This article was published on July 24, 2022. It was last edited/ updated on July 25, 2022.
Given the seriousness of the fentanyl epidemic and the huge number of people who are dying each year due to it, all articles on this website about fentanyl and fentanyl analogs are being made available to everyone and not only to our Members (subscribers). Please share these articles widely by email, social media, and other means.
Here are the links to the articles about fentanyl and fentanyl analogs:
How is illicit fentanyl used?
– Illegally produced fentanyl is sold as a powder or as counterfeit tablets (Kilmer et al., 2022).
– It is sold by itself or combined with heroin, cocaine, or other substances (source).
– When used intentionally, it can be misused through many different routes—orally, by smoking, by snorting, or by injection. In recent years, the use of fentanyl by inhalation has grown the most (Palamar et al., 2022).
Here are some important things that we can do to deal with the intentional and unintentional use of fentanyl.
Talk about fentanyl with persons who have a substance use disorder
Here are some facts that make it essential for us to talk about fentanyl with persons with substance use disorder involving a variety of illicit substances:
– Over 99% of deaths from an overdose of a fentanyl analog are accidental (Rauf et al., 2021).
– Frequently, users are not aware that the illicit substance like heroin, cocaine, etc that they are buying has been adulterated with fentanyl (Volkow, 2021).
This is why widespread education is needed about fentanyl and fentanyl analogs including:
– How potent and dangerous they are
– The risk of unintentional fatal overdose.
Use urine drug screens that include fentanyl
This is explained in some detail in the following article on this website:
Make HIGH DOSE naloxone preparations widely available
Why higher doses and more frequent administrations of naloxone are needed for treating overdoses involving fentanyl was discussed in the following article on this website:
All persons with opioid use disorder should be offered medication-assisted treatment (MAT)
Persons with opioid use disorder are probably at the highest risk of using fentanyl or fentanyl analogs. This is because:
– They may buy heroin and not be aware that it has been adulterated with fentanyl (Volkow, 2021).
– Even if the user is aware that the heroin being purchased may be contaminated with fentanyl or a fentanyl analog, the person may have no choice because of the unavailability or high cost of uncontaminated heroin (Volkow, 2021).
– They may illicitly buy what they think is an oral opioid medication but is actually fentanyl.
So, to reduce the risk of fentanyl addiction and/or overdose, the treatment of ALL persons with opioid use disorder needs to improve.
The problem is that only a small fraction of persons with opioid use disorder who should be receiving medication-assisted treatment (MAT) are getting it.
So, please remember the following rule of thumb and tell others about it too:
All persons with opioid use disorder should be offered medication-assisted treatment (MAT)
Medication-assisted treatment (MAT) has convincingly been shown to be a very effective intervention that reduces both morbidity and mortality in persons with opioid use disorder.
Note: The treatment approach is called “medication-assisted” treatment because medications are used along with psychosocial treatments.
For details of medication-assisted treatment (MAT) for opioid use disorder, please see the following article on this website:
Serious problems can occur in treating fentanyl opioid use disorder
The initial treatment of persons who have been using fentanyl may involve not only addiction specialists but many of us nonspecialists as well. We may these patients in emergency rooms, on inpatient mental health units, while doing consults on non-psychiatric units in the hospital, and so on.
So, all of us should be aware that there are serious problems that can occur in fentanyl users if standard treatments of opioid use disorder are used without being aware of the special issues in treating opioid use disorder when fentanyl or a fentanyl analog are involved.
For an explanation of how the treatment of fentanyl opioid disorder differs from addiction to other opioids, please see the following article on this website:
Simple and Practical Medical Education thanks (alphabetically) Jonathan Beatty MD, and Marina Goldman, MD, for peer-reviewing and approving this article (in July and August 2022).
Dr. Beatty is a board-certified addiction psychiatrist in Philadelphia, Pennsylvania, who has extensive clinical experience in treating patients with substance use disorders. His clinical practice website is https://wavetreatmentcenters.com.
