Fentanyl Sublingual Tablets for Breakthrough Cancer Pain) | journal = P & T | volume = 36 | issue = 2 | pages = 2–28 | date = February 2011 | pmid = 21560267 | pmc = 3086091 }}</ref> which is well absorbed sublingually and generally well tolerated.<ref name="trib" /> Such forms are particularly useful for breakthrough cancer pain episodes, which are often rapid in onset, short in duration, and severe in intensity.<ref>{{cite journal | vauthors = Ward J, Laird B, Fallon M |year=2011 |title=The UK breakthrough cancer pain registry: Origin, methods and preliminary data |journal=BMJ Supportive & Palliative Care |volume=1 |page=A24 |doi=10.1136/bmjspcare-2011-000020.71 |s2cid=73185220}}</ref>

==== Palliative care ====
[[File:A generic fentanyl transdermal patch, with a release rate of 12mcg per hour, applied to the skin (cropped).jpg|thumb|A fentanyl transdermal patch with a release rate of 12 micrograms per hour, on a person's arm]]
In [[palliative care]], transdermal fentanyl patches have a definitive, but limited role for:
* people already stabilized on other opioids who have persistent swallowing problems and cannot tolerate other parenteral routes such as subcutaneous administration.
* people with moderate to severe [[Renal failure|kidney failure]].<ref>{{cite journal | vauthors = Roy PJ, Weltman M, Dember LM, Liebschutz J, Jhamb M | title = Pain management in patients with chronic kidney disease and end-stage kidney disease | journal = Current Opinion in Nephrology and Hypertension | volume = 29 | issue = 6 | pages = 671–680 | date = November 2020 | pmid = 32941189 | pmc = 7753951 | doi = 10.1097/MNH.0000000000000646 }}</ref>
* troublesome side effects of oral morphine, [[hydromorphone]], or [[oxycodone]].<ref>{{cite journal | vauthors = Aurilio C, Pace MC, Pota V, Sansone P, Barbarisi M, Grella E, Passavanti MB | title = Opioids switching with transdermal systems in chronic cancer pain | journal = Journal of Experimental & Clinical Cancer Research | volume = 28 | page = 61 | date = May 2009 | issue = 1 | pmid = 19422676 | pmc = 2684533 | doi = 10.1186/1756-9966-28-61 | doi-access = free | title-link = doi }}</ref><ref>{{cite journal | vauthors = Minami S, Kijima T, Nakatani T, Yamamoto S, Ogata Y, Hirata H, Shiroyama T, Koba T, Komuta K | title = Opioid switch from low dose of oral oxycodone to transdermal fentanyl matrix patch for patients with stable thoracic malignancy-related pain | journal = BMC Palliative Care | volume = 13 | issue = 1 | page = 46 | date = 8 October 2014 | pmid = 25313295 | pmc = 4195703 | doi = 10.1186/1472-684X-13-46 | doi-access = free | title-link = doi }}</ref>

When using the transdermal patch, patients must be careful to minimize or avoid external heat sources (direct sunlight, heating pads, etc.), which can trigger the release and absorption of too much medication and cause potentially deadly complications.<ref>{{cite web |title=Fentanyl (Transdermal Route) Precautions |url=https://www.mayoclinic.org/drugs-supplements/fentanyl-transdermal-route/precautions/drg-20068152 |website=Mayo Clinic |access-date=19 January 2023 |archive-date=19 January 2023 |archive-url=https://web.archive.org/web/20230119051903/https://www.mayoclinic.org/drugs-supplements/fentanyl-transdermal-route/precautions/drg-20068152 |url-status=live }}</ref>

==== Combat medicine ====
[[File:Fentanylové lízatko.jpg|thumb|Fentanyl lollipos Actiq 200 mcg]]

[[Usaf|USAF]] [[United States Air Force Pararescue|Pararescue]] [[combat medic]]s in Afghanistan used fentanyl lozenges in the form of lollipops on combat casualties from [[Improvised explosive device|IED]] blasts and other trauma.<ref name="Shachtman_2009">{{cite magazine| vauthors = Shachtman N |date=10 September 2009|title=Airborne EMTs Shave Seconds to Save Lives in Afghanistan|url=https://www.wired.com/2009/09/airborne-emts-in-astan/|url-status=live|department=Danger Room|magazine=[[Wired (magazine)|Wired]]|archive-url=https://web.archive.org/web/20100706140612/http://www.wired.com/dangerroom/2009/09/airborne_emts_in_astan|archive-date=6 July 2010|access-date=1 July 2010 }}</ref> The stick is taped to a finger and the lozenge put in the [[Buccal administration|cheek]] of the person. When enough fentanyl has been absorbed, the (sedated) person generally lets the lollipop fall from the mouth, indicating sufficient analgesia and somewhat reducing the likelihood of overdose and associated risks.<ref name="Shachtman_2009" />

==== Breathing difficulties ====
Fentanyl is used to help relieve shortness of breath ([[dyspnea]]) when patients cannot tolerate morphine, or whose breathlessness is refractory to morphine. Fentanyl is useful for such treatment in [[palliative care]] settings where pain and shortness of breath are severe and need to be treated with strong opioids. [[Nebulizer|Nebulized]] fentanyl citrate is used to relieve end-of-life dyspnea in [[hospice]] settings.<ref>{{cite journal | vauthors = van Dijk M, Mooren KJ, van den Berg JK, van Beurden-Moeskops WJ, Heller-Baan R, de Hosson SM, Lam-Wong WY, Peters L, Pool K, Kerstjens HA | title = Opioids in patients with COPD and refractory dyspnea: literature review and design of a multicenter double blind study of low dosed morphine and fentanyl (MoreFoRCOPD) | journal = BMC Pulmonary Medicine | volume = 21 | issue = 1 | page = 289 | date = September 2021 | pmid = 34507574 | pmc = 8431258 | doi = 10.1186/s12890-021-01647-8 | doi-access = free | title-link = doi }}</ref><ref>{{cite journal | vauthors = Simon ST, Köskeroglu P, Gaertner J, Voltz R | title = Fentanyl for the relief of refractory breathlessness: a systematic review | journal = Journal of Pain and Symptom Management | volume = 46 | issue = 6 | pages = 874–886 | date = December 2013 | pmid = 23742735 | doi = 10.1016/j.jpainsymman.2013.02.019 | doi-access = free | title-link = doi }}</ref>