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Fentanyl
Charlie Suter
Department of Health Promotion, University of Lynchburg
HP 300 A: Drugs and Behavior Management
Professor Rebekkah McLellan
October 19, 2020
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Fentanyl
The purpose of this research paper is to highlight the misuse and abuse of the drug
Fentanyl. This is a synthetic opioid that was created in 1960 by Dr. Paul Janssen of Janssen
Pharmaceutica in Belgium and was approved for use in the United States in 1972 (Center for
Disease Control and Prevention, 2020; Suzuki & El-Haddad, 2017; Krenzelok, 2017;
Kuczyńska, Grzonkowski, Kacprzak, et al., 2018; Armenian, Vo, Barr-Walker, et al., 2018). In
its pharmaceutical form, fentanyl is approved to be administered in order to treat and manage an
individual’s severe pain (CDC, 2020; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018). It has
been found to be 50 to 100 times more potent than morphine and was originally only used as an
intravenous anesthetic (CDC, 2020; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018; Suzuki &
El-Haddad, 2017). However, since the 1980s, fentanyl has expanded its uses with patches,
tablets, lozenges, and sprays (Suzuki & El-Haddad, 2017).
With the increase in products and modes of administration, misuse and intentional abuse
of pharmaceutical fentanyl has been reported since the 1980s (Suzuki & El-Haddad, 2017). The
majority of the early reports of misuse and abuse were in regard to nurses and doctors who had
“occupational exposure and easy access” (Suzuki & El-Haddad, 2017, pg. 108; Kuczyńska,
Grzonkowski, Kacprzak, et al., 2018). Around the same time, fentanyl and its derivatives began
to appear as designer drugs being sold for illicit use (Han, Yan, Zheng, et al., 2019; Krenzelok,
2017). They have been most often sold as a heroin substitute and are often mixed with heroin or
other illicit drugs to unsuspecting addicts (Han, Yan, Zheng, et al., 2019; Krenzelok, 2017;
Suzuki & El-Haddad, 2017). The combination of misuse and abuse of fentanyl has led to large
and continual increases in fentanyl overdoses with a significant rise in the early 2000s and again
in 2014 (Armenian, Vo, Barr-Walker, et al., 2018; CDC, 2016).
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The reason for my own interest in fentanyl is mainly for three reasons. The first being for
its large involvement with the ongoing opioid crisis in the United States. In 2016, several states
that participated in a study using toxicologic and death scene evidence in opioid overdose deaths
found that over 50 percent found that fentanyl and fentanyl derivatives were involved
(O’Donnell, Halpin, Mattson, et al., 2017). The second reason for my interest in fentanyl is due
to the Netflix show “Bad Blood”. This show depicts the creation, sale, and distribution of heroin
and other illicit drugs in Montreal, Canada. The individuals in the show begin to discuss the cost
benefits of cutting their heroin with nonpharmaceutical fentanyl. The main reason for this being
that it lowers their manufacturing costs of heroin without really explaining why. This interested
me because I wanted to know why the use of fentanyl lowers the manufacturing cost of heroin.
The third reason for my interest in fentanyl is due to a man that I met while taking an aggressive
driver’s course. When the use of opioids while driving was brought up, with the specific mention
of fentanyl, he discussed how he was once addicted to fentanyl patches. He detailed how he
would periodically ball up a fentanyl patch and chew on it throughout the day. He did not give
the reasoning for this which only further piqued my interest in fentanyl.
This knowledge would be applicable to my future professional life because of my interest
in public health. I intend to obtain a master’s in public health so the knowledge of fentanyl and
its effects on the public would be beneficial information to have. While I have not decided on an
exact area in public health I would like to pursue, the information regarding a major public
health crisis could not hurt in any area of the field. Understanding how fentanyl is supposed to be
used and how it is misused and abused in both pharmacological and illicit forms will further my
understanding of the opioid crisis occurring in the United States.
