Key Point 

• While massage therapy in this instance is safe, following the guidelines outlined in this article can reduce and/or prevent complications to the client and practitioner.

Imagine you are massaging a client for the first time—she came for a full-body massage with special focus on her low back, which she says “bugs her.” 

You have already worked with her back and the back of her legs, and the session is going well. Now, she is supine. You pick up her arm to work with her shoulder girdle and are surprised to feel an unexpected texture on the medial aspect of her upper arm. On inspection, you find she has a skin-colored square patch, about 2½ inches, midway between her axilla and the medial epicondyle of her humerus. 

You ask her what it is, and she seems a bit embarrassed: “I didn’t think you’d notice. That’s my fentanyl patch. It’s no big deal. I use it for my back pain, which is much better right now—you are a miracle worker!”

What Happens Now?

This story is fictional, but it has elements in common with many stories on my ABMP podcast “I Have a Client Who . . .”—including two podcast episodes that focus on this topic. Transdermal patches are increasingly popular, and they are being used in many new contexts. Soon, we may see them as a strategy to administer vaccines, insulin, genetic therapies, and more. 

In this article, we’ll look at the technology of transdermal delivery systems, with special focus on the use of fentanyl in this form. We have no formally researched data on the safety of massage on or around transdermal patches, so we will conclude by taking the available information and deducing from that some ideas about appropriate accommodations. 

History of Transdermal Delivery Systems

Using a skin patch to deliver medication is not a new idea. The first transdermal medication approved by the US Food and Drug Administration (FDA) came out in 1979 with a small behind-the-ear sticker that looked like a round bandage. These provided a slowly absorbed form of scopolamine, a drug that treats motion sickness. Now, people with car sickness and any other form of nausea can use these patches for up to three days at a time. It was a big breakthrough because people who had a difficult time taking pills and keeping them down had an option to control their nausea, not just for traveling, but also in the context of anesthesia and other triggers. 

Since then, patches have been developed to administer medications that manage a long list of conditions, including hypertension, chest pain, migraines, depression, Parkinson’s disease, and attention deficit hyperactivity disorder (ADHD). Other patches help manage pain, reduce nicotine cravings, provide birth control, or adjust other hormonal imbalances. 

How Do Transdermal Patches Work?

When the skin “absorbs” massage lotion, moisturizer, or other applications, the truth is that these substances are not truly being absorbed into the body. They may help hydrate the layers of the epidermis, but they don’t enter the bloodstream. This is as it should be: If substances could easily penetrate the skin to the circulatory system, many everyday activities would be dangerous. Washing dishes, pumping gas, petting your cat, or even using a dirty keyboard could transfer dangerous chemicals or pathogens into the circulatory system. Intact skin keeps us safe from inadvertent toxic exposures. 

The greatest obstacle transdermal patches must address is overcoming this barrier. The goal is to get medicine from the surface of the epithelium directly into the capillaries in the dermis. The construction of the stratum corneum, the thickest layer of the epithelium, seems specifically designed to prevent exactly this from happening—the keratinocytes are arranged like overlapping bricks, and the “mortar” between these bricks is a bilayer of water-resistant lipids. Any pathway from the surface into the capillaries in the dermis must diffuse through turning, twisting routes between the cells. This means the molecules of the substance must have a low molecular weight, they must have prolonged contact in a single area, and/or they must be administered in ways that enhance the ability of these medications to penetrate the skin and access the capillaries. 

Transdermal patches can have a variety of construction elements, depending on the substance that is being transferred. The basic design involves four main pieces:

Liner

The liner touches the skin. This layer can sometimes control how quickly a substance crosses over onto
the epithelium. 

Adhesive

It is critical that transdermal patches have complete and uninterrupted contact with the administration site. If they detach in any location, medication can leak out. This has repercussions both for the dosage and for anyone who might touch nearby skin—including the patient. 

Drug Reservoir

This is the layer where the drug is stored. It is sometimes covered by an additional membrane to help control how quickly it is absorbed.

Backing

This is the surface of the patch that we see. It is waterproof and sturdy enough that some patches are meant to stay in place for several days through normal activities like bathing and gentle exercise. 

These devices are constantly being updated and improved so the range of medications they administer can widen. Some patches depend on passive diffusion. Others may use mechanisms like ultrasound, electricity, and light that enhance the ability of the medication to penetrate the skin. 

Another line of development involves microneedles, tiny needles that painlessly penetrate the stratum corneum, delivering the medication much closer to the targeted capillaries. These are now available with several designs, and they may allow for larger molecular weights, like with vaccines or insulin, to be administered through the skin. Microneedles and other patch designs are in experimental trials, so we may see more of this kind of use among clients soon.

