I have seen it work both ways - some patients do well by just decreasing the
interval to 48 hours and some others ended up having to move up in strength.
48 hour dosing seems to be fairly well known to the prescribers but not to
the third party payors and usually requires a lot of effort to convince them
to pay for the decreased days supply.
I too have also limited my stock of it due to its expense and the only
patients I have on it are 3rd party paid.
At AWP minus the store plus a sharp stick in the eye for an expensive drug
with a narrow AWP spread, you hafta watch the inventory.
But my patients are involved in their care with me so they are good about
reminding me a week or so before they plan on getting the next prescription
so I can order it and reduce my inventory exposure.

Brad

We have 2-3 patients on Duragesic 25, but none have had trouble with
the 72hr dosage. Our stock consists of 2 boxes of 25's, as it's a slow
mover. I'm sure we'll get into a 48hr dose situation, but as Brad
mentioned, I hope it's a cash customer. Getting the claim approved
could be a bear.

After the OxyContin fiasco, the docs in our area have switched more
patients to methadone than Duragesic. We have several pain patients on
methadone for pain.

In hospital-based practice, we never vary the frequency of
administration but more commonly make patch strength changes.
More typically, once a workable strength is decided upon, the
patient can get adjunct meds for breakthrough pain; such as
Percocet, Oxycodone regular and CR, MS Contin.  Day-to-day pain
variability and fentanyl's addiction potential seems to sway
the pain specialists (anesthesiologists) to minimize a patch
strength.