Ep 430 - Fentanyl Patches – Another Look: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

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0:02:37.1 Ruth Werner: Hi, and welcome to "I Have a Client Who... " Pathology Conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes as we have all learned, that is harder than it looks.

0:03:24.4 RW: Today, we have a story that I must confess, I have to reconstruct from memory. I had a bit of back and forth with the contributor, but oh, I can't find it anywhere. I checked my mail and my Facebook messages and my file where I store potential episode ideas, it has vanished. But it was a really great story with lots of useful sort of nuances in it, so I will try to reconstruct it here. The topic, which is a client who has a Fentanyl patch is not new to "I Have a Client Who... ". I did an episode on this in early 2022, but given what's going on in the world of Fentanyl overdoses and accompanying scary facts and scarier myths, I felt this was a good time to bring it up again.

0:04:12.4 RW: A brief recap of what I remember of this conversation goes something like this. Contributor: "I Have a Client Who... " uses Fentanyl patches for pain management, he wants to receive massage. I'm worried about exposure and my own safety. Ruth: Okay, do you know why he's using the patches? Contributor: It has something to do with a back injury. He's been using them for a long time. Ruth: Ah, got it. Well, here's a quick answer. Stay away from the patches by a few inches in every direction, so you don't change the drug uptake. You won't have any ill effects by working with him elsewhere. Contributor: Okay, thanks. There was more to it, of course, but this is what I can pull out of the memory hole. I like the story because it opens up a conversation about medication patches in general and Fentanyl in particular, and frankly, I got so interested in this topic that I'm now working on a full massage and bodywork article about it, so you are getting something of a preview about this today.

0:05:16.4 RW: First, let's talk about transdermal medication patches. The first transdermal patch that made it to the American market carried a drug called Scopolamine, which is used for motion sickness, and that came out in 1979. This was a big deal, because if a person has motion sickness or nausea, it's hard to take and keep down a pill. One big advantage of administering this drug through the skin is that it can bypass the GI tract so the stomach doesn't get upset and the liver doesn't have to remove a large portion of the active ingredients before it gets into the bloodstream.

0:05:55.2 RW: Well, nowadays, we have lots of different types and applications of transdermal patches. The biggest obstacle in how they work is the construction of the stratum corneum, the thickest layer of the epidermis. Here's a quote from a lovely research paper that describes this challenge. They say, "Closer examination of the stratum corneum barrier reveals a brick and mortar structure, where the bricks represent non-living corneocyte cells, composed primarily of cross-linked keratin, and the intercellular mortar is a mixture of lipids organized largely in bilayer. Drug transported across the stratum corneum typically involves diffusion through the intercellular lipids via a path that winds tortuously around the corneocytes where hydrophilic molecules travel through the lipid regions and lipophilic molecules travel through the lipid trails.

0:06:52.9 RW: Okay, does that help? In short, I just wanna explain that it's really hard to get through the stratum corneum, which is as it should be. And depending on the type of patch, this strategy only works with drugs that have very small molecules and that work best if they are administered in small doses over long periods. Now, more modern patches have more versatility about this, a fascinating development that I will discuss in my article but not in this podcast. Just be aware that in the future, we might not need needles to administer medicines, even the large molecule or fast-acting meds like, oh, say insulin, and that's pretty cool. Transdermal patches have various construction elements, but the basic pieces are these, there's a surface liner that touches the skin, and this layer is sometimes used to regulate the speed with which the medicine crosses over into the skin. There's a drug reservoir, which is covered by a non-permeable backing, and then special adhesives are used to make sure there's a good seal all the way around the patch.

0:08:07.1 RW: So the medication stays where it is meant to stay, and that's just a short tutorial on transdermal patches, certainly enough for talking about their use and Fentanyl. You are probably aware that Fentanyl is a synthetic opioid, it's used medically for pain management. Big doses for breakthrough pain, smaller doses for chronic pain that can't be managed in any other way. And this way, Fentanyl also ticks all the boxes for being a good candidate for transdermal patches. Its molecules are very small, it works well for pain management over prolonged periods. The typical application of the Fentanyl patch is 72 hours. As an opioid Fentanyl is potentially addictive, and it turns out to be really cheap to manufacture and it's more potent than heroin. 50 times, more potent. And all of these factors together, plus some other issues that have to do with the unavailability of heroin, cracking down on opioid prescriptions even for people who might actually need them, and some other drug policies, all of this has contributed to making Fentanyl a very popular and incredibly dangerous street drug.

