initiation and dose increases. If serotonin syndrome suspected, consider dose reduction or discontinuation of therapy depending on symptom severity. For all patients, prolonged use may lead to drug dependence (addiction), even at therapeutic doses. Risks increased if current or past history of substance misuse disorder (including alcohol misuse) or mental health disorder. Consider additional support and monitoring if at risk of opioid misuse. Explain risks of developing tolerance. Overuse or misuse may result in overdose and/or death. Closely monitor for signs of misuse, abuse or addiction. Regularly review clinical need for analgesia. Drug withdrawal syndrome may occur upon abrupt cessation – gradually taper the dose to minimise symptoms of withdrawal when therapy is no longer required. Tapering of a high dose may take weeks to months. Opioid withdrawal can manifest as: restlessness, lacrimation, rhinorrhoea, yawning, perspiration, chills, myalgia, mydriasis and palpitations. Other possible symptoms include irritability, agitation, anxiety, hyperkinesia, tremor, weakness, insomnia, anorexia, abdominal cramps, nausea, vomiting, diarrhoea, increased blood pressure, increased respiratory rate or heart rate. Consider hyperalgesia if the patient on long-term opioid therapy presents with increased pain – may resolve with opioid dose reduction. Use cautiously with other central nervous system depressants, benzodiazepines and serotonergic medicinal products. The concomitant use of opioids with sedative medicines such as benzodiazepines or related drugs increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effects. Only concomitantly prescribe sedative medicines if no other treatment options possible.The dose and duration of concomitant use should be limited. Inform patients of signs and symptoms of respiratory depression and sedation and monitor closely. Pregnancy and Breastfeeding: Do not use during pregnancy, lactation or in women of childbearing potential not using effective contraception.. If prolonged opioid use required in pregnancy, advise of risk of neonatal opioid withdrawal syndrome – ensure treatment available. Use during labour may depress neonate respiration – ensure antidote for child available. Patients should be warned about effect on driving and, if experiencing dizziness, drowsiness or blurred vision, they should not drive or use machines for at least 24 hours after patch removed Side effects: For the full list of side effects consult SmPC. ‘Very Common’ ‘Common’ and ‘Serious’ side effects are included in prescribing information. Very common (≥1/10) side effects: headache, dizziness, somnolence, constipation, nausea, vomiting, pruritus, erythema, application site reaction. Common (≥1/100 to <1/10) side effects: anorexia, confusion, depression, insomnia, nervousness, anxiety, tremor, dyspnoea, abdominal pain, diarrhoea, dyspepsia, dry mouth, rash, sweating, exanthema, muscular weakness, tiredness, asthenic conditions, peripheral oedema. Uncommon Serious (≥1/1000 to <1/100) side effects: hypersensitivity, tachycardia, circulatory collapse, drug withdrawal syndrome. Rare Serious (≥1/10000 to <1/1000) side effects: anaphylactic reaction, psychotic disorder, angina pectoris, respiratory depression, respiratory failure. Unknown frequency Serious side effects: anaphylactoid reaction, seizures, neonatal drug withdrawal syndrome, drug dependence. MA number: PL 35533/0059-0061 (5µg/hr,10µg/hr, 20µg/hr). PL 35533/0135 (15 µg/hr). Cost: £5.53 for 5µg/hr patch x4 pack; £9.93 for 10µg/hr patch x4 pack; £15.48 for 15 µg/hr patch x4 pack and £18.09 for 20µg/hr patch x4 pack. MAH: Aspire Pharma Ltd, Unit 4, Rotherbrook Court, Bedford Road, Petersfield, Hampshire GU32 3QG. Legal category: POM. Date last reviewed: August 2021 Version number: 1010311145 v 10.0.