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Fentanyl: Drug of Promise and Dangerous Abuse

  • Fentanyl is a dangerous synthetic prescription pain reliever of extraordinary potency and high risk for abuse. This program is designed educate employees about the risks posed by this substance enabling them to be informed and mindful of the dangers with the goal of help reduce addiction and abuse.
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Educate Employees about Fentanyl and spread the word about this powerful, high risk synthetic prescription drug with frightening levels of abuse and risk of death.

If you’ve had surgery anytime in the past 20 years, odds are you’ve been prescribed an opioid for pain relief. Often after major surgery, patients are administered morphine through a pump. To give you an idea of how powerful synthetic opioids are compared to morphine, consider this: Both hydrocodone and oxycodone are slightly more potent than morphine. Oxymorphone and hydromorphone are five times more potent. Methadone is 30 times stronger, and buprenorphine is 50 times stronger. Fentanyl is 100 times more potent than morphine.

What is fentanyl?

Fentanyl is a Schedule II pharmaceutical, according to the United States Controlled Substances Act. This designation means that a drug is considered to have a high potential for abuse and can lead to both physical and psychological dependence. Schedule II substances also are acknowledged as medical treatments in the U.S., but with severe restrictions on their approved uses. Other Schedule II drugs include amphetamine, morphine, codeine and cocaine.

Fentanyl entered the national spotlight after the sudden death of singer/songwriter Prince in 2016. The rock star’s autopsy found the drug in his system and determined that he died from respiratory arrest caused by an overdose of the medication. Prince was a known user of prescription opioids to help manage chronic pain.

In terms of its chemical makeup, fentanyl is classified as a synthetic opioid. Natural opioids, which include morphine, heroin and codeine, come from opium extracts from the poppy flower. Medication made from opiates has been around for hundreds, if not thousands, of years. The difference is that today, more powerful synthetic opioids than those found in nature can be created in labs.

For people diagnosed with cancer, and for post-surgical patients, fentanyl is a miracle drug. Up to 100 times more potent than morphine and up to 50 percent stronger than heroin, fentanyl is the strongest pain medication prescribed in the United States. For people with post-operative and severe chronic discomfort, the pain reliever provides improved quality of life.

Fentanyl on the street

Street fentanyl is often mixed with heroin, cocaine and other drugs, which can make it even more potent. Mixing fentanyl with alcohol or other medications, such as sleeping pills, that also affect respiration, also drastically increases the chance of overdose.

Common names for fentanyl on the street include Tango and Cash, China White, Murder 8, Dance Fever and Goodfellas. It’s often sold as a white powder, but can also be distributed on blotter paper or as a spray. Fentanyl can be substituted for heroin or pills sold as milder opioids, such as oxycodone. Street fentanyl can be snorted, injected or swallowed. Illicit fentanyl is frequently sold as counterfeit pills that resemble less-potent prescription opioids or even benzodiazepines such as Xanax.

Although fentanyl can relieve extreme pain, it comes with a price. For thousands of Americans, this prescription medication, or, more often, illicit versions of it sold on the street, results in a powerful addiction that all too often ends up with overdose and even death. Over the past decade, deaths from fentanyl overdose have been on the rise, often from combinations of the drug with other illicit substances sold on the street.

How fentanyl works

Both natural and synthetic opioids, including fentanyl, work the same way in the body. The human body produces chemicals, such as endorphins, that work in much the same way by binding to particular receptors in the brain and other organs. With opioids, your perception of pain is reduced. When the drugs bind to the receptors in the reward center of the brain, they produce a sense of well-being. Deeper in the brain, binding with opioid receptors can result in drowsiness and respiratory depression, which can lead to overdose and death.

Opioid receptors in other parts of the body can lead to constipation and cardiac arrhythmia. As with pain control, sometimes opioids are prescribed by physicians to treat diarrhea and to reduce high blood pressure after a heart attack.

Double-edged sword

With use over time, fentanyl and other opioids induce tolerance. The user doesn’t respond to the drug as strongly as in the past because the brain’s natural opioid system becomes desensitized and less responsive. More of the drug is necessary to achieve the desired effect.

As with other opioids, patients can become physically dependent on fentanyl the longer they take it, requiring increasing amounts to alleviate pain. If taken as prescribed, patients are less likely to become addicted to the medication. However, misusing fentanyl or having a history of substance abuse can put you at greater risk.

