Fentanyl overdoses

Fentanyl overdose leads to the classic triad of symptoms consistent with the opioid intoxication syndrome miosis, respiratory depression, and CNS depression. Additional toxic effects of fentanyl include bradycardia, hypotension, decreased gastrointestinal motility, euphoria, and acute lung injury. 

Prevention CfDCa. Acetyl fentanyl overdose fatahties-Rhode Island, March-May 2013. MMWR August 30, 2013 62(34) 703-4. Mercado-Crespo MC, Sumner SA, Spelke MB, Sugerman DE, Stanley C. Notes from the field increase in fentanyl-related overdose deaths -Rhode Island, November 2013-March 2014. MMWR June 20,2014 63(24) 531. 

In 1979-1980, some illegal fentanyl analogues appeared that were being sold as substitutes for heroin on the street. Suddenly, a series of more than a dozen mysterious deaths occurred in southern California. Upon autopsy, the victims strongly looked as if they had overdosed on heroin however, no traces of heroin could be found in their bodies. Later, forensic chemists identified a fentanyl analogue (alpha-methyl-fentanyl) that was present in all of the victims. As it turns out, alpha-methyl-fentanyl was being sold on the streets under the name China White (Figure 7.2), because it resembled (and contained) pure synthetic heroin that was produced in Southeast Asia. 

Figure 7.2 China White powder, shown here, is a synthetic form of heroin that is very pure. China White that was tainted with illegal fentanyl analogues, which are hundreds of times more potent than heroin, caused numerous overdoses in heroin addicts in the late 1970s and early 1980s.

Fentanyl transdermal system Fentanyl transdermal systems contain a high concentration of the potent schedule II opioid agonist, fentanyl. Schedule II opioid substances have the highest potential for abuse and associated risk of fatal overdose due to respiratory depression. Fentanyl can be abused and is subject to criminal diversion. The high content of fentanyl in the patches may be a particular target for abuse and diversion. 

Naloxone Narcotic drugs, other opioid derivatives A specific antagonist of opioids 1-2 mg initially by IV, IM, or subcutaneous injection. Larger doses may be needed to reverse the effects of overdose with propoxyphene, codeine, or fentanyl derivatives. Duration of action (2-3 hours) may be significantly shorter than that of the opioid being antagonized. 

A man died after his wife mistakenly applied six transdermal patches to his skin at one time. The multiple patches delivered an overdose of the narcotic pain medicine fentanyl through his skin. 

The street versions of fentanyl are ingested in the same ways as heroin. It is usually sold in a powder form and either smoked, snorted, or injected into a vein. Since fentanyl is water-soluble, the powder form can be cold-stirred into a solution and does not need to be boiled like other opioids. However, injection is the most common method used for ingestion on the street. It is so much more potent than heroin that in many of the overdose deaths, the user is found with the needle still in an arm, in some instances with plunger not fully compressed. Some of the designer fentanyl today is made into pill form, but in this form of ingestion, more time elapses before the user feels its effects. 

As with any narcotic, fentanyl is addictive. Because it interacts with the mu receptor, which has an effect on addiction, it is highly addictive. Fentanyl users also build a tolerance to the drug s effects, thus needing more of the drug to reach the same euphoric experiences. Building up a tolerance to the drug can be harmful to the user. As the user continues to consume more and more of the drug to achieve the same effects, an overdose becomes likely. 

Fentanyl and its analogs are drugs of abuse. Overdose and dependence may lead to respiratory complications and death.58 Adverse effects can be treated with drugs such as naloxone, atropine, and neuromuscular blockers. In general, interactions are similar to those of opioid analgesics. 

A 57-year-old woman using transdermal fentanyl (75 pg/ hour) developed a reduced respiratory rate and bilateral pinpoint pupils when an upper body warming blanket was used as a normal postoperative procedure (24). The resultant increase in skin temperature significantly enhanced skin perfusion, and increased the systemic absorption of fentanyl from the intracutaneous fentanyl depot, leading to sjmptoms of opioid overdose. She recovered after removal of the fentanyl patch and the intravenous administration of naloxone 60 pg. 

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. 

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). 

Frolich MA, Giannotti A, ModeU JH, FroUch M. Opioid overdose in a patient using a fentanyl patch dnrrng treatment with a warming blanket. Anesth Analg 2001 93(3) 647-8. 

Matejczyk RJ (1988) Fentanyl related overdose. Journal of Analytical Toxicology 12 236-238. 

The total dose required to reverse the effects of the opioid is highly variable and is dependent on the concentration and receptor affinity of the opioid. Some drugs (eg, propoxyphene, diphenoxylate/atropine [Lomotil], buprenorphine, pentazocine, and the fentanyl derivatives) do not respond to usual doses of naloxone. However, if no response is achieved by a total dose of 10-15 mg, the diagnosis of opioid overdose should be questioned. 

In an observational study in 1818 patients intended to discover whether the abuse potential of opioids matches the preference for non-therapeutic abuse in the real world, fentanyl, despite being predicted to have the greatest abuse potential, did not rank as high choice, owing to fear of toxicity and overdose hydrocodone and oxycodone were the drugs of choice in 75% of patients [10 ). 

In a community hospital in the USA, there was a significant increase in diamorphine overdoses over a 1-month period (June-July 2006) [59 ]. There were 30 overdoses in this period and nine of these reported having used blue bag heroin, diamorphine laced with fentanyl. During a similar period in the previous year, only six overdoses had been due to diamorphine. The authors suggest that fentanyl-laced heroin may have contributed to the increased increase. 

---