Background:  For opioid tolerant patients with persistent pain from a serious illness like advanced cancer, fentanyl transdermal patches are an appropriate analgesic option. In fact, they are a preferred long-acting opioid option for patients with dysphagia, an obstructing tumor in the upper gastrointestinal tract, intolerance to other opioids, or renal failure (1,2). Concerns regarding fentanyl patches, particularly public health concerns with fentanyl overdoses, compel many patients to feel trepidation regarding their prescribed use for pain. Furthermore, practical concerns regarding transdermal fentanyl (i.e. bathing with the patch, effectiveness in cachexia) arise frequently in clinical care (3). This Fast Fact offers guidance on commonly expressed concerns regarding the fentanyl patch. See Fast Fact #2 for more on dosing.   

Public health concerns with fentanyl: Fentanyl’s potency is much higher than most opioids (4). Because of this, mixing of illicit fentanyl with other illicit substances is dangerous (4,5). In a medical setting, the dosing is highly regulated and calibrated in the transdermal patches (6-8). While many patients and families may agree intellectually that the prescribed use of transdermal fentanyl is appropriate, emotionally they may fear the medication because illicit fentanyl use is a leading cause of opioid-related deaths in the US (9). Furthermore, fentanyl-related deaths occur disproportionately in certain populations (e.g., males, urban areas, individuals with lower education, black Americans), which may contribute to distrust of the medication (9). A public campaign promoting a “Fentanyl Free America” with a call to action to disrupt fentanyl’s supply chain adds more public concerns about its safety (10). 

Responding to patients and families about public health concerns: 

• Be curious and explore their emotional responses towards fentanyl. Many families have had personal experiences with opioid use disorder and overdose. Strong feelings towards a medication with negative connotations are common with some even feeling like they are betraying their recovery or their loved ones by taking prescribed fentanyl for their pain control. Create safety for patients to explore these feelings because they may not do so spontaneously. If the feelings are not acknowledged proactively, future adherence will likely be affected.  To start the conversation, inquire about what they have heard about fentanyl and what concerns they may have. Validate their concerns and if appropriate, refer to mental health professionals if necessary.
• After validating their concerns, offer clinical reasoning on why you recommend it for them and distinguish the supervised/prescribed/indicated use of fentanyl from the dangers of illicit use.
• Make sure they know how important their safety is to you. Provide standard safe opioid counseling such as keeping the medication in a secure place (e.g., locked box), best handling practices (see below), disposing unused patches, and normalizing the co-prescription of intranasal naloxone in case of an accidental overdose of a patient or bystander (see Fast Fact #328). Note, the half-life of naloxone is quite short compared to the patch, so if naloxone is given, notify emergency medical services (or the hospice team if appropriate) immediately even if the person temporarily recovers. Collaborate with clinical pharmacists and nursing to help with this patient education and counseling.
• Ultimately, respect patient autonomy and offer alternative analgesic options if they decline.  

Other counseling for patients and families regarding fentanyl patches:   

• MRI machines:  while many fentanyl patch manufacturers do not require removal for MRI testing, patients may be asked to remove their patch if it will be in the radiofrequency field due to the risk of burns (11). If this is recommended, discard the old patch and apply a new one to a different skin site following the MRI study. Since the half-life of the fentanyl patch is 13-25 hours, patients should be reassured that they will continue to have adequate pain relief during the procedure (12).
• Disposal: consult your institutional/county/state policies and restrictions. Many police stations have take-back policies and will help dispose of them. If not, used patches should be folded in half and flushed down the toilet. This is often preferred to keeping unused fentanyl patches in the house.
• Safe handling: Bystanders should wear gloves if touching the patch, then wash their hands. If it falls off prior to the scheduled next dose, dispose of it and place a new one (13,14). Patches should not be cut or torn (13,14). Avoid direct external heat (i.e. sauna use, heating pad) to the patch as blood circulation can increase systemic intake and raise the risk of overdose (15,16).  Patients can bathe, shower, and swim while wearing a fentanyl patch (14). Avoid skin areas that are oily, burned, or irritated. Wipe away residue from soaps, lotions, etc., before applying patch.
• Patients prone to excessive sweating: patch placement on the inner upper arm or thigh may help, as may fixing it with a nonocclusive film dressing (13,17).
• Site reactions: mild pruritus, swelling, or erythema is common. Instruct patients to tell the clinician about it so they can evaluate and ensure it is not an allergic reaction. Typically, the site reactions are manageable by rotating sites, cleaning the area with water, and/or applying hydrocortisone (17).
• Cachexia – subcutaneous fat provides a reservoir for the medication to be slowly released. Thus, response to fentanyl patches may be less reliable in patients with cachexia (18,19). Still, imminently dying patients often cannot tolerate oral medications, making transdermal routes a viable option to for long-acting opioids at the end of life. Bottom line – monitor patients and dosing carefully. 