The opioid crisis

It’s impossible to discuss fentanyl without bringing up the opioid crisis currently in the U.S. Doctors increasingly began prescribing opioids, such as hydrocodone and oxycodone, around 20 years ago to help patients with chronic pain, such as arthritis, after some evidence indicated the drugs weren’t as addictive as once thought. Between an aging population and heavy marketing by pharmaceutical companies to patients, the number of prescriptions skyrocketed, tripling between 1999 and 2010.

What physicians soon discovered is that, over time, many patients who regularly take opioids often required increasing amounts of the drug to achieve the same pain relief. Some patients taking opioids also began developing a condition that makes them feel pain more acutely, causing them to need even more of the medication. Fentanyl became the next prescription doctors would offer when other, less-powerful opioids stopped working.

What are the signs of fentanyl abuse?

Someone high on fentanyl can display feelings of euphoria and confusion. Users often appear drowsy or sedated. They may also have difficulty breathing. Sometimes fentanyl users report nausea or constipation.

How bad is the problem?

Some parts of the country are reporting that fentanyl overdoses continue to skyrocket. According to the Centers for Disease Control and Prevention, as of early 2017, 183,000 Americans died of opioid overdose. The number of deaths has increased 250 percent since 1999. In 2015 alone, 33,000 Americans died of opioid overdose, according to the National Institute on Drug Abuse.

It’s estimated that two million Americans suffered from opioid abuse in 2015. The CDC estimates that the cost of the opioid drug crisis is approximately $78.5 billion annually. The statistic factors in loss of work productivity, as well as the cost of health care, treatment and criminal justice involvement.

Older Americans are more likely to die of an opioid overdose. Adults between 45 and 54 accounted for 30 percent of opioid-related deaths in 2015. The second-largest group was adults ages 55-64, with 21 percent of the fatalities. However, some researchers find that teens are more likely to die from a street fentanyl overdose.

Law enforcement seizures of illicit fentanyl closely parallels synthetic opioid overdose deaths. In 2013, law enforcement reported 1,000 seizures. In 2015, the number of fentanyl seizures jumped to 13,000.

Effects on others

Although fentanyl is less likely to affect people exposed to it, some medical personnel and first responders have required treatment after coming in direct contact with it. Rescue personnel must take precautions not to breathe in the powder or get it on their skin.

Newborn babies are also adversely affected by fentanyl and abuse of other opioids. It’s believed that one baby born every 25 minutes is addicted to opioids. These tiny victims suffer from NAS, or neonatal abstinence syndrome. Babies endure painful withdrawal, requiring morphine. Neo-natal intensive care units also use cuddling and music therapy to help.

Newborns with NAS require long hospitalizations to become stabilized and then be weaned off opioids. Doctors aren’t sure what the long-term effects of NAS will be as these babies grow into children and adults.

People who inject street fentanyl are also at risk for devastating diseases often found in IV drug users, primarily hepatitis C and HIV/AIDS. Users contract these diseases by sharing or reusing syringes.

Carfentanil: An even bigger danger

In just the past couple of years, a new, even more powerful opioid has made its way to the streets of America. Carfentanil is 100 times more potent than fentanyl, and 10,000 times stronger than morphine. It was developed in the 1970s to sedate elephants and other large mammals. The substance is so toxic to humans that defense experts worry that it could be used as a weapon of mass destruction and may have already been weaponized in Russia to use against its own people. Carfentanil’s potency puts others at extreme risk as well. First responders can overdose and die simply by absorbing a small amount of carfentanil through their skin or by inhaling it.

Carfentanil is already being laced into heroin found on the street, according to an alert from the DEA in late 2016. This dangerous cousin of fentanyl is also found in a powder, a spray and on blotter paper. Both Mexico and China are manufacturing carfentanil and distributing it in the U.S., according to the DEA.

Fentanyl overdose

A person can overdose and die from fentanyl anywhere between 20 minutes and two hours after taking the medication. When someone takes too much fentanyl, breathing stops, which quickly shuts down the body’s functions and results in death. It’s important to get help immediately if you suspect someone has overdosed.

Who’s at risk

Anyone who buys fentanyl on the street is at risk, because there is no way to know what drugs have been mixed with it and no way to gauge its potency. Others at risk include those who are resuming use after attempting to kick their addiction or haven’t had access to fentanyl due to being in jail, treatment or the hospital. Another risk factor is mixing fentanyl with alcohol, benzodiazepines such as Xanax or stimulants, including cocaine or Adderall. People who use fentanyl alone are at higher risk of overdosing and not being discovered before it’s too late.

