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  2. Scottish Palliative Care Guidelines
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  5. Pain medicines / analgesics
  6. Fentanyl patches
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Fentanyl patches

Green – For medicines routinely initiated and used by generalists

Introduction

Description: Potent opioid analgesic in a topical patch lasting 72 hours (on specialist advice some patients may require the patch to be changed every 48 hours).

"Safety Alert: IT IS BEST PRACTICE TO REMOVE ALL TRANSDERMAL PATCHES FOR MRI SCANS. THIS IS OF PARTICULAR IMPORTANCE FOR FENTANYL AND BUPRENOPRHINE PATCHES WHICH CAN CAUSE SERIOUS OVERDOSE IF NOT REMOVED PRIOR TO SCAN" 

 

Tables are best viewed in landscape mode on mobile devices

Format Dose Examples
Matrix patch 12, 25, 37.5, 50, 75,100 micrograms/hour Matrifen®, Fencino®, Mezolar®, Osmanil®, Opiodur®, Yemex®, Mylafent®, Victanyl®
Reservoir patch 25, 50, 75,100 micrograms/hour Tilofyl®, Fentalis®

It is recommended that patients should ideally stay on the same formulation and should not switch between a matrix and a reservoir patch. Consult local guidance for preferred brand.

 

  • Second line opioid for moderate to severe opioid responsive pain.
  • Pain must be stable.
  • Oral and subcutaneous routes are not suitable.
  • Patient unable to tolerate morphine/ diamorphine due to persistent side effects.
  • Compliance is poor, but supervised patch application is possible.

 

  • Fentanyl is a potent opioid analgesic; check the dose conversion carefully. 100 to 150 times more potent than oral morphine.
  • A 25micrograms/hour fentanyl patch is equivalent to about 60mg to 90mg of oral morphine in 24 hours.
  • Frail or elderly patients may need lower doses and slower titration.
  • Heat/pyrexia increases the absorption of fentanyl and can cause toxicity.  Avoid direct contact with heat (for example hot water bottle, heat pad). Showering is possible as the patches are waterproof, but patients should avoid soaking in a hot bath, sauna or sunbathing. If the patient has a persistent temperature of 39◦C, the patch dose may need reviewed - use anti-pyretic measures.
  • Liver impairment: dose reduction may be needed in severe liver disease.
  • Renal impairment: no initial dose reduction. May accumulate gradually over time. Monitor patient and reduce dose. Fentanyl is not usually removed by dialysis.
  • Do not cut patches, cutting patches makes them 'off-label'
  • Remove patches before MRI

Drug interactions

  • Hepatic metabolism is reduced by grapefruit juice and a number of medications (for example fluconazole, QTclarithromycin, QTerythromycin): check British National Formulary (BNF).
  • Alcohol and CNS depressants increase side effects.
  • Anticonvulsants may reduce its effect. Refer to BNF.
  • Manufacturers warn of a risk of serotonin toxicity when fentanyl is used in combination with other serotonergic drugs.

Side effects

  • Similar to other opioids (dizziness, sedation, delirium) but less constipation and possibly less nausea.
  • If signs of opioid toxicity (for example sedation, delirium), remove the patch and seek advice. Fentanyl will be released from the site for up to 24 hours. Monitor the patient for 24 to 48 hours.
  • Naloxone (in small titrated doses) is only needed for life-threatening respiratory depression (refer to Naloxone guideline).
  • An allergic reaction to the patch adhesive can occur – consider switching brand of patch, change opioid or consider one to two doses of a 50micrograms to 100micrograms beclometasone dipropionate inhaler on to site prior to application of patch.

 

Starting a fentanyl patch

  • Do not start in the last days of life
  • Choose a suitable patch - matrix patch allows titration in smaller increments.
  • Calculate the dose of fentanyl from the conversion chart given here or seek advice. Patch strengths can be combined to provide an appropriate dose.
  • Patches are licensed for dose initiation and titration.
  • Make sure the patient takes another regular opioid for the first 12 hours after the patch is first applied to allow the fentanyl to reach therapeutic levels (refer to Switching opioid to fentanyl patch table below).
  • An immediate release opioid (for example oral morphine or morphine SC) must be available 1 to 2 hourly, as required, for breakthrough pain or to treat any opioid withdrawal symptoms (diarrhoea, abdominal pain, nausea, sweating). These can occur during the fentanyl initiation period due to the variable time to reach steady state. The correct 4 hourly equivalent dose should be used.
  • Fentanyl is often less constipating than morphine; half dose of any laxative and titrate.

Switching opioid to fentanyl patch

Tables are best viewed in landscape mode on mobile devices

Current opioid Switching procedure
Immediate release (quick acting) morphine or oxycodone Apply patch; continue the immediate release opioid 4 hourly for the next 12 hours.
Modified release (long acting) 12 hourly morphine or oxycodone Apply patch when the last dose of a 12 hourly, modified release opioid is given.
Subcutaneous infusion of morphine, diamorphine, oxycodone or alfentanil Apply the patch and continue the infusion for the next 8 to 12 hours, then stop the infusion.

