What is fentanyl?
Fentanyl is an extremely powerful synthetic opioid that is about 50-100 times stronger than morphine and 25-40 times stronger than heroin. Opioids are a class of drugs that bind to mu-opioid receptors in the brain to reduce the sensation of pain and induce a feeling of pleasure. They include prescribed painkillers and illegal drugs (like heroin). Fentanyl was originally made for clinical use and is still used in cases where someone has chronic pain and has become tolerant of other opioids.
Fentanyl is an extremely potent and potentially habit-forming drug. MedlinePlus stresses that it should be:
- Used as prescribed
- Not taken more than 4 times per day
- Used as directed and never crushed, split or chewed
- Used in conjunction with other pain-management medications
- Used for episodes of acute (breakthrough) pain
- Used in patients tolerant to other opioids
- Kept out of reach of children
- Stopped only under medical supervision – suddenly stopping may cause extremely unpleasant withdrawal symptoms
Fentanyl was developed as an intravenous anesthetic (Sublimaze) in the 1960s and has since been adapted for use as a potent painkiller. Commonly, prescribed fentanyl is used in the treatment of cancer patients and those in palliative care for pain-management. Unfortunately, its potency makes it a prime target for misuse. Fentanyl is also relatively cheap to make and is often found laced with illicit drugs like cocaine, heroin, methamphetamine and MDMA or in counterfeit versions of drugs, like oxycodone, hydrocodone or benzodiazepines. Users of these drugs often do not know that the drug is laced and do not have a tolerance for opioids, so the risk of overdose and death is extremely high. Users of these drugs may also form a dependence on or an addiction to fentanyl, without being aware that they are taking it.
Prescription fentanyl is currently available as:
- Oral transmucosal lozenges – commonly called fentanyl “lollipops” (Actiq®)
- Effervescent buccal tablets (Fentora™)
- Sublingual tablets (Abstral®)
- Sublingual spray (Subsys™)
- Nasal spray (Lazanda®)
- Transdermal patches (Duragesic®)
- Injectable formulations – fentanyl citrate is used for analgesia and anesthesia
Illicit fentanyl is found in the forms of:
- Drops on blotter paper
- Eye drops
- Nasal sprays
- Pills made to look like other prescribed drugs
- Laced with other illicit drugs
- Diverted prescription fentanyl (via theft, fraud and illicit distribution)
Fentanyl acts on the body much like other opioids. It crosses the blood-brain barrier rapidly, providing fast, short-duration effects. Fentanyl binds to mu-opioid receptors in the brain to change how it perceives pain. Chemically, opioids promote the release of endorphins, which suppress the feeling of pain and are a “feel-good” neurotransmitter.
Fentanyl is a reinforcing drug, which means that the act of taking it becomes associated with the pleasurable feelings from the endorphins. The brain encourages the person to take it again, as it relieved pain – be it physical or psychological. Each time opioids are taken, dopamine (the “reward” transmitter, which also creates a feeling of pleasure) is released, furthering the pleasure associated with taking the drug. Thus, people taking fentanyl are at risk of developing dependency and the development of opioid use disorder (OUD).
Dangers of fentanyl
Fentanyl is a drug that needs to be taken as prescribed and under the care of a qualified medical professional. MedlinePlus lists a range of side-effects. Mild side-effects should be discussed with the patient’s doctor if they are persistent. These include symptoms such as:
- Stomach pain, gas, heartburn
- Pain, sores, or irritation in the mouth in the area where you placed the medication
- Swelling of the hands, arms, feet, ankles or lower legs
Due to its strength, fentanyl has a high potential for overdose. Remember that this drug is 25-40 times stronger than heroin and up to 100 times more potent than morphine. Severe symptoms need to be reported to the patient’s doctor and discussed immediately; if they are not available, emergency services should be contacted. The Centers for Disease Control and Prevention (CDC) reports that overdose deaths related to synthetic opioids, including fentanyl and its analogs increased by more than 16% from 2018 to 2019. Further studies suggest that the rates may have been even higher in 2020.
- Excessive drowsiness or sleepiness
- Slow, shallow or stopped breathing
- Difficulty breathing
- Smaller pupils (black circles in the middle of the eyes)
- Unable to respond or wake up
- Cyanosis (turning blue from lack of oxygen in the blood, especially noticeable at places where the skin is thinner, such as the lips or nails)
- Remove fentanyl from the person’s mouth (if possible)
- Administer the first dose of naloxone (Narcan) – if available
- Call 911 or emergency services
- If the symptoms return within a few minutes of the first dose of naloxone, administer another dose
- Additional doses can be given every 2-3 minutes if symptoms of overdose persist (a person cannot overdose on naloxone, as it simply blocks the effects of the opioid)
- Keep watch over the person until medical help arrives
Fentanyl is an opioid, so the signs of misuse and addiction follow those for opioid use disorder (OUD). The Diagnostic and Statistical Manual 5 (DSM-5) characterizes OUD as when (within the previous 12 months) the individual has been unable to abstain from the drug and shows behavior changes with using or obtaining opioids that has caused dysfunction in their everyday lives. To make a diagnosis, a health professional will determine if at least 2 of the 11 signs of opioid use disorder (as defined by the DSM-5) have been present in the last 12 months.
The 11 factors Include:
- Taking larger doses of the drug or using it for longer than intended.
- Unsuccessfully trying to control or limit opioid use or persistent desire to use the drug.
- Spending a lot of time obtaining, using or recovering from opioids.
- Cravings, urges or a persistent desire to use opioids.
- Difficulty fulfilling home, school or work responsibilities.
- Continuing to use opioids, despite this resulting in negative consequences in your relationships.
