Despite the warnings about opioid abuse and addiction, opioids continue to appear in the medical field and on the street. Many opioids were originally designed for legitimate control of pain from medical conditions, and they continue to be used for this purpose today. Fentanyl is one such opioid.
Fentanyl was developed to relieve pain in cancer patients that was not responding to other pain relievers. Due to its strength and low production cost, however, it has become a dangerous street drug that has led to an increasing number of overdose deaths in the United States. Let’s explain what Fentanyl is, how it has contributed to the opioid crisis, and how to recognize abuse and addiction.
What is Fentanyl?
Fentanyl is a man-made opioid that was developed to treat chronic pain in cancer patients. It was first synthesized in 1960 as a possible alternative to morphine for pain control during surgery.1 In 1990 the United States Food and Drug Administration (FDA) approved Fentanyl in the form of a transdermal patch for the treatment of chronic pain. The first transmucosal form of Fentanyl, Actiq®, was approved for use with chronic breakthrough pain in cancer patients in 1998. This form is administered via a dissolvable lozenge that is held under the tongue or inside the cheek. Additional versions were approved for use with cancer patients throughout the 2000s.2
As the opioid epidemic climbed to massive proportions in the United States, it was discovered that illegally produced Fentanyl was being used as a cutting agent for heroin, making both drugs very dangerous for recreational use. New warnings and restrictions were placed on Fentanyl products and other opioids during 2018, but illegal production and use continue.
Legal Fentanyl is currently used to treat pain in cancer patients that does not respond to other pain relievers. It is administered via transdermal patch, an oral lozenge, a tablet that dissolves inside the cheek or under the tongue, a spray under the tongue, a nasal spray, or an injectable. It is sold under the following brand names:
Street names used for Fentanyl include:
Tango & cash
How to Recognize Fentanyl
Prescription Fentanyl most often comes in a patch that is placed on the skin. It may also come in a lozenge that is placed under the tongue or in an injectable liquid. Legal fentanyl is sealed, clearly marked, and is only available with a prescription from a physician who is enrolled in a government program allowing the distribution of opioids. Prescriptions are most often limited to patients who are undergoing cancer treatment, palliative care, or end of life care.4
Illegal Fentanyl, on the other hand, can come in the following forms:
Small piece of blotter paper with drop of Fentanyl solution
Solution with an eye dropper
Producers of street Fentanyl have started forming the drug into pills that look like other opioids. They also mix it with other powdered drugs, such as heroin or cocaine. The reason for this is that Fentanyl is so potent of a drug that it does not take much of it to produce a high, making it cheaper to produce and sell.5 Because of this practice, people who buy illegal street drugs may not know that they are actually buying Fentanyl rather than the drug that they normally use. This can lead to inadvertently taking much higher doses than intended, resulting in an overdose.
Fentanyl Abuse Statistics
The rate of Fentanyl abuse in the United States is most likely much higher than what statistics can report. According to the 2018 National Survey on Drug Use and Health (NSDUH), sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), the rate of reported Fentanyl abuse among adults age 12 and older who reported misuse of any type of pain reliever was 12.7%. This equals about .1% of the total U.S. population. The report states, however, that these statistics only reflect those people who reported misuse of prescription products, so while the survey results may include prescription Fentanyl that was diverted for misuse, it does not include Fentanyl that was manufactured illegally in secret drug labs and distributed, hidden in heroin, or passed off as other opioids.6
Law Enforcement Seizure Data
Because of the lack of accuracy in self-reports, the Centers for Disease Control (CDC) has endorsed the use of law enforcement seizure data as an acceptable indicator for the supply of illegally produced Fentanyl. A study completed in the state of Ohio found that the rate of seizures of heroin that contained Fentanyl or Carfentanil (a drug similar in structure to Fentanyl) increased from 3.4% in 2014 to 48.6% in 2017.7 The same study found that 7.1% of cocaine seizures in 2017 that did not contain heroin did contain Fentanyl or Carfentanil.
Drug testing also reveals information about the rate of Fentanyl abuse in the United States. In an analysis of drug urine tests conducted between 2013 and 2018, the rate of Fentanyl found in 1 million unique patients’ tests increased as follows.8
- 1850% in cocaine positive test results
- 798% in methamphetamine positive test results
All of these methods of analysis show several disturbing facts:
The production and sale of illegally producted Fentanyl is increasing at a rapid rate
Illegally produced Fentanyl is frequently hidden in heroin, cocaine, or methamphetamine
People who abuse heroin, cocaine, or methamphetamine may not be aware that they are also taking Fentanyl
Fentanyl is considered to have a high risk for addiction. Prescription Fentanyl classified as a Schedule II Controlled Substance by the United States Department of Justice, Drug Enforcement Administration (DEA). Illegal forms of Fentanyl are classified as Schedule I.
Fentanyl Overdose Statistics
The rates of Fentanyl overdoses in the United States are much clearer cut than the rates of abuse. The following chart shows the rates of overdose deaths involving synthetic opioids other than Methadone, including Fentanyl, analogs, and Tramadol, as compared to the overall rates of overdose deaths reported by the CDC from 1999 to 2018:9
Side Effects of Fentanyl
Fentanyl is a strong medication that has many side effects. Anyone experiencing chronic pain will have to weigh the benefits of the pain-relieving effects with the side effects before using the drug. This discussion should be held between the patient and his or her physician. Other pain-relieving drugs should be tried first.
