Fentanyl for Pain Management — Use and Abuse
Fentanyl is a potent narcotic medication used for pain relief. It is a synthetic drug that acts on opiate receptors in the brain and nervous system to blunt pain sensations.
Fentanyl is said to have one hundred times the potency of morphine. In other words, it only takes 0.1 milligrams (mg) of fentanyl to equal 10 mg of morphine. This makes it a powerful pain reliever during and after surgery and in other situations, like cancer pain, that are hard to treat with more 'routine' medications. Note: The actual potency may be closer to 80x morphine, but 100 is used for ease of conversion and to build in 'safety' by overestimating power.
Because fentanyl produces many of the desirable effects of other narcotics, such as euphoria and profound relaxation, it is also a sought-after drug for abuse. Sadly, that abuse often has deadly consequences after only one or a few uses due to its potency.
When is it Used?
As an anesthesiologist, I give intravenous (IV) fentanyl to patients every day. By using multiple drugs, including fentanyl, in a balanced anesthesia regimen, it is possible to minimize the side effects of each agent. Because it has a short onset of action, short duration, and profound pain-relieving qualities, it is an ideal drug for use in the operating room and recovery room. It is metabolized and eliminated quickly from the body, so any adverse effects may be rapidly reversed.
Fentanyl by prescription, in other forms, can also be used to treat pain that is severe and constant. Chronic pain related to injury or nerve problems, as well as cancer pain, are well-treated by fentanyl.
Fentanyl is only prescribed to patients who are already narcotic-tolerant, usually because they have been on increasing doses of less powerful narcotic medications. Giving fentanyl to someone who has not used other narcotic medications will almost always result in an overdose unless doses are significantly limited.
Actiq Fentanyl Lollipop
How is it Administered?
Fentanyl cannot be given in the form of a pill to swallow because it would be too rapidly metabolized or inactivated in the gastrointestinal system. It is, however, available by several other modes of delivery.
- Transmucosal - Fentanyl "lollipops" are available to allow for absorption through the mucosa (lining) of the mouth into the circulation (does not enter into the stomach and gastrointestinal system). There is a newer preparation of tablets that melt in the mouth, also for trans-mucosal absorption. Nasal sprays of fentanyl are also useful in select situations, such as for breakthrough (when other medications are already being used) pain in cancer.
- Intravenous - In the operating room and in recovery rooms, intravenous (IV) delivery is most useful. Fentanyl is supplied as a liquid (usually 50 micrograms per milliliter) that can be injected directly into the bloodstream through an IV line.
- Epidural and Spinal - The same liquid preparation that is used in the IV can be used in epidurals and spinals as well to prevent or treat pain.
- Transdermal Patches - Fentanyl patches, also called the fentanyl transdermal system, contain the drug in a specially designed reservoir attached to an adhesive backing. This system allows fentanyl to be slowly absorbed through the skin over (usually) three days per patch.
Examples of Available Fentanyl Preparations
Route of Administration
Transmucosal — lollipop
Protect medication (and all of these) from children. A lock box is recommended. Do not call them "lollipops" as children may be drawn to them.
Transmucosal — melting tablets or fill
Only available after enrolling in special programs
Use only as prescribed. The drug accumulates under the skin and may take a full day to be eliminated after a patch is removed.
Should ONLY be used by qualified medical personnel with full monitoring of vital signs.
Other examples of opiates and opioids.
Opiates are naturally occurring substances derived from the poppy opium. Opioids are synthetic opiate-like drugs.
- Hydrocodone (Vicodin, Lortab)
- Oxycodone (Percoset, OxyContin)
- Hydromorphone (Dilaudid)
- Meperidine (Demerol)
and quite a few other medicines that would be recognized by name as powerful pain killers and drugs of addiction. When reference is made to "prescription drug abuse" or "prescription painkiller abuse", these are the medications most often indicated by that reference.
Effects and Side Effects
Fentanyl, like all narcotic medications, has a significant side effect and risk profile. Risks are greatly increased when fentanyl is not administered by qualified health professionals. This medication is seriously dangerous and easily fatal when misused or abused. It should only be given in the hospital, with appropriate monitoring, or prescribed by physicians familiar with a patient's narcotic tolerance.
