Death by band-aid: fatal misuse of transdermal fentanyl patch

Abstract

We present a case of fatal intoxication by the application of a transdermal fentanyl patch upon a superficial bleeding abrasion of a 2-year-old girl. The grandmother discovered the body of the child in bed at approximately 7 a.m. External examination revealed a properly developed, nourished and hydrated child, with some vomit in the nostrils and inside the mouth. There was no evidence of trauma besides small contusions and abrasions on knees, with a patch placed over the largest abrasion. Closer inspection revealed that this was transdermal fentanyl patch.Internal examination and microscopic analysis revealed regurgitation of stomach content, cerebral and pulmonary edema and liver congestion. Toxicology analysis revealed trace levels of fentanyl in the blood just above the limit of detection (2 ng/mL), while concentrations in the urine, liver and kidney were approximately 102, 28 and 10 ng/mL, respectively. Investigation discovered that the child injured her knee while playing the evening before. The grandmother applied the patch to cover the injury, unaware that she had used a fentanyl transdermal patch instead of simple band-aid.Although fatal intoxications are uncommon among young children in high-income countries, it is of major interest to raise awareness of such events especially since a great majority of these are preventable. The presented case points at the need for more thorough education of users and more strict rules in prescribing and handling of this potent medicine. As well, we find this case to be a useful contribution to the evaluation of postmortem fentanyl concentrations in fatal intoxication in a small child.

A Fatal Case of Poisoning with Fentanyl Transdermal Patches in Japan

“…reported on a German woman with a history of cancer committed suicide using 34 transdermal fentanyl matrix patches on her body, with release rates ranging from 25 to 100‐μg/h . In Croatia, there was an autopsy case involving a small child who died by the misuse of a fentanyl transdermal patch instead of band‐aid . Carson et al.…”

“…Following application of fentanyl transdermal patches in adult patients, the blood concentration of fentanyl gradually rises, reaching the maximum blood concentration over 12-48 h and remaining steady for up to 72 h. Therefore, once the transdermal patch is detached, it takes over 17 h for the fentanyl blood concentration to drop by 50% (9). Several cases of fatal poisoning caused by misuse or overuse of transdermal fentanyl have been reported worldwide (10)(11)(12)(13), including autopsy case reports describing the use of fentanyl transdermal patch (14)(15)(16)(17)(18)(19)(20). However, to the best of our knowledge, no forensic autopsy cases have been reported in Japan.…”

Fentanyl novel derivative‐related deaths

“…The number of patches applied ranged from 34 (Juebner et al, ), to just one lethal one (Anderson & Muto, ; Jumbelic, ; Kuhlman et al, ). Application to atypical areas, for example, bruised skin (Bakovic, Nestic, & Mayer, ) or oral cavities (Hull, Juhascik, Mazur, Flomenbaum, & Behonick, ; Kramer & Tawney, ; Martin et al, ; Moore, Palmer, & Donovan, ), as well as licking, chewing, swallowing, or injecting the contents of prescription FEN patches, all resulting in enhanced absorption and a quick high (Anderson & Muto, ; Kuhlman et al, ; Thomas et al, ; Palamalai et al, ), were reported. The injection of liquid extracted from patches or obtained from gel matrix was also found (Juebner et al, ; Martin et al, ; Reeves & Ginifer, ; Schauer, Shand, & Reynolds, ).…”

“…Although patches were developed as a safe system for constant delivery of the substance (Tharp, Winecker, & Winston, ; Coopman et al, ), it has been stated that transdermal FEN carries a high risk of overdose, due to the high‐dosage content. Fatalities could arise in physician‐controlled settings and could be due to patients' negligence (e.g., forgetting to remove a patch or application to bruised skin; Bakovic et al, ). However, several intentional misuse and abuse procedures are described: multiple or atypical site application, licking or chewing, volatilization and inhalation, smoking, swallowing (Edinboro et al, ; Kramer & Tawney, ; Kuhlman et al, ; Lilleng, Mehlum, Bachs, & Morild, ; Martin et al, ; Thomas et al, ), extraction of liquid by Durogesic heating or cutting (Reeves & Ginifer, ; Tharp et al, ; Nelson & Schwaner, ).…”

A Novel Transdermal drug-delivery Patch for Treating Local Muscular Pain

“…Out of these, TDD patches are simple and the most patient-compliant. A few transdermal patches for treating muscular pain are available on the market -most based on either narcotic (Fentanyl) or methyl salicylate (Salonpas), which can cause breathing problems, or toxicity issues [11,12]. …”