Common Side Effects
The more common, short term side effects include:
Loss of appetite
Redness or irritated skin underneath the patch
These side effects usually lessen or disappear after a couple of weeks.
Serious Side Effects
Serious side effects of Fentanyl use include:
Dizziness and fainting
Low blood pressure
Adrenal insufficiency – muscle weakness, abdominal pain, fatigue that does not go away
Androgen deficiency – tiredness, decreased energy, trouble sleeping11
If too much Fentanyl is taken or if a prescription is taken more often than prescribed, overdose can occur. It only takes a small amount to cause an overdose. Anyone suspected of taking an overdose should receive immediate emergency medical care. The symptoms of an overdose include:12
Extreme drowsiness and tiredness
Slow or irregular breathing
Cold, clammy skin
Low blood pressure
Fixed pinpoint pupils
Symptoms of Fentanyl Addiction
Fentanyl is a synthetic opioid, so the risk of addiction is similar to other strong opioids. Some signs of a substance use disorder include:13
Taking presription medication more often than prescribed or taking more than prescribed
Taking presription medication because it “feels good”
Taking presription medication in anticipation of pain, even if pain isn’t there
Changes in sleep patterns
“losing” medication so more must be prescribed
Borrowing medication from other people
“Doctor hopping” or seeking multiple prescriptions for medication from mutiple doctors
Poor decision making
Risk taking – putting self and others in dangerous situations
Because Fentanyl is an addictive opioid, it has significant withdrawal symptoms. Anyone who attempts to stop taking it abruptly may experience these symptoms:14
Irritability or anxiety
Muscle aches or backache
Nausea and vomiting
Loss of appetite
High blood pressure
Rapid breathing/heart rate
If these symptoms become severe, they can lead to dangerous health conditions, so stopping should only be done under the direct supervision of a physician and a qualified medical team.
Treatment for Fentanyl Addiction
Similar to other opioids, stopping Fentanyl use requires a medically managed plan of care, usually conducted in an inpatient setting. People with a physical dependence must first go through detoxification, or “detox”, to remove the drug from the body gradually while managing the symptoms of withdrawal listed above.
Once detox has begun, patients begin a full treatment program to overcome addiction. Research is now showing that the most effective form of treatment for opioid use disorder is called Medication-Assisted Treatment, or MAT. This form of treatment combines medications to help stop and prevent Fentanyl abuse with behavioral treatments to help change the patterns of thinking and behavior associated with drug use. Studies show the following regarding MAT:15
Use of MAT decreases opioid use, opioid overdose deaths, transmission of infectious disease, and associated criminal activity
MAT helps to improve the voluntary length of participation in treatment
MAT improves social functioning
Use of MAT improves outcomes for babies of pregnant women with opioid use disorders
Despite the evidence supporting MAT, this type of treatment continues to be significantly underutilized, with less than half of the private treatment programs in the United States licensed to provide MAT and only about 1/3 of the patients attending those programs receiving MAT.16
Medications that are approved by the FDA for use in MAT programs include the following:
Methadone – a synthetic medication that acts on the same receptors of the brain as opioids. Methadone acts on these receptors for a longer period and at a lower intensity than Fentanyl. It relieves the withdrawal symptoms and reduces cravings
Buprenorphine – another synthetic medication that acts on the opioid receptors of the brain. In recent years, alternate forms of Buprenorphine have been developed to improve compliance with taking the medication, including Probuphine®, an implant that rations buprenorphine doses, and Sublocade®, a once per month injectable form of Buprenorphine. These forms eliminate the need to remember to take a daily dose of Buprenorphine
Naltrexone – Naltrexone blocks opioids from accessing the opioid receptors in the body. Naltrexone is also effective for people who have trouble remembering to take other medications
MAT also includes behavioral treatments to change the patterns of behavior that lead to drug use. These treatments, along with medications, provide an integrated treatment that addresses the “whole person”, leading to better outcomes overall. Behavioral treatments that may be used as a part of MAT include:
Cognitive Behavioral Therapy – individual counseling sessions that help a person identify and change the thought processes that lead to drug use. Engaging in cognitive behavioral therapy teaches drug-free patterns of thinking and behavior.
Marital and Family Counseling – Family counseling helps to repair relationships between a person and their spouse or other family members
Contingency Management – concrete rewards programs that reward a person for abstaining from drug use. Contingency programs usually involve vouchers that can be exchanged for prizes or items of monetary value, or incentive programs that allow participants to earn privileges
Support Groups – these groups allow people recovering from addiction to help each other and hold each other accountable for abstaining from drug use
Fentanyl is a strong opioid that can lead to addiction, overdose, and possible death. People who must use prescription Fentanyl to control pain should only do so under the close supervision of a physician. Anyone struggling with Fentanyl through recreational use or misuse should seek help as soon as possible.