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Literature Review
In its pharmaceutical form, fentanyl-based products including “injectable formulations,
oral transmucosal lozenges, buccal tablets, sublingual tablets, [and] intranasal sprays” are
prescribed to individuals in order to treat and manage chronic pain (Kuczyńska, Grzonkowski,
Kacprzak, et al., 2018, pg. 208; CDC, 2020; Comer & Cahill, 2019). The pharmaceutical
transdermal patches are prescribed for acute pain treatment often during the post-operative stage
(Kuczyńska, Grzonkowski, Kacprzak, et al., 2018). When first introduced in a medical setting,
fentanyl was used as an intravenous anesthetic that was found to be superior to morphine. This is
due to the potency being 50 to 100 times more than morphine, a shorter onset, longer duration,
and lessened hypo and hypertension (Suzuki & El-Haddad, 2017). Fentanyl was also preferred
over morphine due to the decreased cost of production. Due to fentanyl being a synthetic drug
and produced in a lab the cost of production is lower than morphine which has to be extracted
from cultivated opium poppies (Suzuki & El-Haddad, 2017). The preference for fentanyl in
medical settings lead to the development of the previously mentioned forms of pharmaceutical
fentanyl.
Once administered, pharmaceutical fentanyl’s high lipophilicity, the ability to dissolve in
lipids, allows for rapid diffusion (Suzuki & El-Haddad, 2017; Twycross, Prommer, Mihalyo, et
al., 2012). This allows fentanyl to cross the blood-brain barrier which gives it a greater analgesic
potency while mainly affecting the central nervous system, gastrointestinal system,
cardiovascular system, and pulmonary system (Comer & Cahill, 2019; Han, Yan, Zheng, et al.,
2019). Fentanyl is quickly distributed throughout the body leading to a variety of effects. These
are similar to many other opioids and includes analgesia, which is the inability to feel pain,
anxiolysis, which is a state of sedation in which the patient is extremely relaxed and often still
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awake, euphoria, drowsiness, nausea, and vomiting (Suzuki & El-Haddad, 2017; Han, Yan,
Zheng, et al., 2019). As well as respiratory depression, which is slow of shallow breathing,
miosis or constriction of pupils, constipation, pruritus or skin irritation, migraines, dizziness,
confusion, hallucinations, bradycardia or slow heart rate, urinary urgency and retention, and
chest wall rigidity or the cessation of chest wall movement especially when fentanyl was
administered intravenously (Kuczyńska, Grzonkowski, Kacprzak, et al., 2018; Suzuki & El-
Haddad, 2017; Han, Yan, Zheng, et al., 2019). The misuse and abuse of fentanyl can also cause
additional symptoms including acute anterograde amnesia or the inability to retain new
information, seizures, foaming at the mouth, and both diffuse and pulmonary alveolar
hemorrhage (Kuczyńska, Grzonkowski, Kacprzak, et al., 2018). Withdrawal from fentanyl can
also cause symptoms such as sweating, anxiety, diarrhea, abdominal cramps, bone pain, and
goosebumps (Kuczyńska, Grzonkowski, Kacprzak, et al., 2018).
