Fentanyl: The dangers of this potent “man-made” opioid

Sarah Wakeman, MD, FASAM, Medical Director, Massachusetts General Hospital Substance Use Disorder Initiative

As we watch the devastation of the opioid crisis escalate in a rising tide of deaths, a lesser known substance is frequently mentioned: fentanyl. Fentanyl’s relative obscurity was shattered with the well-publicized overdose death of pop star Prince. Previously used only as a pharmaceutical painkiller for crippling pain at the end of life or for surgical procedures, fentanyl is now making headlines as the drug responsible for a growing proportion of overdose deaths.

So what is fentanyl and why is it so dangerous?

Fentanyl is a synthetic opioid, meaning it is made in a laboratory but acts on the same receptors in the brain that painkillers, like oxycodone or morphine, and heroin, do. Fentanyl, however, is far more powerful. It’s 50-100 times stronger than heroin or morphine, meaning even a small dosage can be deadly.

Its potency also means that it is profitable for dealers as well as dangerous for those who use it, intentionally or unintentionally. Increasingly heroin is being mixed with fentanyl so someone who uses what they think is heroin may in fact be getting a mixture with — or even pure — fentanyl. More recently, pills made to look like the painkiller oxycodone or the anxiety medication Xanax are actually fentanyl. This deception is proving fatal. It would be like ordering a glass of wine and instead getting a lethal dose of pure ethanol. While many people don’t know they are getting fentanyl, others might unfortunately seek it out as part of the way the brain disease of addiction manifests itself into compulsively seeking the next powerful high.

Helping people who use fentanyl

The way to help patients who are using fentanyl is the same as for other forms of opioid use disorder: to provide effective addiction treatment. However, the first and most important step is helping patients stay safe and stay alive until we can get them that treatment.

It’s worth remembering that dead people don’t recover.

To stop the deaths, we must provide immediate access to lifesaving treatment on demand. While any opioid use is risky, fentanyl has raised the stakes. Every single episode of fentanyl use carries the risk of immediate death. This highlights the need to change how we think about treatment. Many of the traditional models of addiction treatment were designed for alcohol use disorder. Misuse of alcohol can be fatal, but it usually takes many years or even decades to kill someone. In contrast, opioid addiction is imminently fatal, so waiting for treatment is and should be considered unacceptable. We must try to initiate treatment at every opportunity — in the emergency department, at the hospital bed, or even on the street. The best evidence we have shows that a combination of medication and psychosocial treatments is most effective for opioid use disorder. A study of MassHealth patients found that patients on medication treatments like methadone or buprenorphine are 50% less likely to relapse. Other studies have shown that patients treated with these medications are 50% (or more) less likely to die. And yet significant stigma and misunderstanding still exists around these medications. We have treatment programs (and doctors) that don’t offer these medications and patients who are doing wonderfully in recovery thanks to them, but who are also scared to speak out and say they are on medication because the stigma is so pervasive.

Even with our best efforts, it can take time for some people to be open to treatment. In those cases, our priority is to keep them alive and to keep working with them on their readiness to consider treatment. This requires access to naloxone, the antidote to overdoses. But it also includes other education and harm reduction services. People who have loved ones who are actively using and those who are using themselves need to know how to stay safe. There is very concrete education that can reduce the risk of overdose and we need to ensure it is getting to those at the greatest risk.

Moving forward

In Massachusetts alone, deaths due to fentanyl overdose have risen to 57% between 2015 and the first half of 2016. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.

Comments:

  1. Lee

    I know people mean well, but the level of ignorance I’m seeing here is frightening. 15,000 to 20,000 people per year die because they take a MIXTURE of drugs which include legal opiates inappropriately (their fault, not their doctor’s or pharmacist’s fault). Toss in ILLEGAL opiates and you get up to around 30K. There are 320 MILLION people in America. When did people lose the ability to do simple math?

