In this episode I’ll discuss how to taper patients off a fentanyl infusion:
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If a patient has been on a continuous fentanyl infusion for 7 or more days, they are likely to have physical signs of opioid withdrawal if the infusion is suddenly stopped.
This is a fairly regular problem due to opioid-first sedation strategies such as those recommended in the SCCM sedation guidelines, or those popularized by Vanderbilt University Medical Center at icudelirium.org.
Not every patient who has been on a fentanyl infusion for > 7 days will experience withdrawal. Many patients may tolerate a decrease in opioid dose as high as 75% and will not experience withdrawal symptoms.
High quality data for deciding how to taper fentanyl infusions is lacking.
Resources
Some of the resources that I use to shape my practice in this area are:
Pharmacist’s Letter Chart: Medications That Need Tapering
Fentanyl patch Prescribing Information
Chapter 5 from Demystifying opioid conversion calculations – soon to be updated in May 2016
3 Strategies
I’ve used 3 strategies to solve this problem; one that works fast and two that take a bit more time to work.
Faster strategy
Occasionally I’ll encounter a patient who has been on fentanyl >7 days, is ready to transfer to a lower level of care, but has not been weaned off their fentanyl infusion yet.
Such a scenario might occur after a patient on long-term mechanical ventilation undergoes tracheostomy and their sedation needs suddenly change.
For these patients I like to get their fentanyl infusion tapered off as rapidly as possible so as to not delay the transfer.
In this case I’ll usually use methadone 10 mg enterally (or 5 mg IV) every 6 hours. The fentanyl infusion can usually be rapidly tapered off after 1 or 2 doses of methadone have been given.
I like to have a prn fentanyl bolus available for the nurse to administer if the patient begins to experience withdrawal. If the patient was previously on 100 mcg / hr of fentanyl, I’ll make the prn bolus 50 mcg of fentanyl IV.
The methadone can then be tapered off over a period of a few days as the patient tolerates it.
Slower strategies
If I have enteral access for medications and there is no time-pressure to discontinue the opioid infusion, I’ll use enteral oxycodone. I usually give a scheduled dose and a prn dose of oxycodone in case withdrawal symptoms develop.
There are many resources available for calculating equivalent opioid doses to arrive at a conversion from fentanyl infusion to oral oxycodone.
I’ve found patient response to be extremely variable. I think calculating the equivalent dose is much less important than having a good monitoring plan.
Recently I used this oral oxycodone strategy in 2 very similar patients who had been on long term fentanyl infusions of 100-150 mcg/hr.
The first patient got 10 mg of oxycodone q6 hrs scheduled and 10 mg q6 hrs prn. This patient developed withdrawal symptoms but they were not recognized and a prn oxycodone dose was never given.
The second patient got 20 mg of oxycodone q6 hrs scheduled and seemed over-sedated, so we reduced the dose to 10 mg q4 hrs.
I can spend all day calculating equivalent doses but I think it is much better to just pick something reasonable and monitor the patient’s response.
If enteral opioids cannot be used and there is no rush to get the patient off a fentanyl infusion, I’ll just taper the infusion as quickly as the patient will tolerate.
Often a large initial decrease in infusion rate can be made such as 50%. After that, the drip can be tapered in 25 mcg/hr increments at intervals that are at least several hours apart. If at any time the patient develops symptoms of withdrawal, return to the previous rate and consider giving an IV bolus of fentanyl.
One strategy I don’t use
One option that I don’t like to use is switching patients over to a fentanyl patch. While this makes the conversion relatively easy, patches tend to be left on longer than needed. They also can’t be titrated as quickly, and make over-sedation more complicated to deal with due to a “depot effect”.
I’d love to know what fentanyl weaning strategy works best for you – leave a comment below or contact me here.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Joe,
One thing that you mention that always puzzles me when I’m attempting to wean patients off a fentanyl drip is how big of a disparity there is between the fentanyl infusion dose and the dose of oxycodone that seems to keep the patient comfortable.
The conversion calculation for a continuous fentanyl drip at 100mcg/hr is needless to say, much much more than 10-20mg of oxycodone q6 hrs. Yet this dose (or similar doses) seem to have a much greater impact on the patient compared to what I’d expect.
You mention it above but I was curious if you had any additional thoughts on why this might be. Thanks so much!
Interesting that we have both arrived at the same conclusion!
I think a significant part of the reason is that the larger fentanyl dose is used for sedation + analgesia whereas a conversion to enteral oxycodone usually means that only analgesia is being provided.
Perhaps tachyphylaxis and incomplete cross-tolerance also play a role.