Fentanyl - What I Know | Episode 193

Hi, I’m Hans Hansen MD, a board certified pain and addiction medical doctor. I get asked a lot to talk about fentanyl. Fentanyl is tearing it up out there. It doesn't take even five or 10 minutes to listen to the news to hear that the Fentanyl crisis is now front and center. Estimates are somewhere around 100 to 150 deaths a day.

It’s important to notice that it is a huge problem. Today, sadly enough, an infant at an Airbnb with a family staying there succumbed to some fentanyl. There was a party at that Airbnb in Florida, and a little goes a long way. The size of an eraser head in a pill of fentanyl is lethal.

I have a long history of opioids, in medical use and understanding. It goes back to my training in anesthesia. I trained at Yale, and back in the day, we did heart (surgeries) with fentanyl where we put people to sleep with fentanyl because it is a very cardiovascularly stable drug. It can be given to those that have heart and potential lung problems, with proper support. Throughout the years, since 1959 when it was formulated, this synthetic opioid has been very useful in the operative setting. It is a fantastic drug there, in the operative setting, in the hands of an anesthesiologist that can manage an airway, that can help and assist with breathing, and that can understand if blood pressure goes up or down, and is monitoring every heartbeat. 

Fentanyl Was Developed as a Synthetic Opioid

So what's the difference between a synthetic or “natural” drug? The natural opioids come from a plant. That would be the codeines, that would be the morphines and the like. It takes a lot of work to get them from poppy to actual production, to the shelf, by legitimate means, to the pharmacist. It's a manufacturing process that is carefully regulated. The milligram per pill, per dose is carefully monitored and understood through laboratory analysis. So what you see, is what you get. 10 milligrams in 10 cc, one milligram per mil. You draw it up and you give it IV morphine.

When you're giving other medicines like oxycodone and or hydrocodone, those are other drugs that are manufactured. Well, they're involved with manufacturing and they're kind of hard to get. Their process of distribution, purity and understanding by those that prescribe and those that dispense is clear. It's very clear. The FDA is charged with distribution. The pharmacist is charged with getting the prescription to the patient in the proper prescribed recommendations from the physician or healthcare provider. 

Most people don't realize the DEA really doesn't have anything to do with telling somebody what they can give or how much they can give to get the drug out. They're helping us now with the opioid issues by putting the brakes on a little bit and by monitoring where the hot spots are for opioids.

I was using fentanyl in the operating room for hearts and for other procedures.

It's used in the ER, it's sometimes used, as an outpatient, under carefully controlled situations. 

A Common Complaint with Fentanyl

A common comment with fentanyl was that my chest is getting tight, I'm having trouble breathing. That is not respiratory suppression, so to speak. You get that in the central nervous system at the medulla, the respiratory drive center. It's (actually) from the chest wall from the mechanisms that help you breathe, the muscles get tight. I heard that all the time when I was giving fentanyl for induction. That's putting someone to sleep in the heart room. We were giving a lot of it. We would check the drug out based on the cases. So back then in the day, we did two hearts (surgeries) a day. They're four or five hours each uncomplicated. They took a while and you had so much fentanyl in folks. You kept them with the breathing tube on a ventilator for a while. Then you took them to the ICU and got the breathing tube out. That's all changed. But the bottom line is fentanyl is a great drug (for this medical application). 

We get these 20 cc vials. Typically, we'd give 80 to 120 cc’s of 50 micrograms. Now remember the term is microgram, not milligram. We give 20 cc’s. We would watch the vitals, and then we would push it a little further until we had an induction. So the induction dose would be quite a bit. But usually patients are pretty stable and they'd go to sleep. We'd give a muscle relaxer, put the breathing tube in, and we'd have an uneventful procedure. It's a great drug if used properly.

Now, those 20 CC vials had 5 extra ccs in them, believe it or not. Think about that. That's a lot of fentanyl, a huge amount. Unacceptable today. We used to call them party ccs. No one abused fentanyl back then unless there were problems. And yes, they did pull people out from under stalls and they were abusing. Those stories are out there, and I've seen a couple, but you know what? They were pretty rare.

In the 1990’s a Fentanyl Patch Came Along 

Then after that fentanyl started being produced by Janssen. It was produced to use as an outpatient for analgesia. I really didn't see it in pill form. I just didn't see it. I know it could be done, it could be formulated, it could be compounded by a special pharmacy. But the bottom line is, it was a patch, usually a 25 mic, 50 mic, 75, 100 mic patch. It was used a lot in cancer pain. Then we would eventually evolve to these suckers. We used those when I was a resident. We used them when I was a resident in recovery to try to induce pediatrics, or to try to get people to relax and get them ready for surgery.

