Opioids 400mcg Fentanyl Oral / Actiq lollipop - most effective way to get best results?

[neudr]

Hi. I came across this site after spending several hours googling for help with a problem. I am prescribed Fentanyl Oral 400mcg (Actiq and/or Oral Transmucosal Fentanyl Citrate). It is a “generic” but it is made by Cephalon (they also made the patented version).

I have had very irregular results with these for breakthrough pain episodes and my doctor will not prescribe Fentanyl vials for IV/IM/Sc injection. Sometimes Fentanyl Oral will work very well, and sometimes I will need two (or three). My insurance will not pay for the medicine and it is getting to cost a lot of money. I can afford $25 a lollipop, which is what it costs me if I only use one per breakthrough pain, but I cannot afford $50 or $75 per breakthrough pain episode (a result of using two units of Fentanyl Oral).

I was hoping someone with experience could tell me how to get the best response from this medication? I have followed the package insert (and even called Cephalon asking for clarification and telling them how my response to Fentanyl Oral is inconsistent) and the only instructions are “put on one side of your mouth, twirl often, while sucking. Paint a picture along your gums.” There must be a better way.

Is it better to put it under your tongue (a lot of threads suggest this-- why doesn't the manufacturer?!?)? Some of the threads I have found from searching say that you shouldn’t suck on it, but rather just leave in your mouth for 15-30 minutes (the package insert says it shouldn’t be used for longer than 15 minutes)? Should I refrain from sucking and just let it dissolve?

I am aware of the poor bioavailability due to first pass metabolism, but I should still be getting between 100-200mcg of Fentanyl (depending on how much I swallow) from a 400mcg Actiq unit. If I am given Fentanyl 100mcg IV (sometimes repeated once), I am pain free. But with 400mcg of Oral Fentanyl, I usually have to take another lollipop 15 minutes later to get relief. This is why I am so confused-- I must not be using it properly.

So, I ask, what is the best way to maximize one 400mcg lollipop? I appreciate your help!

Thank you.

 

[Tommyboy]

I am not surprised that your doctor is not prescribing ampules of fentanyl for IV/IM administration. I have never heard of pain medication being prescribed for the ROA.

You should just let it dissolve in your mouth, and not suck on and swallow in. The buccal BA is ~ %50, whereas oral ingestion is ~ %33.

"Normally 25% of the drug is absorbed via the buccal mucosa directly into the bloodstream while the remaining 75% is swallowed and then slowly absorbed in the gastrointestinal tract. Two-thirds of the swallowed Actiq (or 50% of the total dose) is metabolized by the liver and becomes unavailable for any pain relief function, leaving only around 33% of the ingested fentanyl available for pain relief. This is why the drug is far less potent if consumed orally compared to transmucosally." source

You can always try putting it in different areas of your mouth to see which way you get the best pain relief (e.g, under tongue, side of bottom cheek, top cheek).

Make sure that you brush your teeth a few extra times now that you are using the lolli pop. I have heard that people experience dental problems from it (I think there may be sugar in it which can cause cavities).

 

[Executor]

Make sure that you brush your teeth a few extra times now that you are using the lolli pop. I have heard that people experience dental problems from it (I think there may be sugar in it which can cause cavities).

Yes, there is sugar in the pops...Lots of it. In fact, there are many documented cases on line where patients have had significant dental damage. There are many lawsuits because of this...Mainly because Cephalon developed a sugar free version but declined to bring it to market.

I cannot afford the brand or generic anymore, so I use a compounded version. Much cheaper and sugar free. A double bonus.

Because the mode of action is buccal mucosa, it doesn't really matter "where" in your mouth you put the pop. The main issue is the speed at which you suck on it. The faster you suck, the more med you will get at once and the higher your BPL, or blood plasma levels will be. Conversely, if you suck on it slowly, or just let it sit in your mouth, absorption will be much slower. Just be careful not to swallow too much as much of the med is lost this way. The literature says sucking for 15 minutes is optimal.

It may be that some of your pain episodes just aren't responsive to the fentanyl at times. This is very normal. Not every med works great every time.

Best of luck to you.