Pharmaceutical fentanyl can be misused accidentally in its many forms by the individuals
it is prescribed to. Pills can be taken at improper times and many transdermal patch designs can
have an increased release when exposed to direct heat which will cause an individual to absorb
more fentanyl at one time than originally intended (Suzuki & El-Haddad, 2017; Schepis,
McCabe, Boyd, et al., 2019). Abuse of pharmaceutical fentanyl can occur in multiple ways. The
first being abuse perpetrated by health care professionals such as doctors, nurses, pharmacists,
and anesthesiologists who have easy access to fentanyl. In the 1990s and 2000s, there were many
reports of health care workers overdosing on fentanyl and its derivatives (Suzuki & El-Haddad,
2017; Comer & Cahill, 2019; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018). Abusers can
take someone else’s fentanyl medication (Schepis, McCabe, Boyd, et al., 2019). Prescription
medication can be purposefully misused by the individual it was prescribed to or resold to others
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for illicit use by patients or clinicians (Schepis, McCabe, Boyd, et al., 2019; McGinty, Stone,
Kennedy-Hendricks, et al., 2019). Transdermal patches can have the fentanyl they contain
extracted for misuse and then administered intravenously, orally, or inhaled (Ruzycki & Yarema,
2016; Suzuki & El-Haddad, 2017; Comer & Cahill, 2019; Armenian, Vo, Barr-Walker, et al.,
2018; CDC, 2020). While pharmaceutical fentanyl misuse and abuse does occur, it represents a
low percentage of overall fentanyl misuse and abuse. The majority happens outside of a medical
setting with the abuse and misuse of illicit fentanyl and its derivatives (Suzuki & El-Haddad,
2017; Han, Yan, Zheng, et al., 2019; Comer & Cahill, 2019; Kuczyńska, Grzonkowski,
Kacprzak, et al., 2018; Schepis, McCabe, Boyd, et al., 2019).
While in other areas of the world the source of fentanyl in the drug market is derived
from diverted pharmaceutical fentanyl, in North America and Europe the large majority of
fentanyl supply is from illicit production (Kuczyńska, Grzonkowski, Kacprzak, et al., 2018;
Suzuki & El-Haddad, 2017; Han, Yan, Zheng, et al., 2019; Comer & Cahill, 2019). Illicit
fentanyl and its derivatives, once manufactured, is most often sold as a powder (Kuczyńska,
Grzonkowski, Kacprzak, et al., 2018; Ruzycki & Yarema, 2016). This powder can then be
dissolved and injected or inhaled as a nasal spray, smoked, snorted, ingested, or made into
counterfeit pills (Kuczyńska, Grzonkowski, Kacprzak, et al., 2018, Ruzycki & Yarema, 2016).
Counterfeit pills containing fentanyl will often be sold as oxycodone or hydrocodone pills to
unsuspecting addicts (Kuczyńska, Grzonkowski, Kacprzak, et al., 2018, Ruzycki & Yarema,
2016; Armenian, Vo, Barr-Walker, et al., 2018). Counterfeit pills containing heroin have been on
the rise since 2014 (Armenian, Vo, Barr-Walker, et al., 2018). The previously mentioned forms
of illicit fentanyl and its derivatives often go by street names such as Fefe, Poison, Flatline, Blue
Bag, “China White, Apache, China Girl, Dance Fever, Friend, Goodfella, Jackpot, Murder 8,
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TNT, Tango and Cash, Synthetic Heroin, Drop Dead, Lethal Injection, Get High or Die Trying”
(Suzuki & El-Haddad, 2017, pg. 111; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018).
The most commonly encountered form of illicit fentanyl and its derivatives is when the
powder is mixed or cut with heroin (Daniulaityte, Carlson, Juhascik, et al., 2019; Armenian, Vo,
Barr-Walker, et al., 2018; Comer & Cahill, 2019; Ruzycki & Yarema, 2016; Suzuki & El-
Haddad, 2017; Frank & Pollack, 2017; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018; CDC,
2020; Han, Yan, Zheng, et al., 2019). This form of illicit fentanyl is often sold unsuspectingly to
addicts and passed off as regular heroin (Daniulaityte, Carlson, Juhascik, et al., 2019; Armenian,
Vo, Barr-Walker, et al., 2018; CDC, 2020; Han, Yan, Zheng, et al., 2019; CDC, 2016). Several
studies have shown via self-reporting that anywhere from 50 to 70 percent of overdose survivors
were unaware that the drug or product they were buying and using contained fentanyl
(Daniulaityte, Carlson, Juhascik, et al., 2019; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018).
The combining of fentanyl and heroin is in order to increase the potency of the heroin at a low
production cost (Han, Yan, Zheng, et al., 2019; Frank & Pollack, 2017; Frank & Pollack, 2017).