Overdose signs and symptoms

A friend or loved one may be suffering an overdose of fentanyl if you detect her breathing or heart has stopped. Other signs include blue lips or fingertips, the inability to wake up, and a clammy, colorless face.

The first thing to do if you suspect overdose is to call 9-1-1. Emergency responders can direct you on what to do until they arrive. Don’t try reviving your loved one with a cold shower or coffee before calling for help. Time is of the essence in order to increase the chance of survival.

Life-saving naloxone

Because the rate of overdose is so high from opioids, the pharmaceutical industry designed an easy-to-administer medication, naloxone, that can reverse the effects of fentanyl. Because of the drug’s potency, patients may require more of the drug to negate the deadly effects.

Known also under the brand name Narcon, the medication is available over the counter at pharmacies in most states. It’s available as a nasal spray or an injectable pen, similar to ones used to counteract an allergic reaction.

It’s important to know that in the case of fentanyl overdose, several doses of naloxone may be required. Emergency medical personnel can instruct you on how to administer naloxone and how often. You may also need to perform rescue breathing until medical personnel arrive.

Who should have naloxone on hand?

Unfortunately, the rate of relapse after treatment from opioid abuse is reported to be high, so anyone who has had a problem with fentanyl addiction in the past should have a naloxone kit in their home. Patients who are at risk of abusing opioids prescribed to them may also require naloxone.

Sometimes people don’t call for help after an opioid overdose because they are afraid of the legal ramifications. Many states have created laws that prevent people who overdose from being charged with drug possession if they go to treatment.

Treatment options

Several treatment options for fentanyl addiction are currently available, and even more are on the horizon. Successful strategies so far have included a combination of medications and behavioral counseling. This treatment protocol, called medication assisted treatment, or MAT, has been found to decrease heroin overdose up to 37 percent in cities where it’s been introduced.

The medications typically used in MAT include methadone and buprenorphine. New extended-release formulations of buprenorphine can be implanted under the skin so patients don’t require daily dosing. Medications help relieve cravings and withdrawal, giving patients a better shot at recovery.

Three medication classes have been approved to treat opioid addiction and are considered first-line treatment options. Agonists, such as methadone, work by activating opioid receptors. Partial agonists, which include buprenorphine, also activate opioid receptors but produce a diminished response. Antagonists, like naltrexone, block the opioid receptor, interfering with the drug’s effects.

More than 30 studies have found that these drugs, coupled with counseling, have a significant impact on curbing opioid dependency. Researchers found patients who are prescribed methadone are four times more likely to stay in treatment. Even without counseling, methadone patients were found to have better outcomes.

Patients on buprenorphine had a 75-80 percent reduction of opioid-positive drug tests. This drug and methadone have been found to be equally effective for reducing opioid abuse symptoms.

Abstinence, a short-term treatment goal, has been found by researchers to result in an increased risk of relapse. Tapering off opioids without prescribed medication and counseling support does not seem to have a positive outcome in the long term for most addicts.

The problem is, one study found that fewer than half of private-sector treatment programs offer first-line medications. Most patients with an opioid abuse issue don’t seek treatment, although one study found that patients who survive an overdose display increased treatment retention and improved outcomes.

Because methadone and buprenorphine must be used at high doses to be effective, some health professionals are wary of prescribing the medications for opioid treatment. A 2011 study found that 22 percent of patients in treatment programs were receiving less than the minimum recommended dose. A new study found that some patients have a gene variant that requires even more methadone.

As with any addiction, fentanyl users are more likely to achieve long-term success with a support system. Supportive friends and family are essential, as are opportunities for work, housing and child care.

Withdrawal symptoms

Fentanyl presents unique challenges when it comes to withdrawal. Because the drug is so potent, users are likely to have a very strong opioid dependency. Although not much research has been conducted about fentanyl in particular, doctors believe that patients could have severe withdrawal symptoms that could be potentially life-threatening. Patients could suffer from seizures or cardiac arrhythmia.

Another area of concern is that the sudden reversal of opioid in the system of a fentanyl user could cause life-threatening effects. Always seek medical help when using naloxone to reverse opioid overdose or when attempting to stop taking fentanyl.

There is hope

Even if you or a loved one is addicted to fentanyl, there is hope for recovery. With support and treatment, addicts can learn to live without this powerful drug before they overdose.

Check with your employee assistance program to find what treatment options are available to you or your family member for fentanyl addiction. Staff will have the latest information about programs in your area.