A schedule II controlled substance narcotic, fentanyl is roughly 80 times more potent than morphine and 50 times more potent than heroin. Although fentanyl is considered safe and effective when used and monitored in appropriate situations, it carries a high abuse potential.
Fentanyl analogues - designer drugs nearly identical to the original - can be manufactured and mixed with or substituted for heroin. Because fentanyl and its analogues are incredibly potent, accidental overdoses with lethal outcomes are an increasingly common and deadly result of illicit use.
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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 in relieving moderate-to-severe chronic pain
- It was introduced into medical practice in the 1960s as an intravenous anesthetic under the trade name of Sublimaze
- Fentanyl has less adverse cardiac effects than other opioid analgesics, making it an option for cardiac surgery patients
- 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 available illegal analogues and derivatives of fentanyl that are much higher potency than the prescription grade
- There has been a significant increase in the confiscation of illicit fentanyl by authorities from 2012 to 2014, raising concerns that these drug seizures may suggest an increase in overdose risk
- Life-threatening respiratory depression could occur at any dose in opioid non-tolerant individuals
- Recreational users often use fentanyl as a substitute for heroin
- The majority of fatal overdoses related to fentanyl are not from the misuse of prescription-grade fentanyl, but rather a fentanyl analogue.
What is fentanyl?
Fentanyl is a mu-opioid receptor agonist, meaning that it binds to the body's opioid receptors, increasing dopamine levels in the central nervous system. An increase in dopamine produces a state of relaxation, relieves pain, decreases the perception of suffering and promotes a feeling of well-being (euphoria).
Fentanyl is a schedule II prescription narcotic analgesic, used to manage chronic pain syndromes and pain during surgery.
A schedule II prescription narcotic analgesic, fentanyl is roughly 50-80 times more potent than morphine. It is used to manage pain during surgery as well as moderate-to-severe chronic pain syndromes in people who are already physically tolerant to opiates.
Fentanyl also depresses the respiratory centers, depresses the cough reflex and constricts the pupils. It works within minutes to relieve pain and produce sedation, unless given in one of its extended release formulations. Fentanyl has a short duration of effect of 30-90 minutes.
Fentanyl affects everyone differently. The effects caused are dependent on an individual's size, weight, overall state of health, the amount that is taken, whether the 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 a 48-72 hour time period.
Medical use of fentanyl
Fentanyl is a schedule II controlled substance and can be legally prescribed by select health care professionals for pain relief and anesthesia.
Fentanyl can be used as an anesthetic agent for people undergoing heart surgery.
Fentanyl can be dosed orally as a lozenge, an extended-release lollipop, a spray or a dissolving strip or tablet. It is also available as a compounding powder, an injectable solution and a transdermal patch.
A fentanyl patch is intended only for patients who are already tolerant to opioid therapy of comparable 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.
When prescribing fentanyl, the US Food and Drug Administration (FDA) warn clinicians on the importance of proper patient selection, dosing and screening of candidates for the potential for abuse.
Serious adverse events including death can occur as a result of improper patient selection and drug storage or disposal. The directions for using fentanyl skin patches must be followed precisely to prevent death or other serious side effects from accidental overdose.
Examples of appropriate medical use of all forms of fentanyl include:
- Anesthesia agent for patients undergoing heart surgery or for patients with poor heart function
- Management of breakthrough cancer pain in patients who are already receiving maintenance opioid medication for their 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
- Intravenously, intramuscularly, spinally or epidurally when potent analgesia and anesthesia is needed.
Illicit use of fentanyl
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 illicit laboratories.
Even discarded fentanyl patches can still contain ample 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 analogues 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.
Persons 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 markedly enhanced by the addition of fentanyl. Because the potency of such drugs is not known, and the inclusion of fentanyl is not disclosed, any illicit drug use - even a reduced dose - can result in accidental overdose or death.
Fentanyl is used orally, smoked, snorted or injected. Snorting fentanyl at a dose of 0.5 mg gives similar euphoric effects to heroin at a dose of 20 mg.
Street names for fentanyl
- Drop dead
- China white
- Serial killer
- China girl
- Dance fever
- Murder 8
Commercial names for fentanyl
- Fentanyl citrate
Side effects of fentanyl
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.
Health risks of fentanyl use
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.
Illicit use of fentanyl can result in dependency, tolerance, abuse and addiction.
Withdrawal symptoms usually start within 12 hours after the last dose of fentanyl and can last a week or more. An individual in withdrawal may experience dilated pupils, vomiting and diarrhea, goosebumps, a runny nose, hot and cold flashes, chills, anxiety, agitation, insomnia and 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. There are different approaches for opioid misuse and addiction treatment, depending on the severity of the person's illness of addiction. Components include inpatient or outpatient detox, medication treatments for managing cravings and relapse, and residential and outpatient behavioral treatment programs.
When not properly prescribed or ingested, fentanyl use can result in accidental death even with just one dose, especially when used by someone other than the person for whom it was prescribed.
Signs and symptoms of a fentanyl overdose include:
- Slow or shallow breathing
- Slow heartbeat
- Severe sleepiness
- Cold, clammy skin
- Trouble walking or talking or feeling faint, dizzy or confused
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.
As it is difficult for illicit fentanyl users to gauge dosages, overdoses are common.
Pure fentanyl powder is very difficult to dilute appropriately, often resulting in a dangerously strong mixture, deadly even to those who have a high opioid tolerance. In some cases, death has occurred so quickly that users have been found with a needle still in the site of injection.
The minimum lethal dosage of Fentanyl is 250 ug (micrograms). Many fatal overdoses determined to be from heroin are actually due to fentanyl as coroners' offices and state crime laboratories do not test for fentanyl or its analogues unless given a specific reason to do so.
The FDA issued a public health advisory to alert patients, their caregivers and health care 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.
Additional safety practices with fentanyl patch use include avoiding application of heat over the patch (heat increases the rate of drug absorption) and removing an existing patch before the application of a new one.
According to the FDA, oral forms of fentanyl are intended for use only in the care of cancer patients and only by oncologists and pain specialists who are knowledgeable of and skilled in the use of Schedule II opioids to treat cancer pain.
Fentanyl overdoses should be treated immediately with naloxone, an opiate antagonist that knocks out an opiate from the brain's receptors, inducing withdrawal. 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.
Law enforcement officials and others who may have potential accidental exposure to fentanyl through the skin or inhalation should protect themselves by using appropriate safety precautions and personal protective equipment.
People who have an addiction to dangerous designer opioids may soon be able to mitigate their condition and avoid fatal overdoses with the help of a new vaccine, says a report published in the journal Angewandte Chemie.
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 health care 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.