Fentanyl: the Scariest Opioid?

With 50 times the strength of heroin, fentanyl poses a rising threat.(Copyright 2016 U.S. News & World Report)

Last week, an autopsy revealed that superstar musician Prince died from a fentanyl overdose. The tragedy has drawn attention to a powerful drug that until recently flew under the radar. Fentanyl, a prescription pain medication, is part of the opioid class that includes prescription drugs such as oxycodone, morphine and hydrocodone, as well as the illegal drug heroin. While fentanyl-related deaths and overdoses are part of a much larger U.S. opioid problem, the drug has unique features that make it a growing threat. Here’s what experts say you should know.

Prescription fentanyl is available as a generic drug or in brands including Duragesic, Actiq and Fentora. It’s used to treat severe, chronic pain patients may have, such as in late stages of cancer or severe orthopedic injuries involving long recoveries. Typically, it’s prescribed for patients who have already tried several other medications, such as OxyContin, but are still having pain. Fentanyl comes in several forms, one easier to obtain than the rest.

For outpatients, the most common form of fentanyl is a transdermal skin patch, which is rectangular and transparent. Patients apply patches to smooth areas like the upper arm. Essentially any physician can prescribe fentanyl patches, which are available at any community pharmacy, says Mohammed Jalloh, an American Pharmacists Association spokesman. Fentanyl patches are less restricted than other forms of the drug because there’s much less potential for abuse and overdose, he says. However, he adds, there have been some cases of overdose with patches, particularly when patients are also taking another opioid medicine and/or abusing the patches.

Fentanyl, which carries a Food and Drug Administration “black box” warning like other opioid drugs, poses safety risks for several reasons. “It’s just so much more potent,” Jalloh says. “It’s even 100 times more potent than morphine. People say it’s pretty effective, but the scary thing is, it can be a little too effective.”

Prescriptions of other forms of fentanyl, including tablets, nasal sprays and lozenges, can only be written by specially licensed physicians and filled at specific pharmacies that participate in a Food and Drug Administration program to promote safer use of high-risk medications.

Access to Fentanyl pills and sprays is heavily restricted “because there’s just such a high risk of toxicity,” Jalloh says. “Unfortunately, this is a medication that’s been associated with overdoses. And people, unfortunately, have overdosed at prescription level. So it’s not like they took more than they should have. They took the medication as recommended by their prescriber.”

Fentanyl works directly in the brain by binding to what are called a mu opioid receptors, Jalloh says. That’s why it’s so effective at eliminating pain in the body. But along with pain relief, or analgesia, fentanyl users experience euphoria. “The black box warning says it can cause an addiction,” he notes. “It can lead to abuse and misuse. Which could lead to overdose and death.”

Illegal Fentanyl

The United States is seeing a sharp rise in illegally diverted and illegally manufactured fentanyl, says Melvin Patterson, an agent with the U.S. Drug Enforcement Administration. In 2015, more than 13,000 seized forensic exhibits involving fentanyl were tested by labs nationwide, according to the DEA’s National Forensic Laboratory Information System. That’s a 65 percent increase from 2014, and roughly eight times as many exhibits as in 2006. “This is an unprecedented threat,” Patterson wrote in an email.

Diversion (theft) of pharmaceutical fentanyl from health care facilities, pharmacies and manufacturing plants for personal use and sale is one concern, Patterson says. However, clandestine fentanyl, which is produced in illegal labs, primarily in Mexico, is a much larger-scale problem. “Clandestine fentanyl is available throughout the United States, most commonly in the white-powder heroin market,” Patterson explains. “Fentanyl is added to heroin to increase its potency, or is mixed with and sold as fentanyl or disguised as highly potent heroin.”

Many times, users buy fentanyl-laced heroin, touted by dealers as stronger heroin, without even being aware that it contains fentanyl, Patterson notes – which only adds to the danger.

Overdoses and Accidents

Having fentanyl in the mix of drugs causing an overdose makes that overdose harder to reverse, says Dr. Maryann Amirshahi, an emergency room physician with MedStar Washington Hospital Center and a medical toxicologist. Fentanyl, which is a synthetic opioid, has a different chemical structure than traditional opioids such as heroin or codeine, she says, making it bind more tightly to receptors in the brain.

Because fentanyl is more potent, more of the emergency drug used to treat opioid overdoses – called naloxone or Narcan – may be needed, she says, twice the standard dose or more. And because paramedics and E.R. doctors may not be aware of that, or even realize that fentanyl is involved, the patient could be undertreated and fail to respond.

“The big thing that kills people is respiratory depression,” Amirshahi says. “People essentially forget to breathe.” If a patient survives and makes it to the ER, a breathing tube can be inserted so he or she can be put on a ventilator.

Children face a different kind of risk from fentanyl. A lozenge form of the drug is sometimes called a fentanyl “lollipop.” It looks like a raspberry lollipop, Amirshahi says, but can contain a fentanyl dose high enough to be fatal to a child. “We don’t really see a lot of it because the medication isn’t used that commonly,” she says. “It’s more for end-stage cancer patients. But it’s an attractive, palatable form, if you think about it, for a child.”

Whether it’s a lozenge, transdermal patch or another form of the drug, Amirshahi says, “What we need to do is counsel people who have fentanyl prescription products in the home to make sure they’re storing them and disposing of them safely.”

Addiction and Recovery

Treating a patient in the ER or hospital for a fentanyl or heroin overdose is one thing, Amirshahi says, but preventing a second overdose is another. “One thing that has been very difficult is the fact that opioid abuse is [something] you don’t quit cold turkey very easily,” she says. Patients who are addicted often need medication assistance with drugs such as methadone or a newer drug called buprenorphine, or Suboxone.

“The problem is that a lot of our patients lack access to substance abuse services,” she says. “Also, just the logistics of getting to a medication-therapy program.”

At the Blue Ridge Mountain Recovery Center, located in Georgia, problems with fentanyl are usually related to heroin. “A lot of heroin, at least in this area, is being cut with fentanyl,” says Todd Stumbo, the center’s CEO and an addiction counseling specialist.

“We can typically detox someone off fentanyl within three to five days,” Stumbo says, by giving Suboxone and tapering the dose. “Most of our clients have mild symptoms of withdrawal. They’ll be agitated, restless; have some chills and sweats, a little insomnia. But we still require them to get up, go to groups, that kind of thing. So they are able to function.”

Detox is just the start. Successful recovery means treating the whole person, Stumbo says, examining his or her physical, emotional, social and spiritual life. After the patient leaves, the program includes follow-ups by staff, outdoor group events and alumni mentoring.

There’s a growing movement in the United States toward more careful opioid prescribing, and that includes fentanyl. More than 6 million fentanyl prescriptions are now dispensed in the U.S. each year, according to DEA documents. There is still a place for fentanyl use among patients with intractable pain, experts say.

“It is an effective medication,” Jalloh says. “I don’t want to be the one throwing fentanyl under the bus.” Educating health care providers, including physicians, pharmacists and nurses, is essential, he says, to ensure patients are safe. In turn, he says, it’s up to providers to “educate, educate and educate” patients. That includes discussing interactions with other medications like the antifungal drug ketoconazole, which can intensify fentanyl’s effects.

When a celebrity like Prince dies from an overdose, Jalloh says, other people who’ve been prescribed the same drug bring up concerns: “I’ve been taking this for a while. Do I need to be on it?” he hears. “And this is where I say, ‘It’s a good opportunity to ask your doctor.'” Switching to another drug might reduce the risk of respiratory depression or other breathing problems, he says, while offering the same therapeutic benefit.

Copyright 2016 U.S. News & World Report