References:  

1. Breitbart W, Chandler S, Eagel B, et al. An alternative algorithm for dosing transdermal fentanyl for cancer-related pain. Oncology (Williston Park). 2000 May;14(5):695-705; discussion 705, 709-17. PMID: 10853461. 
2. Fu Q, Han N, Li N, et al. Cancer Rehabilitation and Palliative Treatment Professional Committee of Hubei Anti Cancer Association. Guidelines for Rational Clinical Use of Fentanyl Transdermal Patch. Drug Des Devel Ther. 2024 Feb 1;18:233-255. 
3. Mellar Davis, Fentanyl Pharmacokinetic Paradoxical in Cancer Cachexia, Journal of Pain and Symptom Management, Volume 68, Issue 1, 2024, Page e78, ISSN 0885-3924.
4. Facts about fentanyl. DEA. (n.d.-a). Accessed February 13, 2026.
5. Rose ME. Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts. Pain Med. 2018 Apr 1;19(4):793-807. doi: 10.1093/pm/pnx048. PMID: 28402482; PMCID: PMC6018937. 
6. Lowry MF, Childers J. Fast Facts and Concepts #484: Opioid Diversion Risk and Management in Palliative Care. J Palliat Med. 2024 Aug;27(8):1090-1092. doi: 10.1089/jpm.2024.0196. Epub 2024 Jun 25. PMID: 38916071.
7. Manetti F, David MC, Gariglio S, et al. Atypical Fentanyl Transdermal Patch Consumption and Fatalities: Case Report and Literature Review. Toxics. 2022 Dec 31;11(1):46. doi: 10.3390/toxics11010046. PMID: 36668772; PMCID: PMC9863810.
8. Kuczyńska K, Grzonkowski P, Kacprzak Ł, et al. Abuse of fentanyl: An emerging problem to face. Forensic Sci Int. 2018 Aug;289:207-214. doi: 10.1016/j.forsciint.2018.05.042. Epub 2018 Jun 2. PMID: 29902699.
9. Centers for Disease Control and Prevention. State Unintentional Drug Overdose Reporting System (SUDORS). Final Data. Atlanta, GA: US Department of Health and Human Services, CDC; [INSERT YEAR, MONTH, DAY]. Access February 13, 2026.
10. Fentanyl Free America. (2025). DEA. Accessed March 31, 2026.
11. University of Connecticut Pharmacy: MRI and patch removal characteristics of common transdermal patches. (n.d.).  Accessed February 13, 2026.
12. Grond S, Radbruch L, Lehmann KA. Clinical pharmacokinetics of transdermal opioids: focus on transdermal fentanyl. Clin Pharmacokinet. 2000 Jan;38(1):59-89. doi: 10.2165/00003088-200038010-00004. PMID: 10668859.
13. Fentanyl Transdermal System. Prescribing information. Mylan, 2025. Accessed February 13, 2026.
14. Fentanyl Transdermal System. Package Insert. Apotex, 2023. 
15. Kriikku P, Ojanperä I, Lunetta P. Death in Sauna Associated With a Transdermal Fentanyl Patch. Am J Forensic Med Pathol. 2020 Dec;41(4):313-314.
16. Ashburn MA, Ogden LL, Zhang J, Love G, Basta SV. The pharmacokinetics of transdermal fentanyl delivered with and without controlled heat. J Pain. 2003;4(6):291-297.
17. Fu Q, Han N, Gui L, et al.  Guidelines for rational clinical use of fentanyl transdermal patch. Drug Des Devel Ther 2024; 18:233-255.
18. Heiskanen T, Matzke S, Haakana S, et al.  Transdermal fentanyl in cachectic cancer patients. Pain 2009; 144(1-2):218-22.
19. Carlini A, Scarpi E, Bettini C, et al. Transdermal fentanyl in patients with cachexia – a scoping review. Cancers 2024; 16(17):3094.

Conflicts of Interest: None to report.
Version History: Originally published in May 2026.
Author Affiliations: 1Mayo Clinic, Jacksonville, FL; 2Medical College of Wisconsin, Milwaukee, WI.
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