Fentanyl history

Remifentanil (Ultiva) is used for induction and maintenance of general anesthesia and for continued analgesia during the immediate postoperative period. This drug is used cautiously in patients witii a history of hypersensitivity to fentanyl. 

Table 8.2 shows a selective timeline of the evaluation, abuse, and regulation of fentanyl, a potent agonist at mu-opioid receptors. Again, the most salient aspects of the drug s recent history can be summed up with two questions. 

Veterinarians do have a dilemma in prescribing fentanyl or other analgesics because they must register with the DEA just as other medical professionals, and are under the same scrutiny. However, they do not have the luxury of providing social security numbers or medical history on their patients. This makes it easier for them to illegally obtain the drug. It also puts them under more scrutiny from the federal government. 

A 26-year-old woman with a history of multiple substance abuse required emergency caesarean section at 30 weeks of gestation as a result of crack cocaine-induced placental abruption and fetal distress (251). Her admission blood pressure was 145/95 mmHg, heart rate 95/minute and respiratory rate 20/minute. The fetal heart rate was 130/minute and non-reactive, with late and variable decelerations and no response to maternal oxygen administration. Spinal block with bupivacaine, fentanyl, and morphine was performed with the patient in a sitting position. No maternal or neonatal postoperative complications were reported. 

Transdermal fentanyl was the cause of an opioid overdose when a 77-year-old man with a history of severe arthritis developed respiratory failure after starting epidural diamorphine-bupivacaine mixture for postoperative pain (50). The fentanyl patch was removed, the epidural infusion was stopped, and naloxone was given to counteract the excessive opioid effects. 

Transdermal fentanyl for chronic non-cancer pain control has been studied in two open trials (60,61). In a multicenter, open, randomized study of 256 patients with a history of chronic non-cancer pain, 65% preferred transdermal fentanyl, whereas 28% preferred modified-release oral morphine. Subjective pain control and quality of hfe were significantly better in the patients who used transdermal fentanyl. Despite a preference for transdermal fentanyl, more patients withdrew because of adverse effects in the first fentanyl period (16%) than in the first morphine period (9%). The difference could have been related to patients previous experience of morphine, with enhanced tolerance of its adverse effects. 

In a prospective study, 64 patients with a recent history of at least one vertebral fracture caused by primary and secondary osteoporosis were recruited from six osteoporosis centers in Germany between December 1999 and April 2001 (63). Transdermal fentanyl 25 pg/hour was the recommended starting dose, with incremental steps of 25 pg/hour if there was insufficient analgesia. Treatment was stopped after less than 28 days in 15 patients (23%). In 10 of these, fentanyl was stopped because of nausea and/or vomiting and/or dizziness. In 49 patients, pain at rest (55% reduction) and on motion (47% reduction) abated significantly from baseline. The starting dose of 25 pg/hour of fentanyl was sufficient in most patients (70%). 

A 24-year-old woman, with a history of polysubstance abuse and extensive psychiatric history, presented with acute opioid overdose caused by the intentional oral ingestion of a fentanyl patch (Duragesic) (74). 

Morphine causes histamine release, which can cause bronchoconstriction and vasodilation, and should be avoided in patients with a history of asthma. Other /i-receptor agonists that do not release histamine, such as the fentanyl derivatives, may be better choices for such patients. 

A 71-year-old man undergoing a minor orthopaedic operation was given a 500-microgram intravenous injection of alfentanil followed by a slow injection of propofol 2.5 mg/kg. Approximately 15 seconds after the propofol, the patient developed strong bilateral fits and grimaces, which lasted for 10 seconds. Anaesthesia was maintained with nitrous oxide/oxygen and halothane and there were no other intra- or postoperative complications. The patient had no history of convulsions. Propofol has also been associated with opisthotonos (a spasm where the head and heels bend backwards and the body arches forwards) in two patients given fentanyl... 

A 39-year-old Asian woman with a history of alcohol problems and alcoholic cirrhosis, who was taking regular sertraline 100 mg/day developed serotonin syndrome after receiving fentanyl 50 micrograms for esophagogastroduodenoscopy [36 ]. 

Relative they are contraindicated in the management of acute or post-operative pain. They are not indicated for use in opioid non-tolerant patients. The safety and efficacy of fentanyl buccal tablets and fentanyl oralet have not been establidied in pediatric patients below the age of 16 years. They ould be used cautiously in patients with a history ofbradyarrhthymias, or with evidence of increased intracranial pressure or impaired consciousness, or with history of chronic obstructive pulmonary disease, or preexisting medical conditions predisposing them to respiratory depression. 

WhUe the fixed-dose system eliminates errors, it also eliminates flexibility. The lack of programmability and the lack of a basal infusion mode may make fentanyl ITS imsuitable for use in many opioid-tolerant individuals. Moreover, the current design only allows an estimation of the actual number of doses administered (within five). Detailed history cannot be obtained from the system to determine the number and timing of attempts relative to dehveries. 

Nervous system In a 58-year-old man with a history of Parkinson s disease, fentanyl as an anesthetic and for postoperative analgesia was associated with severe bradykinesia and rigidity [67 ]. The mechanism was unclear but probably resulted from an effect on the dopaminergic nigrostriatal system. 

Endocrine Secondary adrenal insufficiency was reported in a 64-year-old man with a history of diffuse large B cell lymphoma after he was given transdermal fentanyl 75 micrograms/hour for multifactorial pain Adrenal insufficiency recurred when he was re-started on fentanyl by his general practitioner. 

A 50-year-old man with no previous history of seizures was anesthetized with fentanyl 100 micrograms and propofol 100 mg. Within 30 seconds of receiving the propofol, he developed tonic-clonic seizures over the trunk and lower body. Despite thiopental 125 mg the seizures recurred and required further boluses of thiopental and midazolam. Surgery continued uneventfully and postoperative recovery was unremarkable. A CT scan of the brain was normal. 

A 28-year-old female underwent an imcomplicated umbilical hernioplasty. The patient had a history of migraine but no other neurological or psychiatric disease. She received propofol 230 mg and fentanyl for induction of anaesthesia. The nature and dose of drugs used to maintain anaesthesia and given in the postoperative period and the anaesthetic technique employed are not provided. Six hours after surgery the patient was noted to have facial spasms, hand tremor, jerky neck... 

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