What Is Fentanyl?
Fentanyl is a synthetic opioid analgesic that has similar properties to morphine, though it is up to 50 to 100 times more potent. Pharmaceutical fentanyl is prescribed to treat patients with severe pain management, pain after surgical procedures, or severe chronic pain when patients are physically tolerant to other opioids.1
Fentanyl pharmaceutical products include the following:2
- Actiq (oral lozenges similar to lollipops)
- Fentora (dissolvable “fizzy” tablets)
- Abstral (sublingual tablets)
- Subsys (sublingual sprays)
- Lazanda (nasal sprays)
- Duragesic (extended release, transdermal patches)
- Injectable solution for use in hospitals (Sublimaze, etc.)
The Drug Enforcement Agency (DEA) classifies fentanyl as a Schedule II drug. These drugs have accepted medical use with severe restrictions. Schedule II controlled substances such as fentanyl can result in severe psychological and/or physical dependence.2
Even though fentanyl is legally manufactured in the United States for prescribed medical use, non-pharmaceutical fentanyl is also made in clandestine laboratories and intended for illicit distribution.1
Fentanyl may be encountered on the illegal market in a number of forms:2
- As a powder
- Mixed with or substituted for heroin
- As counterfeit tablets or pills (often mimicking other opioids)
- Spiked on blotter paper
Fentanyl can be snorted/sniffed, smoked, injected intravenously, and consumed orally via pill or tablet form. In its various forms, fentanyl may be mixed into a solution to be used to saturate blotter paper, which is then consumed orally. In some instances, the gel from fentanyl patches may be misused via injectable or orally ingested routes.2
On the street, common fentanyl nicknames include China Girl, China Town, Goodfellas, Jackpot, King Ivory, Tango & Cash, Apache, and TNT.1,2
Similar to other opioids, fentanyl binds to and activates opioid receptors. In doing so, it affects areas of the brain that influence emotions and pain.
As a result, fentanyl short-term effects can include:1,2
- Pain relief.
Side effects of fentanyl include:1,2,3
- Difficulty urinating.
- Slow, shallow breathing.
- Unusual dreams.
- Dry mouth.
- Swelling in hands, arms, feet, or ankles.
- Pupillary constriction.
- Respiratory depression.
- Loss of consciousness.
Mixed With Heroin
Illicit, street-sold fentanyl can be mixed with heroin to increase its potency. However, drug users seeking heroin may not know that it has been “cut” or laced with fentanyl. When they purchase “heroin,” they often do not know the strength of the substance and can overdose.
Any use of fentanyl, even at a reduced dose, can result in death. In New York, 44% of all overdose deaths in 2016 involved fentanyl.4
Dealers are also increasingly lacing cocaine with fentanyl. In fact, in 2016, 37% of overdose deaths in New York involved cocaine and fentanyl without heroin.4
Though some users may specifically seek out fentanyl, it is clear that many people do not know they are being sold fentanyl when they purchase drugs on the street.
How to Tell if Heroin Has Fentanyl
Doctors originally used fentanyl test strips to make sure patients were taking prescription fentanyl and not selling it. But harm reduction groups now offer the strips – which were previously used to test patients’ urine – to heroin users to test for fentanyl in their drug supply before they inject.11,12
Users add sterile water to an empty baggie or cooker that contains a small amount of the drug, dip the strip in the water, and wait 15 seconds. The strips can detect 9 different fentanyl analogues, including carfentanil, which is 10,000 times more potent than morphine.11,12
Based on the results of the test, users can choose to take a smaller shot or “test shot,” use with another person, keep a naloxone kit nearby, or not use. 12
Users should be aware that the strips are not 100% accurate and can give false positive and false negative results. They will not tell you how much fentanyl is present, and a person can still overdose even if the strip is negative. The heroin may also contain a fentanyl analogue that the strip will not detect.12
Similar to other opioids, fentanyl withdrawal can be quite unpleasant for people that have developed a tolerance to the drug. Withdrawal symptoms can begin within 12 to 30 hours of the last dose.6
Withdrawal symptoms can include:6
- Muscle aches.
- Runny nose.
- Abdominal cramps.
- Dilated pupils.
While withdrawal itself is not life-threatening, the symptoms can be very uncomfortable, and medical or psychiatric complications can arise. Due to these concerns, medical professionals may advise against quitting abruptly on your own (“cold turkey”) without appropriate supervision and monitoring.