It was not good. But then other suckers came out. It became a problem, and was prosecuted eventually. But the bottom line is this, fentanyl was out there. Fentanyl became important.

Let me tell you a little bit about OxyContin. OxyContin came along from the parent drug, oxycodone. That's a drug that's pretty common. You've heard of it as Percocet, Percodan, mixed with acetaminophen, aspirin, etc. It's a schedule two drug. The schedule of a drug is not potency. It's abuse potential. That's often misunderstood even by healthcare providers. Schedule two and three does not (indicate) potency, it's abuse potential. 

So here we had oxycodone in 1996. I can remember those reps and from Janssen and others, the pharmaceutical folks coming in saying this is a great drug you have got think about using it. It's pharmacokinetically very stable. You can put a patch on, you leave it for 72 hours. It has a little falloff effect. So even though you take it off at 72 hours, you still got something left.

OxyContin was a front row seat. When you took OxyContin, 30% of it was released within an hour. That's what I was told. I never really believed it, but boy, it came in 80 and 160 milligrams. Are you kidding me? Well, of course those are off the market now. 

Can you imagine that, all that oxycodone just being released? It could be crushed, it could be snorted. The love for opioids started evolving. Janssen, Perdue, the Sacklers. The Sacklers are the ones that got a lot of this opioid stuff going. They were part of a big government settlement, I think it was about 12 billion, through all the states and all the different agencies. I think they declared bankruptcy. It's still available. Oxycodone is still available. It's got abuse potential technology, but it's defeatable. 

Promotion and Marketing of Opioids Back in the Day

I remember these articles such as ”Partners Against Pain” (Purdue) and “Use of opioids in chronic non-cancer pain” from the year 2000 and  “Dispelling myths about opioids, brochure for physicians” (Purdue)

Pain Management Articles from the 1980’s

The New England Journal of Medicine had an article from 1980, “Addiction Rare in Patients treated with narcotics”. Another article is  “Management of pain during debridement, a survey of US burn units. “

In these articles from the 1980's there are very few numbers. The fallacy of false generalization, that's a philosophical statement, and that actually happened. False assumptions were made, and it just extrapolated and got a life of its own. 

I think the Federation of State Medical Boards actually said, go ahead, give pain medications. Pain is the fifth vital sign. It was asked in hospitals. Don't get me going on that one, but it was pursued. If you did not have a handle on pain, you sometimes had sanctions placed on you.

Bless the ER folks. So off to the races we go. Hello, fentanyl. 

So This is the Deal with Fentanyl ...

Fentanyl is out there. It's here to stay. It's synthetic, which means you don't have to grow it like a plant. Therefore, it's kind of a no-brainer. There are so many ways to get this drug in. There's demand. It's here. It's readily available, as you know, it has been purported to come in the form of candy, like chocolates. Other candies that are colored, and kids don't know what it is. Who knows that this poor child in Florida picked up, and then thought it was candy. 

Fentanyl is about a hundred times more, or some less, than morphine. Morphine is the gold standard at one milligram. Everything else is rated against it, either 5 times, 10 times, etc. It's metabolized and distributed throughout the body. It goes to the opioid receptors, it goes to the central nervous system, hence forth. We quit breathing and it goes fast. It has a pretty short half life. In other words, it doesn't last very long, 

The thing about fentanyl is the front row seat. You can spray it on so many things like marijuana, you don’t know what you're getting. I know a guy who was an addict who went through a rehab program. A friend of mine knew him well. He was found in a car, in a parking lot. He was resuscitated with Narcan. Thank God. The folks at the mall had Narcan. He was resuscitated. 

Another very sad situation is a gal who worked at a major pharmaceutical company who was, oh God, she was delightful. She was very smart. She had a lot of credentials and she was an executive, but was promoting other products. She came into our office three times a week. This was about 5 or so years ago. She was going to have her product display at a meeting. She never made the meeting. She stopped at a restaurant, and met a guy. Her car was found with the side of it caved in. Hit a guardrail. She was dead in the back seat. Apparently she had a problem with fentanyl. It was just like, what and where did that come from? 

It can be anybody, so you need to know that. It can be anybody. 

I talk about people that have potential addictions. You need to be aware that they tend to be dismissive. Their desire to enjoy things that are down. They have cravings, they're emotional, or they have a lack of emotion. They isolate themselves. They have poor sleep, huge amounts of caffeine, cigarettes, and other drugs. Maybe they smoke marijuana because, you know, marijuana is one of those drugs they say is not addictive, but it is one of the big ones for addiction. 

