title: A pitfall to avoid when starting a patient on transdermal fentanyl.
abstract: BACKGROUND
  A woman with advanced carcinoma of the ovary developed fentanyl toxicity while being changed from oral morphine to transdermal fentanyl.
  
  
  OBJECTIVE
  To explain the reason for the toxicity and ways to avoid it.
  
  
  CONCLUSIONS
  The transdermal fentanyl patch is proving to be a safe, well tolerated and effective treatment modality in the control of cancer pain, but care has to be exercised when using this drug, especially at the time of initiation, as the consequences may be disastrous for the patient.
authors.affiliation: Department of Palliative Care, Prince of Wales Hospital, New South Wales. jamesalvinlow@hotmail.com
authors.forename: J A
authors.initials: JA
authors.lastname: Low
authors.forename: R
authors.initials: R
authors.lastname: Chye
mesh_terms: D000279:Administration, Cutaneous; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D010051:Ovarian Neoplasms / Q000150:complications; D010146:Pain / Q000188:drug therapy*
chemical_list: D000701:Analgesics, Opioid; D005283:Fentanyl