It causes decreases in heart rate, blood pressure, and respiratory (breathing) rate. These decreases can be significant and may either be desirable or require treatment, depending on the pre-existing status of the patient.
In addition to slowing or stopping breathing, fentanyl also changes how the brain reacts to low oxygen and high carbon dioxide. When breathing slows, carbon dioxide (CO2) levels start to increase since it isn't being blown off during respiration. The brain normally senses that the CO2 is building up and increases respiration to get rid of it, as well as to increase the dropping oxygen levels.
Under the influence of fentanyl, the brain does NOT react normally to changes in CO2 or oxygen. As CO2 builds and oxygen levels drop, there is are dangerous changes in the brain and body that can rapidly lead to death.
Breathing is further inhibited by a side effect of chest wall rigidity or stiffness that occurs with larger intravenous doses of fentanyl. Again, fentanyl should only be administered by clinicians who are not only familiar with these effects and side effects but are trained and well-equipped to treat them.
Nausea and vomiting accompany fentanyl use, as with other opioid medicines. The drugs stimulate the 'vomiting center' in the medulla of the brainstem. Interestingly, fentanyl and other narcotics may have the opposite effect and inhibit vomiting when given very high doses, such as during cardiac surgery.
Constipation is another side effect of opioids. With fentanyl, this effect will be more pronounced with long-term use by patch or chronic transmucosal administration, rather than one-day exposure such as during surgery.
Fentanyl causes itching, particularly of the nose and face, as a peculiar side effect. This is seen with other drugs in the class as well.
"The most common presenting symptom of fentanyl abuse is death."
"Trying fentanyl even once is very likely to result in a lifelong battle with addiction, for as long as you survive, anyway."
These two phrases, or variations of them, were told to us over and over again from day one of anesthesia training. Because we necessarily have access to very powerful anesthetic agents, including narcotics like fentanyl, it was and is important to understand that abuse of these drugs was not only professionally irresponsible, but personally devastating or fatal. Sadly, in spite of these warnings, anesthesia professionals die or struggle every year due to addiction to opioids which they access through their jobs.
Recreational use of fentanyl or the illegal use of fentanyl by people who became addicted to, and then escalated their use of, narcotic pain medications is on the rise.
The most common abuse of fentanyl now is with the use of the patch. Addicts and abusers are not using the patch, however. They are opening the patch and removing the fentanyl for use in divided doses. The drug is then inhaled, injected or absorbed from the inside of the mouth. Because there is no way to know exactly how much fentanyl will be in each "serving" obtained in this way, overdose is very common and death is not unusual.
From the Operating Room: How is Fentanyl Used in the OR?
This example is just — that an example — and a partial one, at that. It is not a complete anesthetic plan. Each individual case MUST BE assessed for many variables before an anesthetic and pain management plan are instituted. Nothing in this case illustration implies that this is how any particular anesthetic or recovery should be managed. Each patient must be evaluated, individually by a qualified professional.
A 27-year-old female is admitted for elective laparoscopy. She is healthy and takes no medications. She weighs about 145 pounds.
Anesthesia Induction (routine): Fentanyl would be used as part of her anesthetic induction (going to sleep phase). Fentanyl helps speed relaxation, blocks pain receptors and helps to minimize the body's response (unconscious) to the placement of the breathing tube. Along with fentanyl, other induction agents will be used including propofol and a muscle relaxant.
Anesthesia Maintenance: During her anesthetic, anesthesia gas is used. About 30 minutes into the procedure, a small increase in heart rate is noted, as well as indications that she is starting to breathe on her own. Because the surgery is not done, increased anesthesia is given. Fentanyl will be titrated in smaller doses than the induction dose. When the heart rate returns to its previous level and spontaneous respiratory efforts have stopped, fentanyl administration is discontinued.
Postoperative Pain Relief: Our patient woke up with no pain. About 40 minutes after reaching the recovery room, she states that she can no longer get comfortable enough to rest. Fentanyl is titrated in small doses to get her pain back under control. At that time, she can be transitioned to longer acting pain medications.