Although fentanyl is considered safe and effective when used and monitored in a medical setting, it carries a high abuse potential.
Fentanyl analogs - designer drugs nearly identical to the original - can be manufactured and mixed with or substituted for heroin. Because fentanyl and its analogs are incredibly potent, accidental overdoses and deaths are increasingly common.
Fentanyl is sometimes mixed with heroin. Because it is much more potent than heroin, there is a hugely increased risk of overdose and death.
In this article, we will discuss the medical uses of fentanyl and its side effects. We will also cover abuse of fentanyl, addiction, and overdoses.
Here are some key points about fentanyl. More detail and supporting information is in the main article.
- Fentanyl is a potent synthetic opioid that is very effective at relieving moderate-to-severe chronic pain.
- Oral formulations of fentanyl contain an amount of the drug that can be fatal to a child.
- The difference between a therapeutic dose and a deadly dose of fentanyl is very small.
- There are many illegal analogs and derivatives of fentanyl that are much stronger than the prescription version.
- Recreational users often use fentanyl as a substitute for heroin.
What is fentanyl?
Fentanyl is around 100 times more potent than morphine.
Fentanyl binds to the body's opioid receptors, increasing dopamine levels in the central nervous system.
The increase in dopamine produces a state of relaxation, relieves pain, decreases the perception of suffering, and promotes a feeling of well-being (euphoria).
A schedule 2 prescription narcotic analgesic, fentanyl is roughly 100 times more potent than morphine.
It is used to manage pain during surgery; it is also used to treat moderate-to-severe chronic pain syndromes in people who are already physically tolerant to opiates.
Fentanyl depresses the respiratory centers and the cough reflex and constricts the pupils. It can work within minutes to relieve pain and produce sedation. Fentanyl has a short duration of effect - just 30-90 minutes.
Fentanyl affects everyone differently. The effects are dependent on an individual's size, weight, overall state of health, the amount that is taken, whether fentanyl is taken in combination with other drugs, and whether the person is used to taking opioids.
Medically prescribed fentanyl is available in a variety of formulations, including lozenges, lollipops, oral and nasal sprays, and injections.
For continuous delivery, fentanyl can be administered through a transdermal patch that adheres to the skin. The patch works by slowly releasing fentanyl through the skin into the bloodstream over 48-72 hours.
A fentanyl patch is only used in patients who are already tolerant to opioid therapy of a similar strength. Because it has already been absorbed through the skin, fentanyl can continue to be effective for 13-24 hours after the patch is removed.
Fentanyl abuse and heroin
Because of fentanyl's potency, abuse poses a high risk of overdose.
Abuse of fentanyl initially appeared in the 1970s and has increased in recent years.
The drug can be obtained by diverting from legitimate medical supplies, or it can be manufactured in illegal laboratories.
Even discarded fentanyl patches can still contain significant amounts of the drug.
Abusers remove the gel contents from discarded patches and may eat it, place it under the tongue, smoke it, or even inject it.
Fentanyl analogs produced in illicit laboratories may be hundreds of times more potent than street heroin and tend to produce significantly more respiratory depression, making them even more dangerous to users than heroin.
Individuals using heroin or cocaine, or in recovery for a drug use disorder may not know that the potency of street-sold heroin and cocaine can be significantly enhanced by adding fentanyl. Because the potency of such drugs is not known, and they are not told about the addition of fentanyl, any illicit drug use - even a reduced dose - can result in accidental overdose or death.
Fentanyl may be used orally, smoked, snorted, or injected and no one method of use is safer than another.
Street names for fentanyl
- drop dead
- China white
- serial killer
- China girl
- dance fever
- murder 8
Medical uses for fentanyl include:
- Anesthesia for patients undergoing heart surgery or for patients with poor heart function.
- Management of breakthrough cancer pain in patients who are already receiving opioid medication for underlying, persistent pain.
- Pain management in patients who have persistent, moderate-to-severe chronic pain requiring continuous, around-the-clock opioids.
- In patients who are already taking narcotic analgesics or who are already opioid-tolerant.
- It can be used intravenously, intramuscularly, spinally, or as an epidural (into a space at the bottom of the spinal cord).
Commercial names for fentanyl
Fentanyl is produced under a number of brand names.
- Fentanyl citrate
Older patients are more likely than younger individuals to experience adverse effects, especially the respiratory depressant effects of fentanyl. Extreme caution and monitoring must be followed with this age group.