    Fentanyl (administered by a nurse in a hospital) is the best pain drug I’ve ever been given. Prince was a victim of Prince, and also of the black market – mislabeled hydrocodone as a result of making a drug “illegal” (demonizing an object). What do most of us do? We demonize fentanyl, incredibly. The lack of empathy for people in pain who are being made to suffer today is jaw dropping, and all because of a falsely advertised “opioid epidemic.”

    The 2011 CDC report didn’t even MENTION the two wars and thousands of injured soldiers. There was no method for delineation among stolen or prescribed (or legal vs. illegal) opiates. Hydrocodone was increasingly prescribed, so taking the spike in ACTUAL number of deaths is meaningless. The PERCENTAGE of the total hasn’t changed a lot. I could go on and on listing idiotic assumptions being made by many, all because loved ones of people who took a whole fucking bottle of pills at the same time want to find someone else to blame; and corrupt politicians (and many doctors and pharmacists) know they can now take advantage of these chronic pain patients. Government control provides the means.

    The lack of empathy is the most shocking thing: The idea a woman would want her father to live for 20 more years in constant, severe pain as opposed to being offered an attempt at relief is odd, but that’s the lack of empathy I’m seeing out of most people. People are different. We deserve the individual freedom of choice. America has regressed by about 30 years, and our most vulnerable (including injured veterans) are being screwed over more and more every day.

  2. Odessa S.

    I am a 72 year old who had paralytic polio at age 6 and now have problems directly and indirectly related to having had polio, including severe scoliosis (inoperable, at least as my age). I have a progressive “neuromuscular disorder” known as the Late Effects of Polio AKA: Post-Polio Syndrome and Polio Sequalae. I use fentanyl, hydrocodone, & oxycodone under the close supervision of my physician. I am indeed dependent but not addicted. I agree with most of, and appreciate the posts by Jennifer S. & the Hospital Pharmacist. Although many people who had polio and suffer from Post-Polio Syndrome and/or the Late Effects of Polio do not have severe pain, some do. I do. Probably because of the total involvement of my back muscles and the severe scoliosis. I had symptoms for 15 years before diagnosis, and another 13 years using only NSAIDS for pain management. Now prescription pain medication makes it possible for me to lead a sometimes normal life and continue to care for myself, interact with friends and be an active member of the local Polio/Post-Polio Support Group. As one post said: “Don’t suggest alternatives.” I have tried alternatives. Some worked a little or for a short while and most none at all. I am very careful with my meds. I keep a log and have read all the literature that comes with each prescription. You can truly only understand if you have walked in my shoes which I pray does not happen to you.

    I get my medical care from a local community health clinic and my primary physician is feeling pressure “from above” to reduce the use of opioids. Ok. But that should be done on an individual basis. Not across
    the board. I do not know the details of the musician Prince’s story, but I doubt seriously the fentanyl was his only problem.

    Until you know both sides of the subject, please do not say things such as “Why don’t they just get rid of the drug?” Please.

  3. Danita D. Ross Santa Fe, NM

    You speak of Fentanyl now often in other meds, like Xanax, etc… BUT IS THIS DONE BY THE DRUG PHARMACEUTICAL INDUSTRY… or Street Drugs?
    That is never mentioned, and if it is being done by Drug Corps., need to send this to MAD in AMERICAN winning suits right and left, now international group, grassroots Harvard four people started it to begin
    watch-dogging the insanely leaping ‘new’ drugs and corrupt ads…MAD is international, as I said, and UK really going to town against Drug Comps. But for here: Again, are drug companies mixing fentanyl in other pills, or are you talking about ‘street’ drug makers? This is a very important distinction. Thank you for your article. Dd Ross, journalist.

