Fentanyl is found in patch form and is a µ receptor agonist (Welsh 19). Fentanyl is composed of, and considered an opioid, analgesic. Fentanyl (N-phenyl-N-(1-phenethyl-4-piperidinyl)propanamide) was first sythesized by Janssen Pharmaceutica. Its primary use is as an anesthetic (Welsh 19). The pharmacological profile of fentanyl consists of its relation with transdermal absorption within the synthesis of fentanyl properties (Welsh 19). With the chemical composition of fentayl its therapy is attainable through the patch by a patient within 1-12 hours (assuming that the patient is able to take opioid and does not have an unhealthy reaction to it). The plasma concentrations do not however reach a steady state until 36-48 hours after the initial fentayl patch is placed on the body (Welsh 19). This rate of absorption is componded by many factors, one being heat, but fentanyl has a very potent chemical combination, in fact it is used eight times as much as morphine,
This is due to rapid absorption of fentanyl by adipose tissue throughout the body and a depot of fentayl in the subcuaneous (SC) tissues immediately under the patch. Due to this, the eliminatin half-life of fentanyl is approximately 17 hours, resulting in significant blood levels persisintg for long periods after removal of the patch (Welsh 20).
Since fentanyl is can be administered with ease it is a main proponent in the PICU (pediatric intensive care unit).
Pain relief in the PICU is the main object of fentanyl. The drug however may prove to be problematic because of its high addiction levels as well as its high toxicity. In the study conducted by Akinci et al. 22 patients were administered fentanyl and their levels of pain were diagnosed by physicians (Akinci 873). This study showed that fentanyl was vital in relieving pain in children and the administration of the drug was low so that any questions about toxicity or addiction did not surface, “…fentanyl is a highly lipid-soluble compound that is cleared by N-dealkylation and hydroxylation in the liver with approximately 5% excreted as unchanged fentanyl by the kidneys” (Akinci 876). Akinci goes on to state that fentanyl, as a drug, has characteristic high intrinsic ‘clearance and falls in the class of high hepatic extraction drugs such as propranolol, lidocaine, and morphine (Akinci 876).
There are however side effects that must be cautioned when using fentanyl. Fentanyl patches consist of a semipermeable membrane which allows fentanyl to seep into the body’s system in a controlled rate (D’Arcy 73). Thus, the fentanyl is spread throughout the body by the blood vessels. The patch has different levels of doses ranging from 12-100 mcg. Patients are advised to change their patch at least every 72 hours for optimum pain relief. This turn around rate is what leads to the addictive side of fentanyl. Patients must pay strict attention to the physician’s warning about fentanyl such as a used patch still being potent enough to harm a small child, or that if a patient cuts the patch the entire dose of fentanyl which is to be administered over a period of 72 hours will be released into the person’s blood stream thereby causing them to overdose. These are just a few examples of the dangerous properties of fentanyl (D’Arcy 73).
As has been stated, fentanyl is a highly addictive drug and patients who do not regulate their patch are in danger of overdosing (Gupta 17). Fentanyl has become so highly accessible and thereby dangerous by its administration through fentanyl HCI patient-controlled transdermal system (PCTS),
…is an innovative electrotransport modality designed for acute pain management in a medically supervised setting. This device transfers fentanyl across the skin into th systemic circulation via an imperceptible low-intensity direct current…The system is designed for th on-demand delivery of pre-set amount of medication over a 10-minute period, during which time additional requests for medication are not fulfilled. The system is intended to provide patients with personal control over pain management without the intravenous (IV) lines, tubing and apparatus associated with currently available IV patient-controlled analgesia (PCA) systems. Gupta, 18.
Although fentanyl is an effective treatment against pain, this self-regulation does not necessarily wean a patient off of the drug. In fact, without the intervention of a physician or nurse, the patients who are self-administering fentanyl even with a lapse time of 10 minutes they are by no means necessarily lowering the time between which they need the drug but instead may be demanding the drug to be administered every 10 minutes without regulation.
The toxicity and the addictive properties of fentanyl however have other side effects besides addiction. In the study conducted by Gupta et al. three separate sets of patients were given fentanyl and their side effects and their withdrawal from fentanyl are as such; the first test group had to withdraw from fentanyl dosage because of high blood pressure, adverse events which included nausea, and vertigo, and for personal reasons (Gupta 20). In the second study conducted by Gupta et al. there were a total of 31 subjects but only 23 completed the project as the other succumbed to generalized maculopapular rash, other adverse effects, personal reasons and violation of the study (Gupta 21). During the third study 20 of the original 28 subjects completed it and the same reasons of slight adverse affects were given.
At the conclusion of the overall study Gupta et al. discovered that no real adverse affects on the subjects were found. There were effects from the fentanyl such as headaches, nausea, and/or vomiting, but the severity of each of these effects was minimal in the overall subject population (Gupta 22). In the cases where fentanyl was administered for a longer period of time there was one advent that raised some concern; the appearance of erythema. This was found in subjects who has been exposed to fentanyl for more than 20 hours (Gupta 23).
