Are any opioids contraindicated in opioid naive patents?
Fentanyl is absolutely contraindicated in opioid naïve patients in the outpatient setting. It can be used in a controlled environment for patients that present for ambulatory procedures, where intravenous (IV) access and intubation is available. Fentanyl is 100 times more potent than morphine and even the lowest dose transdermal patch of 12 µg/hour may result in OIRD. Fentanyl is only indicated for use in patients who are opioid tolerant and have chronic pain. There are also a number of new buccal, sublingual, transmucosal, and nasal formulations FDA approved for cancer patients inadequately managed by higher dose opioid maintenance regimens. These are highly regulated through the Transmucosal Immediate Release Fentanyl Risk Evaluation and Mitigation Strategy program. This helps avoid use of these products in those at high risk for abuse or misuse, and for patients that are not sufficiently opioid tolerant. It should also help reduce the chances of improper interchange between these transmucosal products. With respect to extended release opioids, all doses of transdermal fentanyl and hydromorphone should only be prescribed for opioid tolerant (not naïve) patients. The FDA defines someone as opioid tolerant if he or she has used 60 mg of oral morphine daily (total dose) or an equianalgesic amount of another opioid for 1 week or greater.