Is There Fentanyl Withdrawal? 

Yes there is fentanyl withdrawal. Fentanyl withdrawal is cravings, anxiety, sweat, poor sleep, muscle aching. Fentanyl can't be done well as an outpatient.

Fentanyl withdrawal also screws up people's minds and they get anxious. Very restless. Sometimes it's mistaken for pain. So more pain meds are given because they have a lot of aches and pains, musculoskeletal, GI, nausea, vomiting, and that sort of thing. Between two and four hours. Very short acting drug. You start to get symptoms of withdrawal from fentanyl and then somewhere around 24, 40 hours, somewhere in there, to a peak of about two to four days. You're getting full withdrawal. 

People get this thing called a pink cloud. Bill from Alcoholics Anonymous described this thing. Excessive feelings. You really are ignoring life. Everything looks like pink clouds. Then you start experiencing pleasure, but then you don't want pleasure. Then you start getting guilt, remorse, and all this sort of thing, all the negative feelings, and you sometimes get this low self-esteem anger that you're mad that you're doing this.

Fentanyl withdrawal tends to be ignoring reality. That pink cloud, ignoring reality, negative feelings, you don't get pleasure.

How Long Does Fentanyl Withdrawal Last?

I don't think anybody knows, but it's usually a while. You have cravings, desire to use, and it can go on and on. You can have triggers. The trigger is you might be walking down the street, and that reward pathway we talked about in the science section of addiction can just be triggered. All of a sudden dopamine's going in, and you’ve got to have that drug and you want to go use. You want to suppress that anxiety and that anxious feeling that you have when you don't have that drug. 

That's why methadone and buprenorphine need to be really understood. And I will talk about Naltrexone, the big save drug, and Narcan.

There's a drug out there, and we gotta get it out more often. It's called Naltrexone and you can give it monthly and it blocks the effects of fentanyl. If you have an 18 year old, or 16, or a 14 year old, and they're going to a party, it used to be “don't drink and drive”. Now it's “don't take anything.”  You don't know what it is. If you think it's hydrocodone, or you think it's an oxycodone, like a Percocet, you don't know what it is. 

There was a poor mother, I saw just on tv, and this is why I'm doing this. I just saw her on tv. She was talking in front of Congress. She lost both her sons. They went to parties. One of the kids, it was just the day after graduation from high school. He was partying. He thought he was taking a Percocet, nope. Fentanyl, and he died. 

You have got to know what's out there. Naltrexone, if you got a monthly naltrexone, keep going.

Buprenorphine is a great drug. It's an opioid replacement. Takes care of cravings, sometimes decreases the feelings of desire for the drug, sometimes blocks it a little.

Don't do anything with fentanyl cold turkey. Get help, get professional help. Oh gosh - don't do anything at home! Go to the ER if you have to, but do not do it at home. If you have got to get this drug out of you, you can get it out of you, you can get help. It's a great opportunity to face a problem and change your life, go to 2.0.

I don't really believe in drug abuse starting in stages. You can't even experiment with fentanyl. It'll take your life away too easily. Talking about stages, you kind of take a little more, and then you start getting the cravings, and then you have a habit, and then you seek it. You seek it to avoid the withdrawal. That's what most people do, withdrawal and addiction are not moral failings. They're a physiologic effect of the drug and a mental health issue, and you have to address it.

What else do opioids do? If you're using something like Fentanyl regularly or other opioids, you can have constipation. You're gonna have feelings of anhedonia, you just don't care. You're going to want to sit around in a corner and watch tv. Isolationism is huge. You're gonna itch from the histamine release. That's not an allergy. It's a histamine release. Sometimes it's more morphine. 

You're going to get side effects. People are going to see it. As a matter of fact, I have heard of a story again, urban legend, where a doctor that had problems with opioids, cleaned up, went to rehab, which is good, and then came back. Another doctor noticed he was scratching his nose, scratching his nose, scratching his nose, and sure enough, he was using again. Histamine release. He got him help before disaster.

There's more to come with fentanyl, I'm sure. But the point is, this drug has been around for a while, since 1959. It has its medical uses. It should not be banned. It is a really good drug to be considered in the proper hands for the right reasons. Moms and dads and those that are out there and at risk, you have options to decrease the risk. And you should talk it over with the qualified healthcare professional. 

This is not medical advice. This is an informational podcast and website. Please get help if you need it.

Go to the ER, but don't take a chance. Let's keep the discussion going. I'd love to hear from you. Again, this is an informational channel, this is not a medical channel.

Above is taken from Pain Information podcast episode #193 "Fentanyl ... What I know" by Dr. Hans C. Hansen MD