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Fentanyl is an extremely potent synthetic opioid that has contributed to a sharp increase in overdose-related deaths in recent years. Fentanyl produces effects of euphoria and relaxation, but it can also cause respiratory depression, coma, and death. The drug is highly addictive. Even short-term use can lead to physical dependence, which may then progress to an opioid use disorder.

What Is Fentanyl?

fentanyl bottle and syringe sitting on top of prescription Fentanyl is a man-made, short-acting opioid. It was first introduced as an anesthetic in the 1960s under the name Sublimaze. It is a Schedule II drug that is about 100 times more potent than morphine.1

Other prescription names for Fentanyl include:2,3

  • Abstral
  • Actiq
  • Duragesic
  • Ionsys
  • Onsolis
  • Fentora

Abuse of prescription substances such as fentanyl has played a role in the opioid epidemic currently gripping the United States. Tight DEA and FDA regulations on fentanyl prescriptions has led to a surge in illicitly manufactured fentanyl (IMF), which is made in underground labs all over the world and sold as counterfeit pharmaceutical products. It is also mixed in with or sold as other drugs, especially heroin. Given fentanyl’s potency and the fact that users may not even know that it’s in the drugs they’re taking, the result has been a steep increase in the number of fentanyl-related overdose deaths.4

Common street names for fentanyl include:2

  • Jackpot
  • Dance Fever
  • Apache
  • Murder 8
  • China Girl
  • Friend
  • TNT
  • Tango and Cash
  • Goodfella
  • China White

The supply of IMF includes not only fentanyl, but also fentanyl analogs, primarily made in Mexico and China. The analog acetyl fentanyl (also called desmethyl fentanyl) has been linked to an increasing number of fatalities. Between 2013 and 2015, the DEA confirmed 52 overdose deaths involving acetyl fentanyl. In 2015, the DEA classified acetyl fentanyl as a Schedule I substance.5

Fentanyl analogs and other illicitly manufactured synthetic opioids are frequently much stronger than the opioids used in medical practice.6

  • Carfentanil is approximately 10,000 times more potent than morphine.
  • Acetyl-fentanyl is roughly 15 times more potent than morphine.
  • Butyrfentanyl is approximately 30 times more potent than morphine.
  • U-47700 is about 12 times more potent than morphine.
  • MT-45 is roughly the same potency as morphine.

What Are the Effects?

Fentanyl slows the heart rate and depresses breathing, which is how overdose cases can lead to death.In addition to being highly potent, fentanyl and other synthetic opioids are extremely fast-acting, so overdose can happen within just seconds of taking them.7 The rate of deaths from fentanyl-related overdoses more than doubled from 2013 to 2014;7 and in just 2 years, the rates of overdose deaths from synthetic opioids tripled: from 3,105 deaths in 2013 to 9,580 in 2015.6 Despite these high rates, the true number of deaths is likely higher given that coroners do not routinely test for fentanyl.8

Fentanyl is abused for its intense high and feelings of euphoria. When a person uses fentanyl, the drug binds to opioid receptors in the brain, activating a flood of dopamine in a similar manner as heroin does. As a side effect, fentanyl slows the heart rate and depresses breathing, which is how overdose cases can lead to death without immediate medical assistance.2

Other side effects of fentanyl include:2

  • Confusion.
  • Drowsiness.
  • Constipation.
  • Nausea.
  • Loss of consciousness.

In addition to these short-term negative side effects, repeated or chronic fentanyl use can quickly lead to the development of tolerance, marked physiological dependence, and, eventually, addiction.

How Is It Used?

In medical practice, fentanyl is primarily used to manage surgical and postoperative pain, severe chronic pain, and breakthrough cancer pain. Its use is frequently reserved to treat pain in opioid-tolerant patients for whom less powerful opioid painkillers are ineffective.7 The drug is administered as tablets, transdermal patches, intravenous solutions, oral lozenges or lollipops, nasal sprays, and sublingual sprays.1bottle of blue fentanyl pills spilling out of bottle

Fentanyl should not be used for short-term pain such as dental pain, acute pain from an injury, or migraine pain.3 Physicians are cautious to prescribe fentanyl given the drug’s high risk for abuse and for fear that patients may transition to abusing the drug even if their initial prescription and usage follows recommended guidelines.

