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• W2462633764 abstract "To the Editor: Transdermal delivery of fentanyl has become popular for the treatment of chronic pain. In 1990, the US Food and Drug Administration initially approved Alza Corporation’s Duragesic patch; since this time, numerous reports have demonstrated the potential for toxicity and abuse of such devices. These patches typically contain large amounts of fentanyl, up to 10 mg, sufficient for 3 days of use. They have been substituted for heroin, used as an agent for suicide, and surreptitiously administered by physician narcotic addicts. Opioid toxicity has been reported when patches are dissolved into ‘‘teas,’’ applied overzealously to the skin, inhaled, eaten, and even injected intravenously. Recently, we encountered an interesting case of a purposeful suicide attempt with rectal patch insertion. Although mucosal absorption by ingestion or sucking is well known, this is the first known case of opioid toxicity from rectal fentanyl patch insertion. The patient, a 41-year-old man, arrived comatose to our emergency department after inserting 3 fentanyl (100 mg/hour) patches into his rectum. He received 6 mg of naloxone without response and was subsequently intubated. Clinical examination was consistent with classic opiod overdose. The treating resident physician performed a digital rectal examination and was unable to remove the patches. Subsequently, the resident physician with the longest fingers in the emergency department was recruited and removed all 3 patches. The patient awoke approximately 1 hour later and fully recovered after a brief hospital stay. The increased absorption rate of rectal mucosa contributes to a rapid elevation in serum fentanyl levels and acute onset of coma. Elevated rectal temperature compared to ambient air at the skin’s surface may also increase the release of fentanyl, enhancing toxicity. Separating patients from suspected toxins is a main tenet in all toxic exposures. In the case of rectal fentanyl patch insertion, aggressive digital rectal examination should be done and consideration of therapeutic anoscopy or sigmoidoscopy considered, potentially obviating the need for prolonged hospital stay. Historical failure to recognize internalization of transdermal patches, either ingested or inserted, may lead to incorrect diagnosis and unnecessary highrisk treatments. With the severity of such overdoses and the potential for unintentional internalization, the need for early identification is warranted. Placement of radiopaque markers on all potentially lethal transdermal medication delivery systems should be considered by drug manufacturers. Recently, the US Food and Drug Administration approved a generic fentanyl transdermal system that will lessen the financial limitations to patient access. It is likely that patients will have greater access to transdermal pain management, and emergency departments will begin to see an increased number of accidental, abusive, or intentional toxicities. All emergency physicians should be aware of such potentially lethal overdoses and all routes of possible exposure." @default.
• W2462633764 created "2016-07-22" @default.
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• W2462633764 date "2005-01-01" @default.
• W2462633764 modified "2023-09-26" @default.
• W2462633764 title "Rectal Insertion of Fentanyl Patches: A New Route of Toxicity" @default.
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