Heroin has an average cost of about $65,000 per kilogram while illicit fentanyl and its
derivatives have an average cost of $3,500 per kilogram (Frank & Pollack, 2017). This lower
cost in combination with fentanyl being 30 to 50 times more potent than heroin gives an
incentive for illicit drug dealers and manufacturers to mix the two in order to increase revenue
(Frank & Pollack, 2017). If fentanyl can be mixed with and passed off as heroin and then be sold
for the same price as regular heroin, then the profit margin of the dealer and manufacturer will go
up. This can also be done with other drugs such as methylenedioxymethamphetamine or
MDMA, cocaine, and ecstasy but still most commonly occurs with heroin (Frank & Pollack,
2017; Armenian, Vo, Barr-Walker, et al., 2018; Kuczyńska, Grzonkowski, Kacprzak, et al.,
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2018; CDC, 2020). This can prove to be dangerous to abusers, especially if they are unaware that
the drug they are buying contains fentanyl. This is because of the high potency of fentanyl, lesser
amounts of the drug can overload the body and cause an overdose (Han, Yan, Zheng, et al.,
2019; Comer & Cahill, 2019). There is a high overdose risk when fentanyl is involved with other
illicit drugs due to street dealers and manufacturers who are unwilling to pay for the specialized
equipment needed to measure precise doses (Frank & Pollack, 2017).
Fentanyl has been found to be a major contributor to the opioid crisis in the United
States. Fentanyl-related overdose deaths make up over 50 percent of opioid overdose deaths with
the majority being caused by its illicit forms (O’Donnell, Halpin, Mattson, et al., 2017; Schepis,
McCabe, Boyd, et al., 2019). One study found that many abusers self-reported that they could
identify the difference between actual heroin and fentanyl based on its color. However, those
same individuals had limited knowledge of fentanyl’s derivatives which can appear in a variety
of different colors (Daniulaityte, Carlson, Juhascik, et al., 2019). This could cause difficulty in
recognizing the presence of a fentanyl derivative in the drug they are purchasing and abusing.
Without the knowledge of fentanyl being present in the drugs they are abusing, addicts could be
unaware that the dose they have taken or are about to take could be lethal, especially if they have
little to no tolerance for fentanyl (Daniulaityte, Carlson, Juhascik, et al., 2019; Krenzelok, 2017).
There is an even greater risk when dealing with fentanyl derivatives because some can have an
even higher potency than regular fentanyl (O’Donnell, Halpin, Mattson, et al., 2017; Krenzelok,
2017). The most common derivatives being carfentanil, furanylfentanyl, and acetylfentanyl, with
carfentanyl estimated of being 10,000 times more potent than morphine (O’Donnell, Halpin,
Mattson, et al., 2017).
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When an individual does overdose on fentanyl, an injection of naloxone, an opioid
antagonist, has the potential to reverse the effects (Ruzycki & Yarema, 2016; Krenzelok, 2017;
Frank & Pollack, 2017; Kuczyńska, Grzonkowski, Kacprzak, et al., 2018; CDC, 2020). This
injection, which can be administered intravenously, intramuscularly, subcutaneously,
intranasally, or intralingually or injected into the tongue, must occur within a timely manner in
order to be effective and in many cases, the normal injected amount of 0.4 mg, which can reverse
a heroin overdose, will most likely not be enough due to fentanyl and its derivatives’ potency
(Ruzycki & Yarema, 2016; Krenzelok, 2017; Frank & Pollack, 2017). A higher dose of two to
four milligrams of naloxone, which is five to ten times the normal dose, is often needed to treat a
fentanyl overdose (Krenzelok, 2017; Ruzycki & Yarema, 2016; Frank & Pollack, 2017;
Kuczyńska, Grzonkowski, Kacprzak, et al., 2018; CDC, 2020). This could be done through
multiple administrations of naloxone or a higher initial dose (Krenzelok, 2017; Ruzycki &
Yarema, 2016; Frank & Pollack, 2017). In addition to naloxone, maintaining breathing and
circulation should also be the focus due to the effects of fentanyl (Kuczyńska, Grzonkowski,
Kacprzak, et al., 2018).