0:09:24.1 RW: And this situation is getting worse rather than better. Fentanyl is cheap. So now it is often mixed with other street drugs to stretch them, and buyers are not always aware of this. Consequently, in 2010, there were 38,000 deaths from Fentanyl overdoses, and in 2023, there were 108,000 deaths from Fentanyl overdoses. That said, there are some weird and misleading myths about Fentanyl exposure and overdose risk. Contrary to what is sometimes reported, it is not possible to overdose on Fentanyl by touching it in any form, unless that contact goes over many hours. Like for instance, if a person wears multiple patches at a time. Don't do that.

0:10:19.1 RW: But if you happen to be with someone who uses a patch, or if you happen to be with someone who ingests Fentanyl in another way, like smoking it or snorting it or injecting it, frankly, there is no big risk from that kind of secondary exposure. Get away from it, for sure. But you won't overdose on Fentanyl by being in the same room with it. So where does all this leave our contributor? I looked and looked and looked for any data about any kind of transdermal patches and massage, but wasn't surprised to find nothing, but I did learn a few things that are relevant.

0:11:00.4 RW: Our contributor wants to know if they are at risk if their client uses a Fentanyl patch, and the simple answer is no, if the adhesive on the patch is secure. If it's not, if any edge of the patch is detached or curling up, then the path needs to be removed, the area of the skin needs to be washed and a new patch needs to be applied in a different location, and that is a job for the client, not the massage therapist. Also, if for some reason the client needs to take off a Fentanyl patch in a massage therapy setting, then the patch should be folded, sticky sides together and disposed of in a way that no one, especially children will be able to access it.

0:11:45.6 RW: Not all of the drug is transferred out over 72 hours, so Fentanyl remains within the reservoir of used patches. Some resources recommend flushing used passes down the toilet. I'm not thrilled at the idea of what that might do to the water supply. Lastly, while we don't have information specifically on massage and transdermal patches and what effect that might have, we do have information on heat. Heat makes capillaries more permeable, that is more capable of accepting more drug. People with Fentanyl patches can bathe and shower normally, but they are advised against hot pads, saunas, hot tubs and exercising to the point where they get sweaty because all of these activities increase drug uptake.

0:12:33.4 RW: It's not a leap then to consider that the capillary dilation that happens with a massage plus manipulation of the area where the patch is located could also be a potent combination to alter the rate of uptake. So to our contributor and any massage therapist who has clients who uses medicated patches, I have a few messages. Number one, go ahead and work with this client, but stay away from the patch, usually a margin of three or four inches around is sufficient depending on where it's located. You just don't want to manipulate it. Not so much because you might be inadvertently dosed, but because you don't wanna interfere with this delivery system. Number two, don't use heat-based modalities on or near patches. Number three, don't worry about exposure if all the adhesive on a patch is intact and if it's not, bring it to the client's attention.

0:13:30.3 RW: And as we mentioned before, just stay away from that area. Number four, take care about disposing used patches if that becomes an issue. And number five, understand that this client is using high level pain medication and nothing else worked, so their situation is likely to be complex. Make sure you understand their goals for massage, which might or might not have anything to do with their medication use, and with that, understand the variables that must inform your clinical decisions. If this topic of transdermal delivery systems interests you, watch for my upcoming article in Massage and Bodywork for more information. It's an amazing technology that may change a lot about how we use medicines, and some of this has implications for our work.

0:14:29.4 RW: Hello, "I Have a Client Who... " listeners Ruth Werner here, and I'm so excited to let you know that my library of online self-paced continuing education courses has just expanded. I now have a two-hour ethics course called "A Doctor's Note is Not Good Enough... And what is better" This NCBTMB approved course goes into why a doctors permission, or approval, or even a prescription doesn't provide the legal or safety protection you might think it does. Then we look at how to start useful conversations with healthcare providers that will actually get us to safe and effective massage for our clients with complex conditions. Visit my website at ruthwerner.com for more information and to register for "A Doctor's Note is Not Good Enough... And what is better".