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Fentanyl: widely used, deadly when abused

Fentanyl is 100 times stronger than heroin. Alcibiades via Wikimedia Commons

Fentanyl, a synthetic opioid narcotic about 100 times as potent as morphine, continues to be in the news, as deaths from fentanyl overdose continue to rise and even more potent nonpharmaceutical forms become available on the street. It was the drug in Prince’s body and the cause of his death by overdose. The Centers for Disease Control has issued a health advisory to warn of its dangers, as deaths from synthetic opioids, mainly fentanyl, rose to 5,500 in 2014.

Many legitimate questions arise whenever tragic events happen. When high-profile persons are affected, the conversation becomes a national one. With news of the growing increase in nonpharmaceutical versions of fentanyl coming in from China and Mexico, the conversation broadens to an international one. How can we prevent deaths from overdose of this potent drug?

Let’s address some of the most frequently asked questions I’ve heard about fentanyl recently, but before we do that, I want to put you in my shoes for a minute.

I am an anesthesiologist. To an anesthesiologist, fentanyl is as familiar as a Philips screwdriver is to a carpenter; it is an indispensable tool in my toolbox. It is the most commonly used painkiller during surgery. If you’ve had surgery, it is more likely than not that you have had fentanyl. Fentanyl is used to blunt airway reflexes and to place the breathing tube into the trachea with minimal coughing. It is the potent analgesic that prevents pain from the surgeon’s scalpel while your body sleeps under anesthesia. It is also the painkiller that allows you to wake from anesthesia without feeling existential pain in the immediate recovery room once the gases are turned off. Fentanyl is used to enable millions of people to undergo major surgery in the United States every day.

Before fentanyl existed, there were morphine and other similar, relatively weak opioids that were insufficient for the type of major surgery that happens today. To treat major surgical pain, morphine is not only too weak but it is slow and, once given, lasts a long time. And since opioids slow and stop your breathing, historically, patients who received large doses of morphine for surgery had to remain in intensive care units with the breathing tube in place for a long time after surgery until the morphine wore off. And doubly adverse, morphine causes histamine release in the body, resulting in cardiovascular side effects like low blood pressure – not a good thing to have during surgery if you want to wake up with working organs.

Surgical advances, opioid expansion

Fentanyl has enabled complicated surgery. Operating room image via

The precision and timing of modern surgery required a painkiller that was fast-acting, potent enough to blunt pain from a scalpel, stable enough not to cause cardiovascular problems, and short-acting enough to enable removal of the breathing tube once the surgery was over.

Fentanyl was developed by Dr. Paul Janssen in Belgium during the 1960s to meet precisely this need, and it contributed to the expansion and safety of surgery we do today. In fact, the expansion of open-heart and bypass surgery in the 1970s depended on concurrent progress in the safety of anesthesia through the use of fentanyl.

In the hands of an anesthesiologist who is licensed to prescribe and dispense fentanyl in the operating room, the drug is safe, even given its potency. Unmonitored, it can easily lead to death, as it essentially causes a person to stop breathing.

You may wonder: Isn’t there something safer?

Yes, there are alternatives, but they are not necessarily safer. There are other, even more potent opioids like sufentanil and shorter-acting opioids like alfentanil and remifentanil, most of which are much more expensive but not any safer. There are non-opioids such as ketamine, lidocaine and ketorolac that are used for surgical pain, and these are being utilized more and more to spare the need for large doses of opioids. There are even ways to do surgery under regional anesthesia, where the anesthesiologist can make the region of your body numb and unable to feel anything or very little so that opioids are not required.

But you can’t take your anesthesiologist home, and sometimes a person experiences severe, persistent, pain post-surgery.

Why would anyone need to take fentanyl at home? There are a few reasons, but the most common reason is tolerance. People with prolonged, severe pain who continue to use opioids will experience tolerance as their bodies becomes used to the pain medicine over time. To continue to treat the persistent pain, they may need a dose increase. Eventually some patients end up on very potent opioids like fentanyl.

Persistent pain can occur from surgery, trauma or chronic illness. Cancer is a big one. It can be a source of unending, intense pain, and we treat that with the best tools we have. Over time, as patients become tolerant to weaker opioids, the more potent opioids are needed to control the pain. Fentanyl is one of those drugs strong enough to treat major surgical and unending cancer pain that has become tolerant to other opioids.

Good drug, killer drug

So this begs the question: What happens when a person who is not opioid-tolerant takes fentanyl?

Anesthesiologists give fentanyl and are expert at controlling a patient’s airway and keeping them breathing while they are being observed. Pain physicians prescribe fentanyl in a very controlled manner and only after a patient has been observed and deemed tolerant to weaker opioids.

So, when someone who is not tolerant to opioids takes fentanyl, it is very easy to overdose, to stop breathing and to never wake up. It is very easy for those who do not use these potent painkillers as prescribed to overdose.

Fentanyl can be used safely if used as prescribed, but it is a killer on the streets. Fentanyl analogues are relatively easy to synthesize and are often mixed with heroin or benzodiazepines to quicken the onset and enhance the high. A simple Reddit search reveals the many forms of fentanyl that are being synthesized and sold illegally and the countries it is being smuggled in from. Even the users and dealers there warn about its potential for easy overdose. Indeed, many users don’t even know the heroin or xanax they have bought on the street is laced with fentanyl until it is too late.

Do we need fentanyl, and have we contributed to its abuse? This is a question we ask ourselves as we struggle to get a grip on the modern opioid epidemic, tragedies like the death of Prince and patients who suffer from pain and addiction.

Can we do without medications like fentanyl altogether? Right now, we cannot do without opioids entirely. We would need potent alternatives with limited side effects. The alternative tools we have are insufficient to enable us to quit opioids cold turkey.

A sort-of transition plan has developed in the medical community where we use multiple non-opioid pain medications in combination with nonmedication treatments, such as mindfulness, behavioral therapy and education to minimize the need for opioids. In many instances, these creative efforts have enabled opioid-free options for specific major surgeries. The good news is that the demand for change has reached the top levels of government, hospitals and patient organizations. Money for research and education is being made available. New laws are being enacted. A revolution in pain management is necessary and, hopefully, imminent.

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