Withdrawal complications can include:7
- Gastrointestinal symptoms (vomiting, diarrhea).
- Dehydration and/or electrolyte imbalances.
- Exacerbation of underlying cardiac illness (increased blood pressure, pulse rate, sweating).
- Intensified anxiety symptoms.
- Intensified physical pain symptoms (back pain, dental pain).
Even relatively low levels of opioid use can result in the development of physical dependence to the extent that a user will experience some withdrawal symptoms when their drug use slows or stops. Medical support can be helpful in all cases of opioid withdrawal, as it can help reduce emotional and physical suffering. Such monitoring and structure can also provide a pathway to entering substance abuse treatment.7
An overdose occurs when a user’s body has more drugs in its system than it can manage. The DEA states that pinpoint pupils, coma, and respiratory depression strongly suggest that a person is overdosing on fentanyl.2
Other ways to recognize an overdose include:2,8
- Cold and clammy skin.
- Blue skin tinge (usually lips and fingertips first).
- Limp body.
- Pale face.
- Throwing up.
- Choking sounds and/or gurgling or snoring noises.
- Inability to respond.
Act immediately if you suspect someone is overdosing. Yell the person’s name to determine their level of responsiveness. If there is no response, rub your knuckles over the upper lip or down and the front of the rib cage (sternal rub). If the person is overdosing, they will not respond to either of these simulations. At this point, you will need to call 911 and provide information that the person has stopped breathing and is unresponsive.8
You will also want to perform rescue breathing. This should be done quickly, as it is the fastest way to get oxygen into the body.8
If available, administer the medication naloxone, which can reverse an opioid overdose and restore normal breathing.1 Naloxone is an opioid receptor antagonist that binds to opioid receptors to both reverse and block the effects of other opioids.
The Food and Drug Administration has approved 3 formulations of naloxone:9
- Injectable: This formulation requires professional training. Emergency kits can now provide an atomizer that can turn the injectable solution into something that can be administered nasally. But these have proven somewhat unreliable.
- Auto injectable: Marketed under the trade name Evzio, this is a pre-filled auto-injection device designed for emergency personnel and loved ones to quickly inject naloxone into the outer thigh. The device will also provide verbal instruction on how to deliver the medication.
- Prepackaged nasal spray: Narcan is a pre-filled nasal spray that does not require any assembly and can be directly sprayed into a nostril while the person lies on their back. Narcan is designed for both medical professionals and family members.
Naloxone can work immediately, but it can take up to 8 minutes to have an effect.8 If a person is overdosing, it is important to stay with them until medical help is available.
Data from the Centers for Disease Control and Prevention shows that opioid-related deaths have sharply increased in recent years.
- From 2002 to 2015, there was a 5.9-fold increase in the total number of deaths that involved heroin and non-methadone synthetics (mainly fentanyl).10
- In 2016, there were more than 64,000 drug overdoses in the United States. Among this figure, 20,000 overdose deaths were attributed to the presence of fentanyl.10
- From 2002 to 2011, there was a 1.9-fold increase in the total number of overdose deaths involving prescription opioids.10
Opioid addiction and the dangers of continued abuse of drugs like heroin and fentanyl can drastically impact the lives of users and families alike. Fortunately, professional treatment and help is always just a phone call away. If you or a loved one is struggling, please call for support today.
- National Institute on Drug Abuse. (2016). What is fentanyl?
- U.S. Department of Justice Drug Enforcement Administration. (2017). Drugs of Abuse.
- U.S. National Library of Medicine. (2018). Fentanyl.
- NYC Health. (2017).Health Department Warns New Yorkers About Cocaine Laced with Fentanyl; Occasional Users at High Risk of Overdose.
- Substance Abuse and Mental Health Services Administration. (2013). Fact Sheet: Fentanyl-Laced Heroin and Cocaine.
- U.S. National Library of Medicine. (2018). Opiate and Opioid Withdrawal.
- Substance Abuse and Mental Health Services Administration. (2016). Detoxification and Substance Abuse Treatment.
- Massachusetts Department of Public Health. Opioid Overdose Education and Naloxone Distribution.
- National Institute on Drug Abuse. (2018). Opioid Overdose Reversal with Naloxone.
- National Institute on Drug Abuse. (2017). Overdose Death Rates.
- Bernstein, L. (2018). Fentanyl test strips lead to more caution among illicit drug users. The Washington Post.
- Harm Reduction Coalition. Fentanyl.
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