Fentanyl: uses, abuses, treatment

By Alan Koenigsberg, M.D.

As we approach the High Holidays, health is on my mind even more than usual. As a physician, I work with patients daily on improving their health. Taking point on our shul’s Hearing Men’s Voices events, I frequently choose topics related to health. Personally, I pay attention to my health. I do my best to watch what I eat, avoid those things that are harmful, wear my seat belt and so on. I get all the recommended vaccines and do my best to walk the walk.

I also get three daily newspapers, Yes, the actual paper newspapers we remember fondly. I have gotten our local Dallas Morning News seven days a week for decades and for the last decade or so have gotten the daily Wall Street Journal and New York Times. I take the Journal and the Times to my office, so my early patients have something current to read if they wish. I read what I can.

So these past few weeks, I have read a number of articles, both in the local and national papers, about fentanyl, its dangers and the overdoses it has caused. It’s a serious concern both locally and nationally.

I thought it was a good idea to discuss what fentanyl is, what it’s used for, why it can be dangerous and how it is used appropriately in medicine.

Fentanyl is an opioid drug that is used properly to treat acute and chronic pain in the hospital and in outpatient settings. It is available intravenously, in patches that can be applied to the skin and in a spray that is applied under the tongue.

I have had patients who used the patch for years without problems and a few patients with cancer who used the under-the-tongue (sublingual) spray as rescue medication when their routine pain medicine wasn’t enough; my infant child after surgery was given two micrograms of fentanyl after surgery for his pain and did just fine.

So, when properly administered by trained clinicians, fentanyl can be and is an excellent treatment option.

As with all opioids, fentanyl can slow down and stop breathing (respiration) and cause death. Here is the deal with fentanyl: It is at least 100 times more potent than morphine.

In other words, morphine, hydrocodone and other similar medications are dosed in milligrams, one-thousandth of a gram. To put that into terms that are more common, a small paper clip weighs one gram, which is one thousand milligrams.

So a person may receive a tablet of morphine with 10 milligrams of morphine. One hundred of those doses would add up to 1 gram.

Fentanyl is prescribed in micrograms, millionths of a gram. My son received 2 micrograms after surgery; adult patients have patches of 50-100 micrograms applied to their skin and that patch will last 72 hours, or three days.

A milligram of fentanyl could stop someone’s breathing.

Fentanyl is laced into some street drugs, including amphetamines. At milligram doses, it can kill people.

It’s also inexpensive to manufacture illegally and is done so in various places throughout the world. The reason the microgram potency is so important is that an enormous amount of money can be made with a very small amount that is smuggled in. It’s not like marijuana that takes up a large amount of space.

Overdoses of fentanyl, as with all opioids, can be acutely treated with the now available over-the-counter Narcan spray, available at your local pharmacy in the next week or two. I recommend houses of worship, schools and anyone in the health care field buy a two-pack and know how to use it. There are two one-use sprays in each pack and the pharmacist can explain how to use it.

There have been some concerns about using Narcan if a person suspects someone may have overdosed on fentanyl and they touch some powder which could then be absorbed through their skin and harm them.

While fentanyl can be slowly absorbed through the skin in specially designed patches, there is nothing to worry about when using the Narcan spray if you suspect someone has overdosed on fentanyl.

Alan Koenigsberg, M.D., is a practicing psychiatrist and clinical professor of psychiatry at UTSW Medical School in Dallas. He can be reached at akoenigsberg@mac.com.

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