Ex

 

[BrokedownPalace]

I have never personally used fentanyl lollipops. But would it be possible to crush it into a powder, and then administer the crushed lollipop sublingually/buccaly? This way you'll get it all to dissolve and absorb much faster, which may help your breakthru pain better. I may be totally off, since I have never used fent lollipops, but using the patches buccally has always been the best ROA for me, personally.

 

[neudr]

Thanks for the replies thus far.

So, one person recommends letting it sit in your mouth not sucking on it and just letting it absorb (how long does that take), another says that will cause the absorption to take too long and not be as effective as sucking on it. What is correct? Do both methods work? As you say, the bioavailability is 50% buccal and 33% oral, so it seems just letting it sit in your mouth and dissolve would give you more medicine (but it would take longer to get in your system, so perhaps that is why the manufacturer doesn't recommend it. e.g., if you get 200mcg of Fentanyl over 1 hour from buccal ROA, it may be better to get 150mcg in 15 minutes from oral ROA?)


Executor- Do you suck while against your cheek? How often do you twirl the lollipop? And when salvia builds up in your mouth, do you swallow it immediately or let it absorb over time? Do you have any tips for finishing it quickly and absorbing as much of the Fentanyl as possible buccal rather than swallowing it? Are you constantly sucking on the lollipop against your cheek, or do you take breaks?


When I have sucked on the lollipop at very fast rates, I build up a lot of saliva in my mouth. Is this normal? Should I swallow it or let it sit in my mouth and absorb that way? I usually have trouble finishing it in 15 minutes, even when sucking on it all the time...


Also, how did you go about getting someone to compound the medicine for you? I go to a compounding pharmacy but I never asked them about this. How much do you pay (and what strength)? I thought getting the generic would be cheaper than going to a compounding pharmacy but I guess I am wrong! I would love to get a sugar free version and it would be much better if I could pay less for the medicine.


I did call Cephalon regarding the sugar/cavity problem and they told me there is only 2 grams of sugar in the lollipop. That's not a lot. I do brush twice a day with a Sonicare toothbrush (and if I use an Actiq lollipop, I'll brush as soon as I am comfortable after administration).

I appreciate your help! Thank you so very much.

 

[sekio]

Fiorst and foremost, no price or drug availiability discusiion.

I think the issue with the lollipops is if you're using them for long term chronic care then you can end up putting a lot of sugar directly agfainst your teeth for a long time. This is what causes dental damage (prolonged exposure to sugar), not the amount.

As for absorbtion rate, buccal is undoubtedly faster than oral. For fastest results I suggest crushing the lollipop and holding it against your gums and cheek. Swirl the "juice" around in your mouth as much as you can. It will be strongest if you use the lolly all at once without swallowing your saliva.

 

[SafeTrouble]

The sugar is PART of what causes the dental damage.
Fentanyl also gives you dry mouth so that's part of why the teeth get damaged so quickly.

 

[MartinFn]

If 400mcg/h doesn't stop the pain (i mean if your tolerance is high), search the cyp3a4 inhibitors..


MartinFn

 

[Executor]

I think the issue with the lollipops is if you're using them for long term chronic care then you can end up putting a lot of sugar directly agfainst your teeth for a long time. This is what causes dental damage (prolonged exposure to sugar), not the amount.

That's exactly right. It's the direct exposure of the sugar against the gum line where you have no enamel, is the issue...Not the amount of sugar. Once the sugar penetrates the gum line, you're in big trouble. Best thing to do is rotate it around a bunch and not leave it in one spot and then rinse with a fluoride rinse immediately afterwards.

Also, the pop, whether it be in solid form, or altered, will not effect the amt of med you absorb. Buccal mucosa is buccal mucosa, regardless of how it's done. The fentanyl is evenly distributed throughout the pop, so you get a constant amount. The manufacturer recommends rotating it around in a circular pattern, lasting no longer than 15 minutes for maximum BT action.

A new fentanyl product is out that is a patch (Onsolis) that you place against your gum. Same issue, just a different mode of transmission. No increase in efficiency or potency.

However, Fentora, tends to be the most potent because it comes in a tablet that causes fizzing and the effervescent effect is very efficient. The fentanyl crosses the dermal boundary starting within 5 minutes and is very potent. This why cephelon recommends a much lower dosage for those patients transitioning from Actiq to Fentora.

A new fentanyl nasal spray, Lazanda, was just approved by the FDA. It has the potential to rival Fentora in terms of potency and speed of action.