Conclusion
The opioid crisis is a chronic issue in the United States, with fentanyl being an even more
serious issue which makes up over 50 percent of opioid deaths (O’Donnell, Halpin, Mattson, et
al., 2017; Schepis, McCabe, Boyd, et al., 2019). This is mainly due to its illicit use because of
fentanyl’s higher potency when compared to other opioids and its cheaper manufacturing price
for illicit producers (Ruzycki & Yarema, 2016; Krenzelok, 2017; Frank & Pollack, 2017;
O’Donnell, Halpin, Mattson, et al., 2017; Schepis, McCabe, Boyd, et al., 2019). If fentanyl were
removed from the illicit drug market and was no longer being mixed with heroin or other drugs,
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there could be a potential decrease in the number of opioid overdoses throughout the country,
however this is highly unlikely due to the aforementioned reasons (McGinty, Stone, Kennedy-
Hendricks, et al., 2019). There is more that could be done to prevent the misuse and abuse of
fentanyl in both its illicit and no illicit forms. This would most likely require a multipronged
approach with multiple societal improvements.
Ten possible improvements that could be made by members of society are:
1. Increase the awareness of illicit drug users on how to be able to identify the possibility of
fentanyl or one of its derivatives being mixed into the drugs that they are using. Only
about half of drug users are able to identify fentanyl, which few to none being able to
identify a fentanyl derivative which can appear in different colors than the usual white
(Daniulaityte, Carlson, Juhascik, et al., 2019).
2. Increase the awareness of pharmaceutical fentanyl users by highlighting the dangers of
addiction. While also making sure that they understand the instructions for taking and
using fentanyl products in order to prevent accidental misuse (Schepis, McCabe, Boyd, et
al., 2019).
3. Impose harsher sentences on those who produce and distribute any drug that is found to
be mixed, laced, or cut with fentanyl or any of its derivatives. As well as harsher
sentences to patients and medical professionals who resell prescription fentanyl. This
would be an attempt to prevent the crime (Frank & Pollack, 2017; McGinty, Stone,
Kennedy-Hendricks, et al., 2019).
4. Increase the prevalence and awareness of prescription drug return, disposal, reuse, and
recycling programs (Garcia & Becker, 2020).
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5. Increase the awareness of treatment centers and addicts anonymous meetings sites and
times in surrounding areas. Focusing on communities with higher drug abuse rates
(McGinty, Stone, Kennedy-Hendricks, et al., 2019).
6. Increase the presence and distribution of naloxone kits for use by both first responders
and at home. This would be accompanied by training for at-home use for both users and
relatives of users. Similar approaches have seen some success in Europe and Canada
(Frank & Pollack, 2017).
7. Health professionals could only prescribe fentanyl products in only dire situations where
it would be medically necessary. The development of stricter guidelines for prescriptions
and education on patient selection for prescribers could aid in reducing pharmaceutical
fentanyl misuse and abuse (McGinty, Stone, Kennedy-Hendricks, et al., 2019; Twycross,
Prommer, Mihalyo, et al., 2012).
8. Pharmacists should educate patients about safety while using a fentanyl medication
including how to store and dispose of it (Twycross, Prommer, Mihalyo, et al., 2012).
9. Increase in the presence and availability of drug and pill testing kits for drugs like
MDMA for first responders and users in order to detect the presence of fentanyl. This
could increase the safety for users and improve the response of emergency services
(Frank & Pollack, 2017).
10. Further studies and research looking into the effects of a fentanyl overdose and effective
treatment methods for those effects in order to help reduce death rates (Han, Yan, Zheng,
et al., 2019; Comer & Cahill, 2019).