The transdermal patches are especially noted for their abuse potential, as people commonly remove the gel from the patch and either inject, chew, drink, smoke, or snort the gel.1 This is extremely dangerous, and significantly increases the chances of an overdose. People also freeze the patches, cut them into pieces, and place the pieces under their tongue or in the cheek cavity. Even used patches retain enough fentanyl to present a risk of abuse.1

Pharmaceutical fentanyl can be diverted for sale on the street, but most of the street supply is illicitly manufactured. IMF and fentanyl analogs are frequently mixed with other drugs such as heroin or cocaine, and many people are not aware they are getting a fentanyl-laced product when they purchase these drugs from a dealer. The combination of fentanyl with other illicit drugs may amplify the negative side effects of both drugs and increase the risk of addiction and overdose.2

DEA reports indicate that the highest concentration of fentanyl overdoses occur in areas of the U.S. where white powder heroin is widely used.8 More than 80% of all fentanyl seizures were reported from 10 states, including Ohio, Massachusetts, Pennsylvania, Maryland, New Jersey, Kentucky, Virginia, Florida, New Hampshire, and Indiana.8

The Opioid Epidemic

Fentanyl has played a major role in the current opioid epidemic, which the Centers for Disease Control and Prevention has said is the deadliest drug crisis in the nation’s history.9 In 2015 alone, 33,091 Americans died from an opioid overdose.10 This is on par with the number ofvehicle traffic deaths (33,736) and firearms deaths (33,594) reported in 2014.11 In addition:

  • Addiction to opioids, including prescriptions, heroin, and fentanyl, costs the U.S. more than $78 billion a year in healthcare costs, lost productivity, and criminal justice resources.6
  • In 2014, more than 47,055 families lost a loved one to a drug overdose. 9
  • In 2012, more than 259 million opioid prescriptions were written.9

In 2015, the number of people who overdosed on synthetic opioids, including fentanyl, was 9,500.
Given that prescription painkillers such as Vicodin and OxyContin are themselves highly addictive and considered gateways to more potent substances such as heroin and fentanyl, the number of opioid prescriptions written each year is alarming. Between 1999 and 2011, the sale of prescription opioids tripled. During this same time period, both the number of admissions to addiction rehab centers and the number of overdose deaths from prescription opioids quadrupled.6

Research has demonstrated a strong association between initial prescription drug misuse and later heroin use, with up to 80% of heroin users reporting that they first misused prescription drugs.6 This relationship between prescription opioids, heroin, and overdose is a key point in understanding the opioid epidemic. Heroin is a cheaper and, oftentimes, more accessible drug compared to prescription opioids. From 2010 to 2015, the number of fatal overdoses involving heroin jumped from 3,000 to 13,000.6

The number of fentanyl overdose cases has skyrocketed in the past 5 years, and the number of fentanyl seizures increased by 7 times from 2012 to 2014. In 2015, the number of people who overdosed on synthetic opioids, including fentanyl, was 9,500.6 In 2015, New Hampshire had the highest rate of fentanyl-related deaths in the United States. From 2013 to 2014 the state experienced a 73.5% increase in the number of overdoses.6

To further understand the magnitude of the opioid epidemic, on an average day in the U.S.:12

  • More than 650,000 prescription painkiller prescriptions are written.
  • 580 people begin using heroin.
  • 78 people die from an opioid-related overdose.
  • 3,900 people begin misusing prescription opioids.

Overdose

According to the DEA, a mere 2 milligrams of fentanyl, the size of a few grains of sand, can kill most people.15 Fentanyl slows the user’s heartbeat and rate of breathing, and too much of the drug will cause these functions to stop entirely.

A person who has overdosed on fentanyl may exhibit the following symptoms:13,14

  • Dizziness
  • Confusion
  • Difficulty thinking, talking, or walking normally
  • Small, pinpoint pupils
  • Pale face
  • Bluish hue to skin, especially in the lips or fingernails
  • Slow pulse
  • Trouble breathing
  • Choking or gurgling sounds
  • Extreme lethargy
  • Unresponsiveness
  • Coma

close-up of person overdosed on fentanyl laying on ground next to syringeIf you suspect that someone near you has overdosed on fentanyl, emergency medical treatment is critical. Call 911 immediately.

