Fentanyl

Pronunciation: FEN-ta-nill

Chemical Abstracts Service Registry Number: 437-38-7. (Citrate form 990-73-8)

Formal Names: Actiq, Alfenta, Alfentanil, Duragesic, Durogesic, Innovar, Subli-maze, Sufenta, Sufentanil

Informal Names: Apache, Bear, China, China Girl, China Town, China White, Dance Fever, Fen, Friend, Goodfellas, Great Bear, He Man, Jackpot, King Ivory, Murder, Murder 8, Persian White, Poison, Synthetic Heroin, Tango & Cash, TNT

Type: Depressant (opioid class). See page 24

Federal Schedule Listing: Schedule II (DEA no. 9801)

USA Availability: Prescription

Pregnancy Category: C

Uses. Developed in Europe during the 1950s, this drug became available for medical use in the United States during the 1960s. It is also used in veterinary medicine, especially with cats. Depending on means of administration (injection, oral) fentanyl can be 10 times stronger than morphine, and fentanyl citrate can be 8 to 100 times stronger. One report claims fentanyl is 40 times stronger than heroin.

Relieving cancer pain is a standard use for fentanyl. With cancer, the drug is normally given only when a patient is dying and unable to experience enough pain control from other opioids. Fentanyl does not necessarily reduce the amount of pain per se but can make people less aware of discomfort. The substance also has sedative actions and suppresses coughs. The drug has been used to help treat tetanus. Fentanyl can alter a person's spirits, making someone euphoric or provoking an opposite feeling of sadness and discontent. One dosage format is the fentanyl patch, allowing the drug to be absorbed through the skin.

Drawbacks. Patches are potent enough in themselves, but a case report tells of one drug abuser who decided to heat a patch and inhale the vapor; he instantly lost consciousness, but prompt attention by skilled medical personnel saved his life.

Fentanyl may cause serious and even fatal breathing difficulty, and this problem can still arise after the drug's action has apparently lifted. Risk of that unwanted effect is heightened among "opioid naive" patients who have not developed tolerance to pain relief from other opioids; so because of the breathing hazard those opioid-naive patients often do not receive fentanyl. Nonetheless, it is sometimes used for childbirth, surgery, and dentistry and for persons suffering from lower back ache and pain in bones and joints. Physicians even give fentanyl to infants.

The drug can promote sleepiness and slow a person's pulse rate, alertness, and physical motions. Such effects interfere with ability to operate automobiles or machinery. Other unwanted actions include itching, constipation, urine retention, nausea and vomiting, increased blood pressure, and fainting upon standing up. Cases of muscle rigidity have been reported. Laboratory tests suggest fentanyl might worsen a body chemistry disease called por-phyria.

Fentanyl can provoke seizures in persons prone to such affliction. A drastic treatment for seizures is surgical removal of a brain lobe where seizures originate, and instrument readings during the operation guide surgeons on how much of the brain to remove. Fentanyl is a standard surgical anesthetic, and one study found that the drug can temporarily create seizures in healthy portions of the brain, thereby misleading surgeons about how much they should remove.

Like many other drugs, fentanyl has stronger effects on older persons, and dosage should be adjusted accordingly.

Abuse factors. Tolerance and dependence can occur, with typical opioid withdrawal symptoms. Just three days of medical dosing can produce enough dependence to cause uncomfortable withdrawal upon sudden stoppage of the drug, an exceptionally short time compared to most opioids. Animal experiments indicate that buprenorphine can alleviate fentanyl withdrawal.

Drug interactions. Normally people should avoid fentanyl if they have taken monamine oxidase inhibitors (MAOIs—found in some antidepressants and other medicine) in the past two weeks, as MAOIs can greatly increase opioid actions. For the same reason, using fentanyl with other depressants (including alcohol) can be risky. Midazolam hydrochloride and fentanyl appear to boost each other's actions. The HIV/AIDS medicine ritonavir makes a fentanyl dose last longer.

Cancer. Whether fentanyl causes cancer is unknown, although laboratory tests with one version of the drug yielded no indication of cancer-causing potential.

Pregnancy. Rats receiving fentanyl have lower fertility rates and bring fewer pregnancies to term, compared to rats not receiving the drug, and those effects occurred at smaller doses than humans typically receive. When fentanyl citrate has been given to pregnant rats, birth defects in their offspring have not been attributed to the drug. Whether fentanyl causes congenital malformations in humans is unknown. An infant can be born with dependence if the mother has been using fentanyl. The drug passes into a nursing mother's milk but not in amounts deemed harmful to an infant.

Additional information. Alfentanil (Schedule II, CAS Registry No. 7119558-9) is a derivative of fentanyl used for pain control and anesthesia. Effects last only a few minutes. Depending on dosage form, pain relief is 1 to 10 times stronger than morphine. When given to a pregnant woman alfentanil apparently passes into the fetus. The drug can produce muscle rigidity in infants.

Sufentanil (Schedule II, CAS Registry No. 56030-54-7, citrate form 60561-173) is a derivative of fentanyl used for pain control and anesthesia. It is 50 to 100 times stronger than morphine and is used to knock out wild animals. The drug takes effect faster than fentanyl but lasts a shorter time. Sufentanil can lower heart rate and blood pressure, create muscle rigidity, and cause typical unwanted opioid effects such as itching and vomiting. At normal doses su-fentanil can halt breathing, so medical personnel stand by to provide respiration assistance when they administer the drug. Laboratory and animal experiments indicate no potential for causing cancer. Tests with rats and rabbits did not produce birth defects. Researchers examining the results when sufentanil is used in childbirth found no harm to mother or infant. Sufentanil is assumed to pass into the milk of nursing mothers, but the amount is assumed harmless to the infant.

Other fentanyl derivatives exist. They are used illicitly to experience heroin sensations and can be 1,000 times stronger than heroin.

Fentanyl has the same molecular formula as the Schedule I substance acetyl-alpha-methylfentanyl (DEA no. 9815), but the two drugs are different substances.

Additional scientific information may be found in:

Baylon, G.J. "Comparative Abuse Liability of Intravenously Administered Remifentanil and Fentanyl." Journal of Clinical Psychopharmacology 20 (2000): 597-606. Henderson, G.L. "Designer Drugs: Past History and Future Prospects." Journal of Forensic Sciences 33 (1988): 569-75. Patt, R.B., and L.A. Hogan. "Comment: Transdermal Fentanyl." Annals of Pharmaco-

therapy 27 (1993): 795-96. Schneider, U., et al. "Effects of Fentanyl and Low Doses of Alcohol on Neuropsychological Performance in Healthy Subjects." Neuropsychobiology 39 (1999): 38-43. Zacny, J.P., et al. "Subjective and Behavioral Responses to Intravenous Fentanyl in Healthy Volunteers." Psychopharmacology (Berlin) 107 (1992): 319-26.

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