  4. D. Adam Schwarz, MD

    1. Fentanyl can be abused when made pharmaceutical grade. Patients cut open the patches and smoke the gel, or eat it.
    2. It is readily synthesized in black-market labs, like meth. We cannot differentiate it from pharmaceutical grade with the best LC-MS/MS equipment (toxicology).
    3. Unfortunately, the overdose statistics in our country classify all fentanyl with prescription opiates so that muddies the water a bit. A great publication by the forensic scientist from Montgomery County, OH in 2015 (?) clarified OD deaths from prescription vs illicit fentanyl. OH had heroin > presc. opiate OD 1st time in 2014 (national avg. presc opiate 4x OD vs heroin).
    Dr. Wakeman has a decent post, however I shed caution: While Medication-Assisted Treatment (MAT) may be beneficial in her University group, I have SERIOUS concerns with the majority of the methadone and buprenorphine treatment in this country.
    We have the majority of prescribing for buprenorphine coming from doctors that only received 8 hours of training, one-time only! I see patients that have more addiction problems, have been stuck for years in methadone clinics, or years on buprenorphine (without any counseling), so the jury is out. Yes, if done properly, MAT is the best way. However, as long as the government and doctor’s addiction societies continue to permit this egregious 8 hour only training, then unleash unregulated Drs to prescribe . . . . . .
    Well you will substitute another addiction. It won’t kill them, until they run out.

    • Danita D. Ross Santa Fe, NM

      Just thank you for your well-articulated and meaningful comment.
      Dd Ross, Santa Fe, New Mexico. (Journalist, and generic writer!)

  5. Romanov

    💟💝💓💗💖

  6. Thom Kulesa

    This article sounds like little more than panic and fear-mongering.

    As someone in effective pain-management, using a fentanyl patch, and being seen by a doctor every 30 days, I fully understand how useful fentanyl is when it’s the only medication that works.

    Not once in your article did you mention that fentanyl has theraputic value that doesn’t cause addiction when properly used. Not once did you simply say that fentanyl should only be used under proper medical supervision, and only by people who have been living with sever chronic pain.

    I understand that there is supposedly an epidemic going on. However, if you listen to the news, there is always some fear-mongering, end of the world, epidemic going on. This is just the latest. Don’t feed the trolls. Or better yet, don’t become one of them.

    • Olga

      Fearmongering right, more likely in denial. We all know that we have an epidemic of drugs abusers in the US, the fact that Hollywood glamorize it isn’t helpful either. This is absolutely missleading the young generation that easily get trap between peer pressure and thinking is cool. While is destroying their brains and life. Not too glamorous when you can actually see brain scans and objectivity see the massive damage drugs do to the human lives

  7. Tyler Neill

    Thank you for this useful article on this very urgent topic.

    The wording on the “57%” statistic struck me as a bit odd. “57% of what?” I asked myself. At the provided link:

    “Sixty-six percent of 2016’s confirmed opioid-related overdose deaths had a toxicology screen that tested positive for fentanyl, an increase over 2015 (57%).”

    In other words, as I understand it, fentanyl’s involvement in opioid-related overdose rose from 57% in 2015 to 66% in 2016. This article seems to focus on the lower number. Regardless, either number is terrible.

    Thanks again.

  8. Wendy

    When my mother was prescribed phentanyl patches, after 2 unsuccessful surgeries to repair a broken hip, the only warning they gave us was to avoid heat. For example, do not use electric blankets. In her case, even the phentanyl did not eliminate her intense constant pain. We needed to move her from Florida to California to get her the pain relief she needed. She passed away 12 days after this mammoth move. That was 10 years ago and I’m not sure what we have learned about pain management or death with dignity since then.

  9. Aalt van den Ham

    I am a Dutch physician and on fentanyl 12 micrograms per hour. Thanks to my general practitioner, now seven years ago! It’s the only medication relieving my back pain, so I can sleep. Even the X-rays didn’t get worse in this period.

  10. Wim van der Pol, Hospital Pharmacist

    With some pharmacological knowledge (I am a pharmacist), I can say that potency is a misleading issue. The dose is always in relation with potency. However, if dealers and users (!) think in milligrams, and they make or mix the fentanyl dose themselves, yeh, than the situation is critical dangerous, because the dose of fentanyl is in micrograms. It is this problem that can be misleading, not the use of fentanyl in itself. This fact is also true for any opioid. Fortunate, the antidote is the same. There are far more potent opioid substances (than fentanyl) , and for sure they all will reach the black market in the future. In conclusion, potency is not the danger, but the inexperience with the right dose, as every pharmacist knows.