The risk of overdose on fentanyl is especially high because it is often concealed in or sold as other street drugs such as heroin, or cocaine. Another factor that can increase the risk of fatal overdose is using fentanyl in addition to other drugs, especially benzodiazepines, sleeping pills, and alcohol.6

Fentanyl also poses a unique risk to first responders, medical workers, and law enforcement officers because it is easily absorbed through skin and inhalation.15 Just being near the drug, or near people who have used it, could be dangerous. Given that fentanyl is often smuggled or mixed in with other drugs, it can be difficult for emergency personnel to know whether a substance they are handling contains fentanyl. Many cities recommend additional precautions for these responders, such as face masks and latex gloves, when handling patients or suspects who may have been using fentanyl. Canine units are also at risk for inhaling fentanyl during drug checks.15

If you do come into physical contact with fentanyl, you may exhibit the following symptoms within minutes:15

  • Clammy skin
  • Pinpoint pupils
  • Drowsiness
  • Disorientation
  • Respiratory depression

Using Naloxone to Reverse Overdose

Expanding access to naloxone for first responders and healthcare providers is a top priority in the U.S. Department of Health and Human Services’ response to the opioid epidemic.12 Also known by the brand names Narcan and Evzio, naloxone is a life-saving drug that reverses the effects of an opioid overdose.

Naloxone is a fast-acting drug that works by removing opioid molecules such as fentanyl from opioid receptors in the brain and blocking those receptors to prevent further binding. By uncoupling the drug from opioid receptors, naloxone restores normal heart rate and breathing in the overdosing patient.

Naloxone has no potential for abuse and can be injected into the muscle, vein, or under the skin, or sprayed into the nose. The nasal spray (Narcan) and auto-injection devices (Evzio) require only minimal training, so laypeople can administer naloxone on their own to help reverse an overdose prior to ambulance arrival. In some areas, naloxone is available without a prescription,16 and federal, state, and local budgets call for increased funding for naloxone access and training for first responders and healthcare providers.12

After receiving naloxone, the individual may experience immediate withdrawal symptoms, such as vomiting, diarrhea, and tremors. These effects are not life-threatening, but officials recommend monitoring the patient for at least 2 hours after receiving the medication.16 When the individual wakes up, help to keep them calm and make sure they do not take more opioid drugs, as they may risk overdosing again. Stay with the individual until medical services arrive.

It’s important that naloxone be administered as early as possible in the case of an overdose. Use of the self-administered formulations should not preclude seeking help from emergency services.  A fentanyl-related overdose can be difficult to reverse due to the drug’s potency, and may require repeated doses of naloxone.7

It’s important to note that naloxone is not a substitute for addiction treatment. Patients who receive naloxone should follow-up with appropriate detoxification and rehabilitation services to properly treat their addiction and avoid future overdoses.

Tolerance and Dependence

When a person develops a tolerance to a drug, they require increasingly higher doses in order to feel the same effects. A tolerance to opioids can develop rather quickly, in some cases after just a single dose. Increasing the dosing or frequency of use to counteract a fentanyl tolerance not only increases a person’s risk of overdose, but it can also hasten the onset of dependence and addiction.

Physical dependence occurs when the body becomes used to the presence of a drug in the system and experiences withdrawal symptoms when the person stops using the drug. Withdrawal from opioids such as fentanyl can be particularly uncomfortable, and many opioid users continue taking drugs in order to avoid the sickness of withdrawal. This pattern can lead to compulsive, drug-seeking behavior and people may continue using opioid drugs despite negative consequences, both key indicators of addiction.

Today, pain is one of the most commonly treated medical conditions in the U.S., with more than 30% of Americans living with acute or chronic pain.17 Pain is also one of the most difficult conditions to manage. Many argue that physicians have become overly reliant on prescribing opioid medications to treat pain and, in turn, patients develop tolerance and physical dependence on those prescription opioids.

Unfortunately, it is common for a person who has developed a tolerance to and/or dependence on prescription opioids to turn to illicit substances like heroin or fentanyl when they are no longer able to obtain or afford their prescription drugs. The high potency of these street drugs, coupled with the fact that users don’t know exactly what mixture of heroin, fentanyl, or fentanyl analogs they may be getting, further increases the risk of overdose and developing addiction.

man standing in park with his head in hand dependent on fentanylAnother danger associated with opioid tolerance is when someone relapses after not using fentanyl for a period of time. Tolerance may significantly lessen in just a few days or weeks after stopping opioid use. At this point, should someone relapse and return to using fentanyl, the dose they previously needed to get high may now be enough to kill them.

People especially vulnerable to overdosing after returning to drug use are individuals who:

  • Are leaving jail.
  • Are leaving hospitalization.
  • Are leaving detoxification or other drug treatment.
  • Have gone cold turkey at home.

Withdrawal Symptoms

Although fentanyl withdrawal is not deadly, it can be extremely uncomfortable. If you abruptly stop taking fentanyl, you may experience a number of unpleasant withdrawal symptoms that can interfere with your ability to go to work, school, or participate in other activities that you enjoy.

