Let’s talk about fentanyl…

The other week, I wrote about how wrong the president was when he said that fentanyl is “just a painkiller”.

From that blog post, we learned that it’s not just a painkiller. Because it is part of a group of drugs called opioids, this class of drug interacts with opioid receptors in the brain and elicit a wide range of responses in the body – from a feeling of relief from pain to relaxation, pleasure and contentment.

We talked about it’s licit (approved and proper) use for medicinal purposes. It’s approved indication include: managing acute and chronic pain particularly that due to cancer, nerve damage, back injury, major trauma and surgery. The caveat here is to use this only when all other lesser potent and addicting analgesics (narcotic or non-narcotic) fail.

It’s illicit (illegal) use is multiple and dangerous. Drug addicts get hold of the patch and extract the fentanyl from the patch and inject it. More commonly, however, is “diverting” method.

Diversion occurs when a medication that is prescribed by a medical professional, is not used appropriately, or is given or sold to a third party. (Alcohol and Drug Foundation, Australia)

Prescribed fentanyl can be “diverted” when:

  • individuals obtain medication inappropriately through their profession (e.g. doctors prescribe for themselves or among their peers)
  • individuals use their own prescribed medication recreationally for a non-medically intended purpose (e.g., to get euphoric effects or use it for sleep problems and not as a pain reliever)
  • individuals use medication prescribed to another person

There is NO safe level of drug use and what may be good for the goose, may not be good for the gander.  This means that its effect varies within and among different persons using the drug.

The most common side effects or “experiences” are:

  • nausea, vomiting
  • constipation and/or diarrhea
  • reduced appetite
  • wind, indigestion, cramps
  • drowsiness, confusion
  • weakness or fatigue
  • dizziness
  • euphoria
  • headache
  • incoherent or slurred or impaired speech and thought process
  • impaired balance
  • slow pulse (bradycardia) and hypotension (lowering of blood pressure)
  • rash (especially inflammation, itching, swelling at the patch site for those on the transdermal preparation

Since we know what fentanyl does and what its side effects are, let’s talk about withdrawing from this drug.

Withdrawing after using it for a long time is very challenging.  That’s because the body has gotten used to having opiates work at the receptor sites and withdrawing will mean that the body has to get used to functioning without it.  That’s what addiction is.  Whether you are a nicotine, alcohol, caffeine or drug dependent, the physiological function and response of your body has been altered to adapt to these.  Your body craves and longs for it.  Anything that changes your physiological function by craving for a substance that has made your body adapt to the pharmacologic effects of the regulated products.

The problem with fentanyl is that the withdrawal symptoms start as early as 8-12 hours after the last dose.  Withdrawal symptoms include:

  • goose bumps
  • bouts of chills alternating with bouts of flushing and excessive sweating
  • irritability
  • insomnia
  • loss of appetite
  • yawning and sneezing
  • watery eyes and runny nose
  • vomiting and nausea
  • diarrhea
  • increased heart rate and blood pressure
  • pains in the bones and muscle
  • general weakness
  • depression alternating with bouts of anger and confusion

Fentanyl is NOT JUST a pain killer.  It’s use and abuse are dangerous if not used properly (I heard that someone doesn’t really like following his doctors and takes an extra pop of the drug if he feels like it).

I am writing this to educate people that quitting after being on addicting agents is challenging and difficult to do.  That the side effects are sometimes difficult to differentiate from the actual disease (example is pain in bones and muscle during withdrawal versus using the drug for treatment of pain).  That when we are addicted to a substance, we will always rationalise why and how it is used.

You are wrong!

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When news like this circulates, it is mandatory that the medical community should react.

Whatever the president insists, he is totally wrong on this matter.

Fentanyl is a potent synthetic opioid.

It is 100 times more potent than morphine as an analgesic. (Yes, Mr. President.  It is a painkiller.  A very very very strong pain killer.)

Its pharmacologic effects are – analgesia, sedation, nausea, vomiting, itching and respiratory depression. Compared to other opioids, fentanyl causes more muscle rigidity.

It’s approved medical uses (licit) are:

  • management of cancer pain in patients already receiving opioid medication for their underlying persistent pain  (for the sublingual tablet formulations)
  • management of chronic pain in patients who require continuous opioid analgesia (for the transdermal preparation)
  • analgesia and anaesthesia in surgery (as citrate for injections given intravenously, intramuscularly, spinally or epidurally)

It is abused (illicit) for the following effects:

  • euphoria
  • substitute for heroin in opioid dependent individuals

Whether it is used licitly or illicitly, fentanyl use is addicting. Drugs that cause dependence are classified as habit forming and categorised as dangerous drugs. Under the DEA (drug enforcement agency of the United States), Fentanyl is controlled under Schedule II of the Controlled Substances Act.

A drug under Schedule II of the Controlled Substances Act means that:

  • The drug has a high potential for abuse.
  • The drug has a currently accepted medical use in treatment in the US or a currently accepted medical use with severe restrictions.
  • Abuse of the drug may lead to severe psychological or physical dependence.

In the Philippines, the Dangerous Drug Board and Philippines Drug Enforcement Agency have rules on prescribing narcotics and regulated substances.  The schedule in the Philippines is similar to the United States. Fentanyl is classified under Level II (previously called Schedule II). While it carries the same classifying definition as the US DEA, in addition:

  • Only doctors with S2 licences can prescribe them.  (Not all doctors have a S2 license.)
  • There is a separate yellow prescription form (that can only be purchased through the selected hospitals by S2 licensed physicians) that needs to be accomplished.  Fentanyl falls under that category.

Fentanyl is a controlled substance. In any part of the world. And yes. Even in China and Russia.

It is not JUST a pain killer.

It is addicting. It is regulated. Controlled substances are classified as with medical evidence or without. Either ways, it has abuse potentials. Only schedule or level II drugs are “legally” allowed to be prescribed. But it does not mean that just because it is prescribed it is not addicting.

I really don’t care if you’re using this for the various pains you claim to have. I’m really not concerned whether you’re really sick or not, or how sick you are. I just don’t like the fact that you go around having to rationalize what medicines you use to the point of changing the science of medicine, pharmacology and regulatory science.

Just because you are president, you do not get to change the fact that fentanyl is an opiate.