  11. Lily Tremblay

    Parce que je me sens très seule surtout, je vais enfin parler de ma dépendance à ce puissant narcotique. Voilà, j’ai déménagé, i mooved, i was without doctor in my city, so, my pain was really hight because my psychologic healh wasn’t good too. I was in deep depression after i lost everything, everyone who was important in my life. My futur hushband lift me after i have do everythigs for him, including my money. After i lost my home, after live my job because i was victim of harassment after 20 years of working, for my government in drug adiction, in psychology, i left my job, and i return with my house’s parents because i was unable to find a new work after many stop of work for healty problems, it’s hard to find a new job. The law prohibited to give information onto the medical record of an employee but they make him, (it) all the same. So, my psychological distress improve my pain. I have decide to take my patch of ‘Fentanyl’ by oral way, mouth. I took during this period, onme month of fentanyl during 5-6 days and i wanted die. After a paralycis of my hand, i changed my dose and now, i have less physical pain and i dont need fentanyl but i’m also addict in 2 ways. I need professional help for continue to reduce but it’s my first time in my life, i lost all control of products .During this period, i can understand i take drug for my psychologicals problems: i didnt have a good treatments: i have a disorder humor, bipolar probably. All my life, nobody tooks enought of time for give to me a good diagnostic ,so i didnt have a baby, an hushband because i felt unable to be a good mother cause my humor wasnt unstable. I can say, i canada, in Quebec, they treet us like a number in hospital and everyplace. I saw many psychiatrist and before to contact one who pratice in his own office, in private care, he discover i didnt have the good diagnostic. Now, i’m still waiting next appointment with a new doctor and a medication to gonna help me, i suppose, to stop ‘fentanyl’ because i didnit need fentaly anymore. I hope a good treatment gonna help me to stop this medication.
    I’ m sorry for my bad bad englisn , iM french Canadian and very bad in english. Sorry. Thank you for reading me.

  12. Destiny

    Fentanyl really is a dangerous drug. It’s sad to know that drug users are using this drug to achieve a better high than they would from a different drug. People should be informed of how powerful and dangerous fentanyl can be to their health.
    Hopefully, with the increase of Fentanyl overdoses, people can realize how harmful the drug really is.

  13. Anya

    Once people become addicted (by choice) to narcotics or other drugs such as methamphetamine, there is not much treatment that works. Even with rehab they frequently relapse.

  14. terry b hanson

    Similar Statistics to those aforementioned exist in British Columbia Canada. Fentanyl related deaths permeate communities both at recreational and serious drug use levels.
    terry bengt hanson (aa;bfa;Med)c
    abbotsford bc

  15. Jen

    Why don’t they get rid of this drug.

    • Jennifer S

      Because Fentanyl is an effective pain management medication when used properly. The people who die from “fentanyl” are ILLEGALLY taking illegally manufactured fentanyl that is made in other countries and that contains 100 times more fentanyl than that which is prescribed, manufactured and taken LEGALLY in this country. Legal fentanyl lozenges contain micrograms of the drug. Illegal fentanyl contains grams of the drug. Legal fentanyl is taken as a lozenge or patch, or IV when used surgically. Illegal fentanyl comes in many forms, in lethal doses, is sold illegally by criminals and taken illegally. It is almost impossible to be prescribed legal fentanyl these days and legal fentanyl is prohibitively expensive – over $10,000 for a 30 day supply – even though when taken correctly it is a very effective breakthrough pain medicine. It is rarely covered by insurance. Unfortunately, because legal fentanyl has been shamefully demonized in the press, and has not been distinguished from illegally manufactured and sold fentanyl, people like you come to conclusions that are based on incorrect information. This situation, along with the demonization of other legally prescribed and used pain medication, is causing immense suffering among individuals who follow the rules. Almost all of the problems related to prescription pain medicine are caused by people illegally manufacturing, selling and taking the drugs. This fact is hardly mentioned in articles about drug abuse – and law-abiding people are unfairly being punished because of the irresponsible way information about this issue is disseminated.