Why Use Transdermal Patches?

Transdermal patches have several advantages over other types of drug administration. Any orally taken drug is first filtered and metabolized by the liver, where a large percentage of the bioavailable ingredients are typically neutralized—which means a bigger dose is needed. Transdermal patches skip this “first pass” through the liver. They also allow users to avoid any irritation or damage to the gastrointestinal (GI) tract that some drugs cause. Also, if a person has limited ability to absorb drugs in the GI tract, possibly because of previous surgery, transdermal patches can accommodate for that limitation.

Transdermal patches allow for a slower, steadier application over several hours or days. This can be preferable to the big fluctuations seen with oral or injected medications. 

Patients who use patches don’t need to use needles to administer their medications. This cuts down on “sharps” waste, which can be difficult to dispose of. It also addresses substantial needle phobias that might prevent patients from getting the care they need. Further, patches can be self-administered, unlike many injectable medications. 

Problems with Transdermal Patches

All this is not to say that using transdermal patches carries no risks or disadvantages. The steps in using them are specific, and any shortcuts can lead to problems. For instance, there are cases in the medical record where patients using medicated patches didn’t wash their hands adequately afterward, and then touched their eyes, which led to substantial damage. 

The most common adverse reactions typically involve itching or redness at the application site. However, people with any kind of skin breach are at risk for more serious problems, which is why people with eczema, dermatitis, psoriasis, or other chronic skin conditions may not be good candidates. Some patches are also not recommended during pregnancy or breastfeeding.

Overdosing with skin patches is possible. Wearing more than one fentanyl patch at a time can cause an overdose. Nicotine poisoning is possible with nicotine patches. Patches for ADHD are meant to be removed after nine hours. If they are left on too long, serious side effects can develop. While hormone overdoses are probably not life-threatening, they can create serious and painful consequences. 

At this point in time, patches are more expensive than traditionally administered medications, but that appears to be shifting, and the price difference is becoming less of an issue than in earlier days of transdermal patch use.  

Returning to Our Client

The client from the beginning of this article who reported back pain didn’t disclose the use of her narcotic painkiller on her intake form. You are more than halfway through the session when you discover her fentanyl patch, with no knowledge about potential harm to your client or yourself. 

Furthermore, she says it’s “no big deal,” which isn’t a typical way to describe using a narcotic painkiller, and that is a good reason to get a lot more information about her back pain. But based on what we just covered, we can now draw some important conclusions about this situation.

Risk to the Massage Therapist 

If the patch is fully adhered and intact, the massage therapist is not at risk for exposure. However, if the patch is peeling or appears to be damaged, the client must remove it, cleanse the area, put on a new patch in another location, and then thoroughly wash their hands before proceeding with the massage. 

Risk to the Client

In addition to leaking, if a patch is damaged in some way, the drug uptake rate may be altered. Also, if the massage therapist manipulates the area where the patch is attached, especially with movements that compress the patch, this might affect the release and uptake of medication.

Further guidelines for fentanyl patches (this can also be applied to other medicated patches) may be condensed to these suggestions:

• Working with the client is safe, but stay away from the patch—probably a margin of 3–4 inches around is sufficient. Don’t press or manipulate it, so you don’t interfere with the delivery system.

• Don’t use heat-based modalities on or near patches. Users are advised to avoid heating pads, heat lamps, saunas, and exercising to the point of sweatiness. It’s safe to assume this would also apply to hot stones, thermophores, or other heat sources.

• Take care of disposing used patches if that becomes an issue. Even a 72-hour dose doesn’t extract all the drug from a fentanyl patch. All medicated patches should be folded, sticky sides together, and put where no one else—especially children or pets—can access them. 

• Specifically for fentanyl patches: Understand that this client is using a narcotic analgesic, so their situation is likely complex. Their ability to interpret pain may be impaired, and they may be easy to overtreat. 

• Add a place on your intake form for information about medications applied to the skin so the likelihood of a repeat experience like this is diminished.

Be Cautious

Transdermal patches may become increasingly common in the near future. If this happens, it would be helpful to know what happens to uptake and patient risks when they are externally manipulated, as with massage. Until then, we must act with more conservatism than might be strictly necessary to preserve our clients’ well-being.  

