NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBTANCE ABUSE SERVICES
Addition Services for Prevention, Treatment, Recovery
Addiction Medicine FYI
Fentanyl is a synthetic opiate that was invented in the 1950’s and is presently a schedule II narcotic. Fentanyl has similar effects as other narcotics such as heroin. However, fentanyl’s potency and duration of action differ greatly from other opiates (fentanyl has a much shorter half-life than heroin). It appears that transdermal fentanyl may also have a lower risk of causing constipation than other long-duration opioids, according to the results of a retrospective study published in 2004 (South Med J. 2004;97:129-134).
Medically, fentanyl is used in the intravenous form as an anesthetic (Sublimaze ®) and as an extremely potent analgesic (80 times that of morphine) in the transdermal patch (Duragesic®) or the newer lollypop formulation, where a raspberry lozenge is attached to a handle (Actiq®). The lozenge must be swabbed inside the mouth and gums to be absorbed. If fentanyl is swallowed, it is not effective.
There are several analogues of fentanyl which were synthesized for their analgesic properties; alfentanil ( very short acting) , sufentanil (5 to 10 times more potent than fentanyl) and remifentanil (the analogue with the fastest onset of action). There is also an analogue that is used in veterinary medicine to immobilize large animals called carfentanil. Of note, there are several analogues of fentanyl that have been manufactured by designer drug labs and are illegal.
Fentanyl has a long history of illegal use. Fentanyl, which has a stimulant effect when given to horses, was involved in a major horse racing scandal in 1979. Owners and trainers were fined and/or suspended. Several years ago, it was sold on the street as “China White” or “Starsky and Hutch.” Actiq is being sold on the streets today and is called “percopop.” In 2002, a fentanyl analogue was used by Russian security forces to incapacitate rebels in the Moscow theater siege.
The NYS DOH Bureau of Narcotic Enforcement (DOH BNE)website states that “ fentanyl is most often diverted by those healthcare professionals directly responsible for its administration and safeguarding. The injectable form of the drug is diverted primarily from operating rooms. This is accomplished by substitution, outright theft, the underdosing of surgical patients, and the falsifying of medications administration records. Fentanyl transdermal patches are often stolen from ward stocks or, in some instances, actually removed from the skin of patients. The patch is then punctured or sliced open to extract the fentanyl. Whatever the method employed, the diversion of fentanyl is a danger to the public health. Impaired healthcare professionals pose enormous potential consequences for patients. A surgical patient's life can be placed in jeopardy. A patient from whom a diverted fentanyl patch is removed is made to suffer unrelieved pain.”
It is recommended by DOH BNE that administrators of healthcare facilities where fentanyl transdermal patches are used, implement the following measures to both detect and prevent their diversion:
During shift counts of controlled substances, the foil packets containing fentanyl patches should be removed from their boxes and inspected for signs of tampering.
Each time a fentanyl patch is newly applied to a patient's skin, a pen or magic marker should be used to write the date, time, and initials of the medication nurse on the patch. During the time the patient wears the patch, this documentation should be regularly checked against medication administration records. The patch should also be inspected for cuts, needle holes or other evidence of tampering, such as a dried-out appearance.
Each time a fentanyl patch is removed from a patient, it should be rendered both unusable and unrecoverable. Even after the 72-hour period during which a fentanyl patch is effective for the patient, it still contains a significant amount of drug.
The above suggestions are extremely important in light of an increasing number of opiate overdoses in New York State which are directly related to fentanyl patches misuse. The fentanyl can be removed from the patch by boiling the patch and injecting the resulting liquid or even by chewing the patches.
It is important for medical and counseling staff to know that routine urine drug screens do not identify fentanyl use. Therefore, urine drug screens cannot be relied upon to alert the staff of this drug’s misuse.
The use of fentanyl in the non – fentanyl tolerant user could easily result in an overdose due to the potency of fentanyl as compared to other opiates that could be abused.