Ex

 

[neudr]

That's exactly right. It's the direct exposure of the sugar against the gum line where you have no enamel, is the issue...Not the amount of sugar. Once the sugar penetrates the gum line, you're in big trouble. Best thing to do is rotate it around a bunch and not leave it in one spot and then rinse with a fluoride rinse immediately afterwards.

Also, the pop, whether it be in solid form, or altered, will not effect the amt of med you absorb. Buccal mucosa is buccal mucosa, regardless of how it's done. The fentanyl is evenly distributed throughout the pop, so you get a constant amount. The manufacturer recommends rotating it around in a circular pattern, lasting no longer than 15 minutes for maximum BT action.

A new fentanyl product is out that is a patch (Onsolis) that you place against your gum. Same issue, just a different mode of transmission. No increase in efficiency or potency.

However, Fentora, tends to be the most potent because it comes in a tablet that causes fizzing and the effervescent effect is very efficient. The fentanyl crosses the dermal boundary starting within 5 minutes and is very potent. This why cephelon recommends a much lower dosage for those patients transitioning from Actiq to Fentora.

A new fentanyl nasal spray, Lazanda, was just approved by the FDA. It has the potential to rival Fentora in terms of potency and sspeed of action.

Ex

Thanks. I can't afford Fentora nor do I think I will be able to afford Lazanda.

Do you have any suggestions for how to make up and down strokes with the Actiq lollipop WHILE sucking at the same time? Or are you not suppose to do both at the same time? When I suck and twirl, that's all I can do... I don't see how you can suck and move the lollipop up and down in your mouth? Am I missing something? Or does the sucking motion not need to be very strong (but rather very lightly suck...)?

Thank you.

 

[Executor]

Do you have any suggestions for how to make up and down strokes with the Actiq lollipop WHILE sucking at the same time? Or are you not suppose to do both at the same time? When I suck and twirl, that's all I can do... I don't see how you can suck and move the lollipop up and down in your mouth? Am I missing something? Or does the sucking motion not need to be very strong (but rather very lightly suck...)?

Thank you.

Personally, I just cut off the stick and let it sit in the cheek of my mouth like a lozenge, and move it around from time to time. It takes about 30-45 minutes to go through one. I do it this way so that I swallow very little, if any of the pop melting in my mouth. Fentanyl is very poorly absorbed by the stomach. In fact, if one were to eat a pop, not much would happen.

The literature from the manufacturer says to "twirl" the pop on the stick against your inside of your cheek, taking about 15 minutes to digest the pop. That's too fast for me, so I just let it sit. I'm on a much stronger strength also. Plus, I don't like the stick hanging out of my mouth with the huge warning label on it and people ask me what it is. That huge yellow triangle is a deal breaker for me. I realize why it's there, but not applicable to me, especially if I'm at work. This way, people just think it's a piece of candy or something. Since my are compounded, they are a totally different shape, more like the size of a regular lollipop.

Best of luck to you with this.

Ex

 

[neudr]

I'm still having quite a bit of trouble.

I tried to let the lollipop just sit in my mouth without sucking on it but I didn't feel any effect. I finished it in about an hour. Any idea what I did wrong?

When I actively suck on the medicine and twirl it around, I can never finish the lollipop in 15 minutes-- are there any tricks to speeding up the time to finish the medicine?

Where is the right place to put it against your cheeks? My pharmacist said as far back in your mouth as you can, against the cheek. Is that right?

 

[Tommyboy]

I usually break it into a few pieces (4 is ideal for me, but it doesn't always break that way) and put a piece on each cheek, meaning bottom left, bottom right, top left, top right. From there, I rub the outside of my cheek in the place where the piece of the lolli pop is.

Have you tried something like that? I didn't like doing the whole lolli pop in one area of my cheek because I would often end up bleeding there. Quartering it helped in both increasing the speed of dissolution, and with preventing any bleeding.

 

[neudr]

You don't cut your cheeks doing that? I would think that broken pieces would cause your gums/cheeks to bleed? (once I start sucking on the lollipop, the medicine become hard with a lot of small bumps, all waiting to make my cheeks bleed once a bump ruptures the buccal space...)

 

[neudr]

I just wanted to provide an update to this thread.

First, thank you to all who offered advice and helped me with my problem using Actiq.

