The use of fentanyl and alfentanil sprays for episodic pain

The recent paper by Zeppetella encouraged our palliative care team to consider the use of fentanyl via alternative routes. We have used fentanyl via the buccal, sublingual, and nasal routes using a nasal spray bottle supplied by Go Medical Industries. Any patient needing more than a single spray exceeded the maximum tolerated volume for nasal preparations (0.16 ml) with the prepared fentanyl concentration (7 mg per spray, 50 mg/ml). We, therefore, allowed patients to use the buccal and sublingual routes to allow for greater volumes to be administered. Our pharmacy manufacturing department now provides us with alfentanil in the same type of spray bottle. Although alfentanil has one-fourth the potency of fentanyl, it can be formulated in a more concentrated solution, so that the patient uses fewer sprays per dose. We use a concentration of 500 mg/ml, with the device supplying a dose of 70 mg per spray. Alfentanil has a faster onset and one-third the duration of action of fentanyl. A recent chart review has shown that we have treated 15 patients with fentanyl spray and 10 patients with alfentanil spray. In all but three cases, the pain was an incident bone or nerve pain secondary to a malignancy. The three patients, with a nonmalignant diagnosis, have again used the spray for incident pain, due to stroke, vasculitis, and osteoarthritis, respectively. Pain has been relieved without hangover side effects. The duration of use of the preparations varied between one day and 13 months (median=three months). The number of sprays per dose varied between 2 and 10 and was not related to the dose of regular analgesia. The spray was tolerated well in all but one patient, who described nasal stinging after fentanyl, which settled after several days. Poor manual dexterity has been a reason for a patient stopping the fentanyl spray in one patient, poor sight in another, and confusion in another. Four patients were transferred to fentanyl OTFC lozenges because of dexterity problems or inadequate dosage using fentanyl via the nasal route. Three patients have used both spray preparations with no preference for either. Fentanyl is well absorbed sublingually but we have found that patients prefer using fentanyl and alfentanil spray buccally. Our experience is that fentanyl and alfentanil sprays provide rapid, simple, controllable pain relief for patients with episodic pain. Work on the use of opioids via different routes continues and may help us to find a completely patient-friendly administration model for episodic pain.