The epidemic of Fentanyl overdoses is killing our people. The chart above, from the CDC, shows unintentional deaths that characterize overdoses mostly from Fentanyl.
There are many reasons that Fentanyl is the problem. Fentanyl is approximately 70 – 100 times more potent than Morphine and 20-30 times more potent than heroin. Analgesic doses of Fentanyl, used in the Emergency Room for pain management, are 25 to 100 micrograms (mcg) per dose intravenously. In a hospital setting, Fentanyl is primarily used in Anesthesia for surgery and in the Emergency Department for acute pain management.
Legitimate uses of Fentanyl outside of the controlled hospital environment include pain management in opioid-tolerant and cancer patients. Dosage forms are topical dermal patches, oral mucosal tablets, and lollipops (Actiq). The patches are designed to deliver 12 -100 mcg/hr, and the mucosal-absorbed preparations deliver 100 – 1600 mcg over their intended use design. All of the out-of-hospital use has a BOLD disclaimer to be used only in opioid-tolerant patients.
Illegal uses of Fentanyl are responsible for most opioid overdose deaths. The patches start out with 2500 mcg to 10,000 mcg of Fentanyl in order to provide the 12 – 100 mcg/hr therapeutic dosing. Studies have shown that 1,000 mcg up to 9,000 mcg remain in the used patch at disposal. Much of this remaining dose can be extracted by abusers. Similarly, abusers can recover much fentanyl from oral mucosal products. Black market products, usually pills and powder, have no standardization of the amount of fentanyl per dose. The illicit user cannot determine the amount of Fentanyl in whichever form they use.
The amount of Fentanyl required to kill is undetermined, but there are some ranges to consider. Doses as little as 25 mcg can cause respiratory depression in an adult. The literature contains numerous case reports of chest wall rigidity after using Fentanyl for sedation, requiring intubation and paralytics to combat the effect until the fentanyl is metabolized and wears off. This is a rare, potentially fatal effect of Fentanyl. The dose size and the administration route increase the chance of a fatal outcome. IV doses of 200 mcg or greater can routinely suppress or cease respiration and, if not addressed immediately, can cause anoxic brain injury and can be fatal. Oral routes are more variable in absorption, but the effects are more prolonged.
A significant consequence of Fentanyl use/abuse is addiction. Anesthesiology literature shows a withdrawal effect after a single dose of Fentanyl. Fentanyl is exceedingly addicting to the user/abuser. This leads to repeat use and increases the possibility of overdose and death.
Why is this happening?
- Increasing the use of Fentanyl in the clinical setting increases the awareness of the drug and the potential for diversion and abuse.
- Fentanyl synthesis in illicit labs is profitable.
- Permissive government regulations regarding drug use.
- The “Narcan” after the event bandaid.
- Illegal trafficking in Fentanyl from China via Mexico.
- The adoption of pain as the fifth vital sign increases the use of pain medication.
- Lack of sufficient psychosocial treatment centers and the increase of opioid maintenance programs.