- Changes in your normal activities to accommodate and prioritize using opioids.
- Using opioids in potentially hazardous physical environments or situations.
- Despite physical or psychological problems resulting from or exacerbated by opioid use, continuing to use the drug.
- Developing a tolerance for opioids – needing more of the drug to get the same effects.
- Experiencing withdrawal when abstaining from the drug or taking opioids (or a closely related substance) to avoid or self-medicate opioid withdrawal syndrome.
If you notice any of these signs in yourself, or a loved one, please reach out to Lakeview Health’s admissions team today. Learn more by contacting us at 866 704 7692 or reaching out online.
The exact potential for developing substance use disorder from using fentanyl, as compared to other drugs or opioids (like heroin), is not easily measured. However, fentanyl is 25-40 times stronger than heroin – which the Independent Scientific Committee on Drugs (ICSD). rated as the drug with the most potential harm to the individual and the second most harmful drug to society. Fentanyl is not only stronger and often cheaper than heroin, but also works faster, as it crosses the blood-brain barrier easily. It is also available through both licit and illicit means, which heroin is not.
The CDC reports that over 150 people die every day from overdosing on synthetic opioids (including fentanyl). While not all of these deaths are related to fentanyl addiction, there was a substantial increase in pills containing fentanyl seized by law enforcement between 2018-2021. These all seem to point to a growing population of people using fentanyl (knowingly or unknowingly), a drug with a high potential for addiction and misuse.
Once the body has built a physical dependence to opioids (like fentanyl), it gains an increased tolerance for the drug. This means that the body needs more of the drug to get the same effects and to avoid withdrawal. A person’s tolerance for opioids rapidly decreases as soon as they stop taking the drug. If the person finds withdrawal unmanageable, they may go back to taking the same dose of fentanyl as they were taking prior to detox. Their body might not be able to cope with this dosage, especially due to how potent fentanyl is. This can lead to fentanyl poisoning (overdose) and death. It is also highly recommended that people taking fentanyl have a few doses of naloxone on-hand in the event of an emergency. Due to the high risks associated with detoxing from fentanyl alone, people may consider detoxing at a rehabilitation treatment center.
Dangers of detoxing alone
As with other opioid use disorders, a combination of medication-assisted treatment, behavioral treatments and mutual-support groups has been found to be most beneficial. Detoxing from fentanyl alone can be extremely dangerous and should only be done under strict medical supervision. Finding a treatment center with an on-site medical detox center, like Lakeview Health, can make the detox and treatment transition easier and more integrated.
Behavioral treatments involve “talk therapy” or counseling. Therapists may have different approaches (such as cognitive behavioral therapy, dialectical-behavioral therapy and holistic therapies). These therapies focus on introspection, mindfulness-techniques, teaching emotional intelligence and facilitating changes in the person’s life that will assist in their recovery journey. The skills learned during this stage of treatment will provide patients with new, healthy ways to cope with life’s difficulties. These skills will help to combat and replace unhealthy coping mechanisms (such as abusing substances).
Social support is often integral to creating and maintaining a lifestyle free of substance abuse. Communities often have support groups that meet at convenient times and places or online. These groups, like Narcotics Anonymous (NA) and SMART Recovery, add another layer of support to the recovery process.
Medication-assisted treatment (MAT):
Medication-assisted treatment (MAT) for fentanyl may include providing drugs to cope with the negative side effects of withdrawal and reduces the risk of death by overdose. These medications are one of the most effective ways to combat relapse and the dire risk of relapse-associated overdose and death. Non-addictive, Food and Drug Administration (FDA)-approved medications for OUD, and fentanyl in particular, are methadone and buprenorphine.
Methadone and buprenorphine have been shown to improve treatment outcomes. Despite being a class of opioids themselves, in opioid dependent people, they will not produce the feelings of euphoria associated with previous drug use. Their primary use is to help people with OUD attend treatment programs, work and rebuild functional lives.
The National Institute on Drug Abuse stresses that medications (such as methadone and buprenorphine) used during the process of detoxing from fentanyl or opioids are not a case of one drug being replaced by another. The World Health Organization (WHO) recommends that these medications be used as a part of opioid dependence or addiction treatment plans. Here’s how they work:
Methadone – an opioid receptor agonist – occupies the same receptors as opioids in the brain, but at a slower rate. This activates these neurons, like opioids would have previously, so it removes withdrawal symptoms and cravings for opioids. Unlike opioids methadone does not give opioid users the feelings of euphoria associated with the drug.
Buprenorphine – an opioid receptor partial agonist – also binds to the opioid receptors, but activates them less strongly. Like methadone, this eliminates withdrawal symptoms and cravings but does not produce euphoric effects.
Naloxone is added to many of these medications to reduce the chance of misuse and overdose. Naloxone can be administered on its own as a nasal spray or by injection into the veins (intravenous), muscles (intramuscular) or under the skin (subcutaneous). It can also be combined with buprenorphine, as seen above, to make the medication safer to take. It is strongly suggested that all people keep naloxone doses on hand, in a place family and friends know about, if they (or a loved-one) are taking fentanyl or any other opioids.
Reducing the Impact of the Opioid Crisis
Although there is no direct route to immediately resolve the opioid crisis, the CDC suggests:
- Increased access and education around the use of naloxone in the case of overdose
- Education around overdose prevention
- Early intervention for people at high risk for overdose
- Improving how to detect outbreaks of overdose-related deaths
- Increased awareness around and access to treatment facilities for substance use disorders
If you or a loved one is looking for fentanyl or opioid treatment reach out to Lakeview Health’s admissions team today. Learn more by contacting us at 866.704.7692 or reaching out online.