Side effects of fentanyl include:
- dry mouth
- constricted pupils
- slowed respirations
- decreased heart rate
- stiff or rigid muscles
- tight feeling in the throat
- difficulty in concentrating
Adverse effects associated with transdermal fentanyl patches include redness, rash, itching, and swelling at the site of application.
As with any opiate, there is a risk of dependency, tolerance, abuse, and addiction with fentanyl use. Physical dependence results in withdrawal symptoms when individuals abruptly stop taking the drug.
Withdrawal symptoms usually start within 12 hours of the last dose of fentanyl and can last 1 week or more. An individual in withdrawal may experience:
- dilated pupils
- vomiting and diarrhea
- a runny nose
- hot and cold flashes
- severe generalized pain
Fentanyl users swiftly develop a tolerance to high doses, meaning that more of the drug is needed for users to achieve the desired effect.
Repeated opioid use often results in addiction - a chronic relapsing disease that goes beyond physical dependence and is characterized by uncontrollable drug-seeking behavior despite harmful and negative consequences. Seeking and using the drug of choice becomes the primary purpose in life.
Treatment for fentanyl addiction is the same as for any opioid use disorder and depends on the severity of the addiction. Treatment may include inpatient or outpatient detox, medication treatments for managing cravings and relapse, and residential and outpatient behavioral treatment programs.
Fentanyl use can result in accidental death even with just one dose, especially if it is taken incorrectly or by someone other than the person with the prescription.
Signs and symptoms of a fentanyl overdose include:
- slow or shallow breathing
- slow heartbeat
- severe sleepiness
- cold, clammy skin
- trouble walking or talking
- feeling faint, dizzy, or confused
Preventing fentanyl overdose
Fentanyl is sometimes used as a substitute for heroin in opioid-dependent individuals. However, it is a very dangerous substitute because of its marked potency and the inability for users to gauge dosages, resulting in frequent deadly overdoses.
Pure fentanyl powder is very difficult to dilute appropriately, often resulting in a dangerously strong mixture; it can be deadly even for people who have a high opioid tolerance. In some cases, death occurs so quickly that users are found with a needle still in the site of injection.
The minimum lethal dosage of Fentanyl is estimated to be 250 ug (micrograms). Many fatal overdoses thought to be from heroin are actually due to fentanyl; coroners' offices and state crime laboratories do not test for fentanyl or its analogs unless given a specific reason to do so.
The FDA issued a public health advisory to alert patients, their caregivers, and healthcare professionals that deaths and overdoses have occurred in patients using both the brand name product Duragesic and generic transdermal fentanyl patches. Children are at particular risk for accidental death from exposure.
The directions for using a fentanyl skin patch must be followed precisely to prevent death or other serious side effects from overdosing with fentanyl. The FDA highlight the following important information regarding the use of fentanyl skin patches:
"Fentanyl skin patches are very strong narcotic (opioid) painkillers that may cause death from overdose. The fentanyl skin patch should always be prescribed at the lowest dose needed for pain relief. Fentanyl skin patches should not be used to treat short-term pain, pain that is not constant, or for pain after an operation.
Fentanyl skin patches should only be used by patients who are already taking other narcotic painkillers (opioid tolerant), and who have chronic pain that is not well-controlled with shorter-acting painkillers."
The product labeling for fentanyl patches specifically mentions the need to dispose of used patches by folding the sticky sides together and flushing the patch down the toilet.
It is also important to avoid putting the patch near a source of heat because heat increases the rate of drug absorption. They also advise removing the existing patch before the application of a new one.
Fentanyl overdoses should be treated immediately with naloxone, an opiate antagonist that knocks opiates from the brain's receptors. Although fentanyl overdoses can be reversed with naloxone, because of the high potency of non-pharmaceutical fentanyl, higher or multiple doses of naloxone may be required to revive an individual.
Fentanyl is an extremely potent opioid that offers significant pain relief to those who suffer from severe acute or chronic pain conditions but is also capable of causing considerable harm or death to individuals who misuse or are accidentally exposed.
Some patients and healthcare providers may not be fully aware of the dangers of this very strong narcotic. All of society, including families, schools, the medical community, law enforcement, and government officials should be aware of the potentially lethal outcomes of improper medical and illicit fentanyl use.