My doctor switched me to Fentanyl Citrate 200mcg/1ML solution to use buccally or sublingual. It was prepared sterile so I could have used it IV/IM/Sc but I would not attempt that unless my doctor knew. I don't think he would care, but if something were to happen, he would protect himself.

I didn't have a good experience with Fentanyl Citrate liquid solution because I was swallowing a lot of the medicine (especially when used buccally). I was able to get new insurance and my new insurance covers Fentora so I'll be trying that. I was given the lowest dose (100 mcg) and my doctor said figure out what dose is needed and then we'll use that indefinitely. He said if for some reason Fentora does not work, we can also try Onsolis, Abstral and the Lazanda nasal spray. (Luckily my new health insurance will cover all of these options. Ironically, they won't pay for Actiq, probably due to the bad press.)


I hope Fentora works as well as IV Fentanyl!

If anyone has any questions about Fentora (or Fentanyl), I'll do my best to answer.

 

[_Synapse]

I have never used the lollipops but I would expect them to work very well. All I have used is the patch and I used the drug orally (not the whole patch.. don't think I just chewed a patch... a measurement was done and I chewed a piece for an hour and swallowed) and it worked well. I would think just eating the sucker normally would be the best way. Sublingual is probably not necessary I would just stick to regular orally. And 25 bucks a pop is a lot especially because fentanyl is so short lasting of an opiod.

 

[neudr]

The problem with Actiq is you swallow a lot of the medicine, which has a very poor bioavailability, leaving only the amount absorbed bucally (which has a BA of 50% ). And you have no idea how much you swallow vs absorb bucally (along the cheek).

I was cutting up my gums from rubbing too hard, or dry mouth would cause me to take 30 minutes to finish the unit of Actiq. As a result, rarely did it help my breakthrough pain.

 

[echo101]

This is my first post and I stumbled upon this thread searching for ways or info on how to bang oral transmucosal fentanyl...however I am an opioid tolerant user (cranial giloblastoma, m.s., l4,l5-s1 spinal fusion, spinal pedical screw implantation, spinal cord stimulator implantation (St. Jude formerly Medtronic) and chronic malignant pain suffrage ) and Ive tried just about every type of available fentanyl product as well as other chronic pain meds oxy, hydomorph, ...etc and my best relief has been with the oral transmucosal fentanyl lozenges. However I do understand that they are cost prohibitive, my pain Dr. had an easy fix to allow quicker bioavailability and ultimately a way to make them go longer and stronger. I'm not sure if I'm allowed to discuss it here on a public forum but PM or email me and I will tell you how to make your lozenges work twice as stong and thus last twice as long ... for about a dollar. This came directly from my pain doc, who has been practicing for over 30 years without an incident, lawsuit or malpractice allegations or state restrictions in South Central Texas.

Suffering and trying to help all who suffer as I do.

 

[Rybee]

PM or email me and I will tell you how to make your lozenges work twice as stong and thus last twice as long ... for about a dollar. This came directly from my pain doc, who has been practicing for over 30 years without an incident, lawsuit or malpractice allegations or state restrictions in South Central Texas.

Suffering and trying to help all who suffer as I do.

I'm sorry, just in case I've got the wrong end of the stick and misread what you've typed.

You know how to make Fent lozenges work twice as strong, and hence have the possibility of lasting for twice as long and it will cost 'about a dollar'.

What exactly, would cost a dollar? To PM you for you to reveal the info, or it would cost a dollar to implement the strategy that you are willing to tell via PM.


Your post isn't quite so clear.

 

[echo101]

Sorry about that... ive been reading alot and I dont see any problem posting after what ive read in these forums...lol

A box of regular baking soda, not baking powder. Has to be baking soda. Stick the lozenge in your mouth as to wet it with your saliva, then stick it in the box of FRESH baking soda, pref. Arm and Hammer, flick the stick handle to knock off excess powder and stick it between gum and cheek. Its Salty and Harsh ... but believe me it works! My doc told me about this and it seems that fentora is mimicked in this manner by its effervesence ..I wouldn't be suprised if fentora has some kind of sodium bicarbonate as an ingredient. I never use my lozenges without baking soda now. When I do they suck. My doc told me using BS increases the bioavailabilty and rapidly increases the rate of absorption. Good luck!