Withdrawal symptoms can include the following:18

  • Nausea
  • Vomiting
  • Diarrhea
  • Stomach cramps
  • Back pain
  • Joint and muscle pain
  • Sweating
  • Excessive yawning
  • Runny nose
  • Watery eyes
  • Anorexia
  • Fever
  • Chills
  • Insomnia
  • Anxiety
  • Weakness
  • Feeling of hair standing on end
  • Increased blood pressure
  • Increased heart rate
  • Rapid breathing

Withdrawal symptoms from shorter-acting opioids like heroin and fentanyl typically begin within hours after the last use and decrease in severity within a few days.19 Protracted withdrawal symptoms can continue for weeks and even months after the last drug use.19

Many addiction treatment providers recommend discontinuing opioids according to a tapering schedule (gradually decreasing dosage) in order to minimize withdrawal symptoms.

Detox

Detoxification is your first step in treating fentanyl abuse and addiction. At a professional rehab facility, treatment specialists will work with you to develop a custom detox plan and timeline based on your unique circumstances, including factors such as:20

  • Other drug or alcohol use.
  • Mental health conditions that may have contributed to addiction.
  • Drug use patterns and history (length of time you’ve been abusing fentanyl).
  • If you are pregnant or breastfeeding.
  • Your support system at home.

female portraying a patient sitting with head down discussing detox with woman portraying a doctorDuring detox your doctor may prescribe medications to help you manage the uncomfortable effects of withdrawal. There are 3 classes of medication approved to treat opioid addiction, including:6

  • Opioid agonists (methadone).
  • Partial opioid agonists (buprenorphine).
  • Opioid antagonists (naltrexone).

Studies have documented the effectiveness of these drugs in treating addiction. For example, one study found that people taking methadone were more than 4 times more likely to stay in treatment.6 Additionally, 33% had fewer drug-positive drug tests compared to people not using methadone.6

Combining addiction treatment drugs with individual and group therapy in addiction rehab is known as medication-assisted treatment.

Medication-Assisted Treatment

Addiction is a serious chronic condition, but recovery is possible. Using medication-assisted therapy (MAT) can help individuals remain drug-free even after leaving rehab. MAT is a proven and effective way to treat opioid use disorder and studies show that it can reduce opioid use as well as risky behaviors that can lead opioid users to health problems such as HIV and hepatitis C.12 MAT combines medication with counseling and therapy to holistically treat addiction.

MAT drugs that may be prescribed as part of a comprehensive treatment plan include:21

  • Methadone: This drug has been used for decades to ease symptoms of withdrawal with fewer euphoric effects than opioids of abuse. Methadone is taken in a designated methadone clinic once a day. The total length of methadone treatment can vary from person to person, but in many cases may last at least 12 months. Some individuals require methadone treatment for years. Once a person is ready to stop methadone treatment, they will taper off slowly under the guidance of a physician.
  • Buprenorphine: This medication is designed to help people reduce or quit their opioid use by suppressing and reducing cravings. Buprenorphine comes as a dissolvable film (in combination with naloxone, as Bunavail or Suboxone) or a sublingual tablet (Zubsolv and generic). The drug is a partial opioid agonist, so there is a maximum or ceiling level to its potential effects, and taking greater amounts does not get the user high. This feature, as well as the inclusion of naloxone in some combination formulations, helps to prevent misuse and dependency. In 2016, the FDA approved Probuphine, the first buprenorphine implant, for long-term maintenance of opioid dependence.
  • Naltrexone: This medication is an opioid antagonist that blocks the euphoric effects of drugs like fentanyl or heroin, as well as alcohol. If a person relapses to drug use while actively taking this medication, they won’t feel the desired effects, which discourages ongoing abuse and minimizes the risk of slipping back into addiction. Treatment professionals recommend using naltrexone therapy for at least 3 months after completing rehab.

female portraying doctor talking to patient about prescription medication for treatmentResearch shows that using these therapeutic drugs alongside behavioral therapy increases their effectiveness. For example, when people use methadone in combination with counseling for more than 6 months, they have significantly better treatment outcomes compared to people who just use methadone.6