With the previous study having stated that the fentanyl patch should be changed every 72 hours and that even disposed patches could be harmful for children it is no wonder that Gupta study concluded that within a short time frame and one that is far less than the recommended 72 hours that subjects had reports of erythema. In fact, in Lancet’s study he reports that fentanyl laced drugs were wreaking havoc with heroine.
This combination of chemical compounds are so viable that overdoses related to this hybrid drug spiked in late 2005. Lancet gives examples of just how prevalent this drug is in relation to overdosing, as can be witnessed in the amount of methadone clinics being attended by drug users who want off the chemical, “In 2003, some 10,000 people seeking publicly funded substance abuse treatment in Illinois were turned away…” (Lancet 569). Although fentanyl has been used in hospitals for decades it has been available on the streets as an alternative for heroine or mixed with heroine just as long.
Fentanyl found its way to the streets in the 1970’s, and is known as a narcotic. Fentanyl is similar to heroine except the ‘high’ lasts longer but the euphoria is not as potent. Fentanyl leads to overdosing more often than heroin. In combination with heroin, however, fentanyl compensates for poor quality heroin and it is used as a means to cut the drug and make it’s mass larger in order for the dealers to have more stuff to sell (Wikipedia). As it is cut with heroin in such large cities as Chicago, Detroit, and Washington D.C. it is known as magic,
Several large quantities of illicitly-produced fentanyl have been seized by U.S. law enforcement agencies. In June 2006, 945 grams of 83%-pure fentanyl powder were seized by Border Patrol agents in California from a vehicle which had entered from Mexico. Mexico is the source of much of the illicit fentanyl for sale in the U.S. However, there has been one domestic fentanyl lab discovered by law enforcement, in April 2006 in Azusa, CA. The lab was a source of counterfeit 80 mg OxyContin tablets containing fentanyl instead of oxycodone, as well as bulk fentanyl and other drugs. (Wikipedia).
There are several different forms of fentanyl available on the street with different names according to the chemical composition of the drug and what other drugs it is cut with. One fentanyl variation is ‘china white’. This refers to the drug being produced alpha-methyl strain (AMF). This ‘china white’ variation of fentanyl is surmised to be twice as strong as regular fentanyl. This new drug provides “resistance to metabolic degradation resulting in a drug with an increased duration” (Wikipedia).
Fentanyl is not only found to be an addictive property on the streets but in the hospitals with regards to the patient and the health care provider. Fentanyl is an attractive street drug because of its low cost and because it is indistinguishable form nasal inhalant heroine (Lancet 570). Fentanyl in the hospital environment is pushed more often and in greater quantity than any other drug because hospital staff do not want to use specific drugs but rather a catch-all. In this environment as well fentanyl has been known to be abused by health care providers as well as patients, “The risk of addiction to drugs of abuse through occupational exposure is an important but relatively neglected public health problem” (Lancet 570).
Lancet goes on to state that second hand crack inhalation causes addiction in those who breath in the vapors but this problem has been little studied and is far less known. This juxtaposes the abuse and exposure to anesthesiologists to second-hand fentanyl. Fentanyl is airborne and as such its detection in operating rooms is dense and of high concentration levels (Lancet 570). The highest level of fentanyl in an operating room is found near a patient’s mouth which is where anesthesiologists spend most of their time in the operating room.
This second-hand exposure to fentanyl can sensitize the brain ‘making abuse, dependence, and behavioral disorders more likely among anesthesiologists and surgeons than other health professionals’ (Lancet 570). Thus, there is an obvious increase in public health with regards to the risks of fentanyl which in turn may quickly spread if ignorance on the drugs effects remains intact. Thus, although fentanyl has its positive effects in aiding in retarding pain in a patient, it has a high toxicity as well as a high level of predictable addiction.
Akinci SB. “Remifentanil versus fentanyl for short-term analgesia-based sedation in mechanically ventilated postoperative children.”, Paediatric Anaesthesia, Vol. 15 (10),
(October 2005). pp. 870-8.
Bayshev FK. “The sterility of fentanyl vials.”, Anaesthesia; Vol. 59 (6), (June 2004). pp. 627.
D'Arcy Y. “What you need to know about fentanyl patches.”, Nursing. Vol. 35 (8),
(August 2005). pp. 73.
Gupta SK et al. “Effects of application site and subject demographics on the pharmacokinetics of fentanyl HCl patient-controlled transdermal system (PCTS).” Clinical Pharmacokinetics. Vol. 44 Suppl 1, (2005). pp. 25-32.
Lancet, Boddiger D. “Fentanyl-laced street drugs "kill hundreds"”. World Report, Vol. 368 (9535), (12 August 2006). pp. 569-70.
Welsh J. “Physicians' knowledge of transdermal fentanyl.”, Palliative Medicine; Vol. 19 (1),
(January 2005). pp. 9-16.
Wikipedia. “Fentanyl.” (Online). Available: http://en.wikipedia.org/wiki/Fentanyl.