Resources

Cai, B., H. Engqvist, and S. Bredenberg. “Development and Evaluation of a Tampering Resistant Transdermal Fentanyl Patch.” International Journal of Pharmaceutics 488, nos. 1–2 (July 2015): 102–7. https://doi.org/10.1016/j.ijpharm.2015.04.061.

Centers for Disease Control and Prevention. “Fentanyl Facts.” Last modified April 4, 2024. www.cdc.gov/stop-overdose/caring/fentanyl-facts.html?CDC_AAref_Val=https://www.cdc.gov/stopoverdose/fentanyl/index.html. 

Drug Policy Alliance. “Overdose Deaths.” Accessed April 2024. https://drugpolicy.org/overdose.

He, J. et al. “Wearable Patches for Transdermal Drug Delivery.” Acta Pharmaceutica Sinica B 13, no. 6 (June 2023): 2298–309. https://doi.org/10.1016/j.apsb.2023.05.009.

Injury Facts. “Drug Overdoses.” Accessed April 2024. https://injuryfacts.nsc.org/home-and-community/safety-topics/drugoverdoses/data-details.

Khan, S., and T. Sharman. Transdermal Medications. Treasure Island, Florida: StatPearls Publishing, January 2024. www.ncbi.nlm.nih.gov/books/NBK556035. 

Kim, T. S. et al. “Comparison of Adhesion and Dissolution of Fentanyl Patches: Fentadur and Durogesic DTrans.” Journal of Pharmaceutical Investigation 45, no. 5 (May 2015): 475–80. https://doi.org/10.1007/s40005-015-0195-y.

Mahato, R. “Chapter 13—Microneedles in Drug Delivery.” Emerging Nanotechnologies for Diagnostics, Drug Delivery and Medical Devices. Boston: Elsevier, 2017. https://doi.org/10.1016/B978-0-323-42978-8.00013-9.

Mann, B., A. Pattani, and M. Bebinger. NPR. “In 2023 Fentanyl Overdoses Ravaged the US and Fueled a New Culture War Fight.” December 28, 2023. www.npr.org/2023/12/28/1220881380/overdose-fentanyl-drugs-addiction. 

MedlinePlus. “Buprenorphine Transdermal Patch.” Accessed April 2024. https://medlineplus.gov/druginfo/meds/a613042.html.

Poison Control: National Capital Poison Center. “Using Skin Patch Medicines Safely.” Accessed April 2024. www.poison.org/articles/using-skin-patch-medicines-safely. 

Prausnitz, M. R. and R. Langer. “Transdermal Drug Delivery.” Nature Biotechnology 26, no. 11 (November 2008): 1261–8. https://doi.org/10.1038/nbt.1504.

Shearn, I. T. NJ Spotlight News. “Fentanyl Myth: Police Cry Overdose, Facts Prove Otherwise.” May 9, 2023. www.njspotlightnews.org/special-report/fentanyl-myth-police-cry-overdose-facts-prove-otherwise. 

US Food and Drug Administration. “Accidental Exposures to Fentanyl Patches Continue to Be Deadly to Children.” Last modified May 18, 2023. www.fda.gov/consumers/consumer-updates/accidental-exposures-fentanyl-patches-continue-be-deadly-children.

Washington State Department of Health. “Fentanyl Exposure in Public Places.” Accessed April 2024. https://doh.wa.gov/community-and-environment/opioids/fentanyl-exposure-public-places. 

WebMD. “Duragesic Patch, Transdermal 72 Hours—Uses, Side Effects, and More.” Accessed April 2024. www.webmd.com/drugs/2/drug-14008/duragesic-transdermal/details.

Werner, R. “Fentanyl Patches.” January 7, 2022. In The ABMP Podcast, “I Have a Client Who . . .” Pathology Conversations with Ruth Werner, episode 186. www.abmp.com/podcasts/ep-186-fentanyl-patches-i-have-client-who-pathology-conversations-ruth-werner.

Wong, W. F. et al. “Recent Advancement of Medical Patch for Transdermal Drug Delivery.” Medicina 59, no. 4 (April 2023): 778. https://doi.org/10.3390/medicina59040778.

Yu, Y.-Q. et al. “Enhancing Permeation of Drug Molecules Across the Skin via Delivery in Nanocarriers: Novel Strategies for Effective Transdermal Applications.” Frontiers in Bioengineering and Biotechnology 9 (2021): 646554. https://doi.org/10.3389/fbioe.2021.646554.

This column addresses the use of medicated patches that contain fentanyl. If you or someone you care for is experiencing substance abuse, help is available. US Substance Abuse and Mental Health Services Administration (SAMHSA): 800-662-HELP.