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References
Armenian, P., Vo, K. T., Barr-Walker, J., & Lynch, K. L. (2018). Fentanyl, fentanyl analogs and
novel synthetic opioids: a comprehensive review. Neuropharmacology, 134, 121-132.
https://doi.org/10.1016/j.neuropharm.2017.10.016
Center for Disease Control and Prevention (2020, March 19). Fentanyl. Center for Disease
Control and Prevention (CDC). https://www.cdc.gov/drugoverdose/opioids/
fentanyl.html.
Center for Disease Control and Prevention (2016, July 31). Reported Law Enforcement
Encounters Testing Positive for Fentanyl Increase Across US. Center for Disease
Control and Prevention (CDC). https://www.cdc.gov/drugoverdose/data/fentanyl-
lereports.html
Comer, S., & Cahill, C. (2019). Fentanyl: Receptor pharmacology, abuse potential, and
implications for treatment. Neuroscience and Biobehavioral Reviews, 106, 49–57.
https://doi.org/10.1016/j.neubiorev.2018.12.005
Daniulaityte, R., Carlson, R., Juhascik, M., Strayer, K., & Sizemore, I. (2019). Street fentanyl
use: Experiences, preferences, and concordance between self-reports and urine
toxicology. The International Journal of Drug Policy, 71, 3–9.
https://doi.org/10.1016/j.drugpo.2019.05.020
Frank, R. G., & Pollack, H. A. (2017). Addressing the fentanyl threat to public health. New
England journal of medicine, 376(7), 605-607. https://doi.org/10.1056/NEJMp1615145
13
Garcia, A., & Becker, C. (2020). Medicine donation program helps many Georgians who can't
afford what they need. Retrieved October 2, 2020, from https://www.ncsl.org/research
/health/state-prescription-drug-return-reuse-and-recycling.aspx
Han, Y., Yan, W., Zheng, Y., Khan, M., Yuan, K., & Lu, L. (2019). The rising crisis of illicit
fentanyl use, overdose, and potential therapeutic strategies. Translational
Psychiatry, 9(1), 282–289. https://doi.org/10.1038/s41398-019-0625-0
Krenzelok, E. P. (2017). Abuse of fentanyl derivatives: History repeating itself. American
Journal of Health-System Pharmacy, 74(8), 556. https://doi.org/10.2146/ajhp170050
Kuczyńska, K., Grzonkowski, P., Kacprzak, Ł., & Zawilska, J. B. (2018). Abuse of fentanyl: An
emerging problem to face. Forensic science international, 289, 207-214.
https://doi.org/10.1016/j.forsciint.2018.05.042
McGinty, E. E., Stone, E. M., Kennedy-Hendricks, A., Sanders, K., Beacham, A., & Barry, C. L.
(2019). US news media coverage of solutions to the opioid crisis, 2013–2017. Preventive
medicine, 126, 105771. https://doi.org/10.1016/j.ypmed.2019.105771
O’Donnell, J., Halpin, J., Mattson, C., Goldberger, B., & Gladden, R. (2017). Deaths Involving
Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July–December 2016. MMWR.
Morbidity and Mortality Weekly Report, 66(43), 1197–1202.
https://doi.org/10.15585/mmwr.mm6643e1
Ruzycki, S., & Yarema, M. (2016). Fentanyl misuse. Canadian Medical Association Journal
(CMAJ), 188(9), 673–673. https://doi.org/10.1503/cmaj.151378
14
Schepis, T. S., McCabe, V. V., Boyd, C. J., & McCabe, S. E. (2019). The epidemiology of
prescription fentanyl misuse in the United States. Addictive behaviors, 96, 89-93.
https://doi.org/10.1016/j.addbeh.2019.04.022
Suzuki, J., & El-Haddad, S. (2017). A review: fentanyl and non-pharmaceutical fentanyls. Drug
and alcohol dependence, 171, 107-116. https://doi.org/10.1016/j.drugalcdep.2016.11.033
Twycross, R., Prommer, E., Mihalyo, M., & Wilcock, A. (2012). Fentanyl
(transmucosal). Journal of Pain and Symptom Management, 44(1), 131–149.
https://doi.org/10.1016/j.jpainsymman.2012.05.001
