Fentanyl: Good, Bad and Getting Ugly

The opioid epidemic has been making headlines for the last few years as overdose deaths reach crisis levels. Overprescribing of pain medication was at fault for much of the issue, while heroin use surged as well. As legislation begins to change prescribing practices for physicians, more and more opioid users have turned to illicit drugs for relief. Those drugs can include illegally obtained prescription drugs, heroin and the newest threat making news…fentanyl.

According to the CDC, Fentanyl is up to 100 times more potent than morphine with effects similar to heroin. While fentanyl has legitimate medical applications and can be prescribed legally, the fentanyl problem in this country is driven by the explosion of inexpensive, imported fentanyl available in the illegal drug market. It is being blended into both illicit opiates and other drugs such as cocaine and benzodiazepines make it a silent killer that users may not see coming.


The Good: A brief history of fentanyl

Fentanyl was introduced in 1959 as an intravenous anesthetic. It was very effective in this regard and a number of brand name versions were created for use. Due to its effectiveness and fast-acting nature, clinical trials were performed in the 1990’s to test a fentanyl patch as a mechanism to administer strong pain relief slowly, over a period of time.

The success of these trials lead to the creation of Durgesic® and Actiq®, patches which offer relief to those suffering from severe, chronic pain. Currently accepted applications for prescription use of fentanyl include relief for patients with cancer, post-surgical patients in the hospital and patients for which other opioids offer no relief.

Its effectiveness, working in just minutes to relieve pain, is aided by how easily it can be delivered.

Fentanyl can be given as:

  • An injection
  • An oral or nasal spray
  • An adhesive patch
  • A lollipop
  • Lozenges

Because fentanyl is so incredibly potent and effective, using it to manage chronic pain and other conditions can become a slippery slope. Unfortunately, this opioid can also be highly addictive and very dangerous.


The Bad: The brain and body takeover

When taken properly and administered by trained medical professionals, fentanyl is both a relatively safe and effective opioid. However, an accidental overdose can occur quite easily due to its potency. In fact, users of fentanyl can develop a tolerance to high doses of the opiate fairly quickly, which means that more of the drug is needed to achieve any pain relief. As patients seek relief, they may choose to use prescriptions differently than prescribed, and even with the best of intentions may experience addiction and overdose as a result.

A key part of the dangers of fentanyl are due to how the opiate works in the brain. In addition to sending out dopamine, it prevents pain signals from reaching the brain and spinal cord. Fentanyl also travels quickly through the fat in the brain and binds to opioid receptors so tightly that even a tiny amount triggers effects in the body.

Once the brain gets used to having an opioid present, chemical messengers like dopamine stop behaving normally. In turn, the body will look to the opiate to feel balanced. So when fentanyl wears off, withdrawal symptoms begin, which can include:

  • Agitation
  • Anxiety
  • Depression
  • Flu-like symptoms
  • Insomnia
  • Abdominal pain
  • Nausea
  • Vomiting

To ward off these symptoms, more fentanyl is taken. This can become a vicious cycle of not being able to control how much to take or how often, putting a user at greater risk for an overdose.

Fentanyl also affects the brain in another way. Receptors that control your breathing rate are also found in the same area as opioid receptors. So if you take a high dosage of fentanyl, you can trigger receptors that can cause your breathing to slow down considerably or stop completely which can result in death.


The Ugly: Illicit fentanyl

The sharp increase in overdose deaths related to fentanyl are due in very large part to the availability of illicit fentanyl on the streets, imported from places like China and Mexico. It is inexpensive to produce and is often found mixed into other drugs including heroin and cocaine, or pressed into fake prescription pills. Individuals buying drugs off the street may not even know that they contain fentanyl. The Netflix documentary “Dope” illustrates this practice, showing dealers intentionally adding fentanyl to their drug supply. When added to heroin, it intensifies the high significantly, often making that “product” very popular amongst users for its potency.

Because there is no standard unit of measure when it’s made illegally, the amount of fentanyl that’s included in heroin or other drugs varies widely. The version that’s sold on the street is also less pure, so its effects on the body tend to be more unpredictable. Because of its high potency, a little goes a long way. When added to an illicit drug, the risk for overdose greatly increases since even a tiny amount could potentially be deadly.

As little as .25 mg of fentanyl can be lethal. That amount is comparable to cutting one 81 mg baby aspirin tablet into 324 pieces, with one of those pieces equaling .25 mg. An estimated 2 mg is lethal for a full-sized adult. In comparison, about 30 milligrams of heroin would be lethal.

In 2017, a Centers for Disease Control and Prevention (CDC) report cited that in 7 out of 10 states participating in the Enhanced State Opioid Overdose Surveillance Program, fentanyl was involved in at least 50% of overdose deaths due to opioids.

Signs of overdose may include:

  • Slowed pulse
  • Drop in body temperature
  • Mental confusion
  • Drowsiness
  • Lethargy
  • Small pupils
  • Loss of consciousness

The danger that fentanyl poses is not just limited to users. Since the drug can be inhaled through the nose or absorbed through the skin, it can pose a threat to anyone that makes contact with it, particularly first responders. Exposure may produce a sudden slowing of breathing, nausea and other symptoms.

If a fentanyl overdose is not lethal, the potential long-term harm it can cause can be extensive. It can damage the brain as well as the cardiovascular and respiratory systems. It also carries with it the same risks as other opiates including the risk of contracting HIV/AIDS or hepatitis if injected. Opioid misuse wreaks havoc in other areas of life as well. Damage to personal relationships, inability to get and keep jobs, loss of home and stability and worsening mental health conditions are just some of the lasting effects of addiction.

Although fentanyl can be an effective treatment option for those experiencing severe, chronic pain when used as prescribed, its dangers when used illicitly are undeniable. The DEA, legislators and local law enforcement are all working to try and decrease the availability of the drug while first responders, health care workers and addiction specialists work to help those struggling with addiction to get help and decrease the demand for fentanyl and other opioids. While it may seem an impossible task, the work must continue to put an end to this deadly crisis.