Behavioral therapies used in conjunction with MAT include:22

  • Individual therapy: One of the most effective forms of therapy is meeting with a therapist one-on-one. These sessions are completely confidential and give you the time to talk about things that you may not have ever shared out loud. Maybe you will use this time to talk about past trauma, situations that cause you to want to use drugs, or anything else on your mind.
  • Group counseling: Group counseling forms the base of most recovery programs. In group counseling you will meet regularly with others who are going through treatment to offer support and share space. A trained facilitator will lead the discussion and ensure that everyone gets time to share their experiences. This offers an opportunity to meet others in recovery and create a support network of people who do not use fentanyl.
  • Family behavioral therapy: Family therapy can be incredibly helpful in your journey to recovery. Oftentimes, family plays a major role in your drive to use drugs or your inability to quit. When the family gets involved you can begin repairing any trauma that happened in the past, create healthy boundaries with one another, and learn how to communicate in a compassionate and respectful way to avoid future harm.
  • Cognitive behavioral therapy: During this type of therapy (commonly utilized in various individual and group counseling settings) you will learn how to change your way of thinking to help manage cravings and triggers.
  • Contingency management: This type of therapy relies on small rewards to help incentivize you to remain drug-free. For every drug-free urine sample you produce, you may be given privileges such as time on the computer, time outside, or vouchers with a small amount of money on them for groceries or other personal items.
  • Motivational interviewing: When you engage in this type of therapy, your counselor acts more as a coach. They will help motivate you towards realizing your own treatment goals.

Despite MAT’s effectiveness, it is severely underutilized. In 2014, there were an estimated 2.2 million people dependent on opioids, but fewer than 1 million who actually received MAT.23

Aftercare

Recovery does not end after you finish treatment. After leaving rehab, it is important to stay engaged with care and sober communities.

Aftercare refers to inventions that you take a part in after leaving treatment. Your aftercare plan should be personal to you and designed to keep you engaged and interested. Additional support in the form of support groups, private counseling, or volunteering can help you stay sober.

One of the major goals of treatment is to set you up for success as you transition out of treatment. Your risk for relapsing may be high given the number of triggers to use that exist outside of the facility when you leave treatment. By having a solid aftercare plan in place, you will feel ready to meet these challenges.

Recovery Is Possible

Fentanyl addiction might feel hopeless, but with proper care from treatment professionals, living a full and healthy life in recovery is possible. Fentanyl carries a high risk of overdose and people die every day from this potent drug. You don’t have to be one of these statistics; reach out for help today.


References:

  1. Drug Enforcement Administration. (2016). Fentanyl.
  2. National Institute on Drug Abuse. (2016). Drug Facts: Fentanyl.
  3. U.S. National Library of Medicine. (2017). Fentanyl.
  4. Centers for Disease Control and Prevention. (2016). Morbidity and Mortality Weekly Report: Increases in Fentanyl-Related Overdose Deaths: Florida and Ohio, 2013-2015.
  5. Drug Enforcement Administration. (2015). Acetyl Fentanyl.
  6. National Institute on Drug Abuse. (2017). Research on the Use and Misuse of Fentanyl and Other Synthetic Opioids.
  7. U.S. Department of Health & Human Services. (2017). Testimony from Debra Houry, M.D. on Fentanyl: The Next Wave of the Opioid Crisis before Committee on Energy and Commerce.
  8. National Drug Early Warning System. (2015). Fentanyl and Fentanyl Analogs.
  9. National Safety Council. (2016). Prescription Nation 2016.
  10. Centers for Disease Control and Prevention. (2016). Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015.
  11. Centers for Disease Control and Prevention. (2016). All Injuries.
  12. U.S. Department of Health & Human Services. (2016). HHS Opioid Initiative: One Year Later.
  13. Massachusetts Department of Public Health. (2011). Opioid Overdose Education and Naloxone Distribution.
  14. National Library of Medicine. (2016). Fentanyl Transdermal Patch.
  15. U.S. Department of Justice. Drug Enforcement Administration. (2016). A Real Threat to Law Enforcement: Fentanyl.
  16. National Institute on Drug Abuse. (2016). Opioid Reversal with Naloxone (Narcan, Evzio).
  17. Volkow, N., & McLellan, A. (2016). Opioid abuse in chronic pain—misconceptions and mitigation strategies. New England Journal of Medicine, 374(13), 1253-1263.
  18. Food and Drug Administration. (n.d.). Duragesic (fentanyl transdermal system).
  19. Schuckit, M. (2016). Treatment of opioid-use disorders.New England Journal of Medicine, 375(4), 357-368.
  20. U.S. Department of Health and Human Services. (2011). Medication-Assisted Treatment for Opioid Addiction.
  21. Substance Abuse and Mental Health Services Administration. (2005). Chapter 3. Pharmacology of Medications Used To Treat Opioid Addiction. 
  22. Iowa Department of Public Health. (n.d.). Medication-Assisted Treatment (MAT).
  23. National Institute on Drug Abuse. (2016). FDA approves six month implant for treatment of opioid dependence.

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