      • Cheryl Pappas

        I say, with all due respect, that I disagree with your argument that it’s only the illegal use of fentanyl that is a problem. The problem on the medical side is that doctors are overprescribing the drug for pain, and this, in turn, causes an addiction. My father was prescribed a fentanyl patch for his back pain and was on it for years. He became so dependent on it that his doctor made him sign a form that he woudn’t ask for any higher doses. I would take a closer look at the connections between the medical community and the pharmaceutical companies. My father’s doctor, though I’m sure she did want to help him, should not have given him a drug that he could become dependent on in the first place. Fentanyl was created to help alleviate pain of patients who were in the last stages of cancer. It was not meant to be prescribed for neck or back pain. Consider this company that produces Fentanyl as a spray.

        Respectfully,
        Cheryl Pappas

      • Jennifer S

        To Cheryl Pappas: I’m sorry for your father’s situation. As I have said over and over again, I believe the root of most opioid addiction problems in untreated/undertreated pain (as in the case of Prince). If doctors and regulators and law enforcement and politicians were honest about this issue, then perhaps better pain management treatments would be developed (new classes of pain medicines that don’t cause dependency issues). Properly managed pain is the best deterrent to misuse of opioids. Imagine how different your father’s situation would have been If such medications were around when he needed them. Also, it is vital that those debating this issue are very clear about addiction vs. dependency. Physical dependency is not problematic. It may cause physical discomfort if not managed correctly but it is not the same as addiction. To use both terms interchangeably is unhelpful to this debate. I assume you meant that your father became addicted to fentanyl patches. Physical tolerance to specific doses of opioids is another factor that can be problematic if not treated correctly, but tolerance is not addiction. Regarding present day prescribing practices versus those ten years ago, please understand that fentanyl prescribing practices are much more stringent today. Fentanyl cannot be prescribed unless all parties (Dr., patient, pharmacist) sign a very detailed document (Actiq and Fentora REMS Agreement) about properly using the medication. Fentanyl is the only opioid requiring a signed REMS agreement. A REMS agreement is not the same thing as the “contract” between doctor and patient when being prescribed pain medicine. Also, fentanyl is hugely expensive and not normally covered in most insurance plans. Finally, fentanyl is no longer prescribed for chronic pain (like it was 10 years ago). Besides hospital/surgical use, it is primarily prescribed for breakthrough, end of life pain. These are the three reasons that I believe that the majority of deaths from fentanyl overdoses can be attributed to illegally manufactured, sold and consumed fentanyl. An honest debate about how to solve this tragic situation would include both the failure of the healthcare industry to treat pain and the truth about what is actually causing overdoses (illegally obtained drugs) and who is actually overdosing (people illegally misusing illegal drugs). Unfortunately, those debating this issue have not been very honest, therefore, law-abiding pain management patients, doctors and pharmacist are being treated like criminals and looking at fingers pointed in the wrong direction.

    • Karen J. Ostby

      I’ve used a Fetanyl patch for severe, chronic, excruciating back pain for 10 1/2 yrs. & still needed an implanted spinal stimulator to manage my pain. I use it according to my pain specialist’s directions. I use the smallest dose possible for me, responsibly.
      I have an extremely bad back that is not a candidate for surgery. It’s due to rheumatoid arthritis for almost 30 yrs., some spinal stenosis, osteoporosis and adult onset scoliosis. My back no longer supports me. I need this drug! I have another taken at bedtime. I already tried PT many times. The last time all the wrong exercises made my pain worse for almost a yr. Don’t suggest alternatives.

  16. Norma

    I was given fentanyl as anesthesia for a colonoscopy. I made me I’ll for 3 days afterward.

  17. طرح توجیهی

    very nice and useful post. tnx