[Opioid intoxication. Inappropriate administration of transdermal fentanyl]

A 22-year-old male suffering from neuropathic pain in his right leg had sufficient analgesia with oral tilidin 300 mg per day. Nevertheless, the general practitioner decided to change the therapy to transdermal fentanyl. Having cut a fentanyl patch (50 micrograms/h) into pieces, he applied one-fourth of the patch; 60 min later the patient developed signs of opioid intoxication, including heavy sedation, nausea and respiratory depression. After the patch was removed another 60 min later, the patient made a complete recovery. The risks following inappropriate application of transdermal fentanyl are discussed.