Adjusting the fentanyl patch dose

  • Review the fentanyl patch dose after 72 hours; drug levels will be at steady state.
  • If the patient shows signs of opioid toxicity (drowsiness, confusion), reduce the dose and reassess the pain. Seek advice.
  • If the patient still has pain which is opioid responsive, titrate the fentanyl dose in 12micrograms to 25 micrograms/hour increments depending on the patch strength in use. Remember to include the breakthrough doses used. It will take 12 to 24 hours for the new dose to take effect so give breakthrough analgesia at the correct dose, as required. If there is a significant increase in the number of breakthrough doses required seek specialist advice.

Fentanyl patches in the last days of life

  • Continue the fentanyl patch, changing it every 72 hours.
  • If a new, opioid responsive pain develops, use subcutaneous morphine as required for breakthrough pain. Use the conversion chart to calculate the dose of morphine. If the patient is known to be renally impaired alfentanil may be a more appropriate choice (eGFR less than 20ml/min although specialists may recommend earlier – refer to Renal disease in the last days of life).
  • After 24 hours, the breakthrough doses of morphine given in that period can be totalled and this dose of morphine administered as an SC infusion in a syringe pump over the next 24 hours in addition to the fentanyl patch.

Switching a fentanyl patch

  • If switching from a fentanyl patch to any other strong opioid by any other route, specialist palliative care advice should be sought.

 

  • All opioid dose conversions are approximate.
  • Patients should be monitored closely so that the dose can be adjusted if necessary.
  • Manufacturers of the various formulations of fentanyl have issued different recommendations for dose conversion, as have drug regulatory bodies.
  • Fentanyl is approximately 100 to 150 times more potent than oral morphine; the table below provides a guide to dose conversions, but if in doubt seek advice.

Tables are best viewed in landscape mode on mobile devices

24 hour oral morphine dose Fentanyl patch dose (micrograms per hour) Immediate release oral morphine (1) Suggested breakthrough dose (refer to guidance in dose and administration above)
30mg to 60mg 12 5mg to 10mg
60mg to 90mg 25 10mg to 15mg
90mg to 120mg 37 15mg to 20mg
120mg to 180mg 50 20mg to 30mg
180mg to 240mg 62 30mg to 40mg
240mg to 300mg 75 40mg to 50mg
300mg to 360mg 87 50mg to 60mg
360mg 100 60mg

(1) The above table is based on the use of 1/6th of the 24 hour oral morphine dose.

Converting from fentanyl given by IV infusion or via a PCA device. This conversion is not routine practice. Liaise with a specialist. If pain is stable the patient may be considered for conversion to a fentanyl patch.

Fentanyl patch care

  • Apply to intact, non-hairy skin on the upper trunk or upper arm; avoid areas treated with radiotherapy, scar tissue or oedematous areas.
  • Apply each new patch to a different skin site; clean the skin with water only as soap products can alter absorption. Make sure skin is dry. Following removal of both parts of the protective liner, the patch should be pressed firmly in place with the palm of the hand for approximately 30 seconds, making sure the contact is complete, especially around the edges.
  • Record the date, time and site if the patch is changed by different people.
  • Change the patch every 72 hours at about the same time of day.
  • Check the patch daily (or as per local guidance) to ensure it is still in place.
  • If patch adherence is poor, check local guidance for advice – micropore tape may be recommended; fentanyl is unsuitable for patients with marked sweating.
  • Used patches still contain active drug. When removed, fold the patch in half with the adhesive side inwards. Dispose of it safely (sharps bin for in-patients, domestic waste in the community). Wash your hands after patch changes.

 

  • Fentanyl patches are used for moderate to severe, stable pain.
  • Fentanyl patches are licensed to be applied whole. In clinical practice where small (less than 12 micrograms/hour) dose titrations are required for safe opioid management and to overcome short term supply issues, patches that are matrix formulation may be cut diagonally however this procedure is unlicensed and specialist advice should be sought. Reservoir patch formulations must not be cut.  Dispose of the unused part of the patch safely as described in the fentanyl patch care section.
  • Record the daily patch check and ensure this information is communicated in medicines documentation/reports if the patient transfers care setting
  • Do not change fentanyl patches to another opioid in a dying patient, continue the fentanyl patch and use an additional opioid as required via CSCI.
  • Do not initiate fentanyl patches in the last days of life.
  • Ensure patients understand the safe use, storage and disposal of the patch, and the importance of not heating the skin under the patch.

 

Ahmedzai S, Brooks D. Transdermal fentanyl versus sustained-release oral morphine in cancer pain: preference, efficacy, and quality of life. The TTS-Fentanyl Comparative Trial Group. J Pain Symptom Manage. 1997;13(5):254-61.

Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, Cherny N, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012;13(2):e58-68.

Dean M. Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004;28(5):497-504. Epub 2004/10/27.

Donner B, Zenz M, Strumpf M, Raber M. Long-term treatment of cancer pain with transdermal fentanyl. J Pain Symptom Manage. 1998;15(3):168-75.

Fine PG. Fentanyl in the treatment of cancer pain. Semin Oncol. 1997;24(5):20-7.

NICE. Palliative care for adults: strong opioids for pain relief CG140. 2016 [cited 2018 Oct 02]; Available from: https://www.nice.org.uk/guidance/cg140.

Twycross R, Wilcock A, Howard P. Palliative Care Formulary PCF6. 6th ed. England: Pharmaceutical Press; 2017.

Watson M, Lucas C, Hoy A, Wells J. Oxford Handbook of Palliative Care. 2nd ed: Oxford University Press; 2009.