Dr. Goldman is a board-certified addiction psychiatrist. She is a Clinical Assistant Professor and Core Faculty in the Addiction Medicine & Addiction Psychiatry Fellowships at Thomas Jefferson University, Philadelphia, Pennsylvania. She also has a busy private practice in Jenkintown, Pennsylvania.
Opioid use disorder
Opioid use disorder—Management
Substance use disorders
American Society of Addiction Medicine. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020 Mar/Apr;14(2S Suppl 1):1-91. doi: 10.1097/ADM.0000000000000633. Erratum in: J Addict Med. 2020 May/Jun;14(3):267. PMID: 32511106.
Antoine D, Huhn AS, Strain EC, Turner G, Jardot J, Hammond AS, Dunn KE. Method for Successfully Inducting Individuals Who Use Illicit Fentanyl Onto Buprenorphine/Naloxone. Am J Addict. 2021 Jan;30(1):83-87. doi: 10.1111/ajad.13069. Epub 2020 Jun 23. PMID: 32572978; PMCID: PMC7755703.
Danilewitz M, McLean M. High-dose buprenorphine for treatment of high potency opioid use disorder. Drug Alcohol Rev. 2020 Feb;39(2):135-137. doi: 10.1111/dar.13017. Epub 2019 Nov 25. PMID: 31769109.
Hailozian C, Luftig J, Liang A, Outhay M, Ullal M, Anderson ES, Kalmin M, Shoptaw S, Greenwald MK, Herring AA. Synergistic Effect of Ketamine and Buprenorphine Observed in the Treatment of Buprenorphine Precipitated Opioid Withdrawal in a Patient With Fentanyl Use. J Addict Med. 2021 Nov 16. doi: 10.1097/ADM.0000000000000929. Epub ahead of print. PMID: 34789683.
Hartley J, Rieke E, Blazes C, Smith B, Gregg J. Successful Transition from Fentanyl to Buprenorphine in a Community-based Withdrawal Management Setting. J Addict Med. 2022 Jul 21. doi: 10.1097/ADM.0000000000001014. Epub ahead of print. PMID: 35861342.
Huhn AS, Hobelmann JG, Oyler GA, Strain EC. Protracted renal clearance of fentanyl in persons with opioid use disorder. Drug Alcohol Depend. 2020 Sep 1;214:108147. doi: 10.1016/j.drugalcdep.2020.108147. Epub 2020 Jul 2. PMID: 32650192; PMCID: PMC7594258.
Jegede O, Parida S, De Aquino JP. Buprenorphine Treatment of Fentanyl-Related Opioid Use Disorder. Prim Care Companion CNS Disord. 2022 Apr 26;24(3):21cr03163. doi: 10.4088/PCC.21cr03163. PMID: 35486939.
Mars SG, Rosenblum D, Ciccarone D. Fentanyl: the many challenges ahead. Addiction. 2019 May;114(5):785-786. doi: 10.1111/add.14587. Epub 2019 Mar 15. PMID: 30873700.
Morris NP. Opioid Use Disorder Treatment in the Age of Fentanyl. JAMA Intern Med. 2022 Mar 1;182(3):249-250. doi: 10.1001/jamainternmed.2021.8114. PMID: 35099514.
Quattlebaum THN, Kiyokawa M, Murata KA. A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine. Fam Pract. 2022 Mar 24;39(2):292-294. doi: 10.1093/fampra/cmab073. PMID: 34173647.
Shearer D, Young S, Fairbairn N, Brar R. Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series. Drug Alcohol Rev. 2022 Feb;41(2):444-448. doi: 10.1111/dar.13394. Epub 2021 Oct 13. PMID: 34647379; PMCID: PMC8926080.
Silverstein SM, Daniulaityte R, Martins SS, Miller SC, Carlson RG. “Everything is not right anymore”: Buprenorphine experiences in an era of illicit fentanyl. Int J Drug Policy. 2019 Dec;74:76-83. doi: 10.1016/j.drugpo.2019.09.003. Epub 2019 Sep 25. PMID: 31563098; PMCID: PMC6914257.
Sue KL, Cohen S, Tilley J, Yocheved A. A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine are Urgently Needed in the Fentanyl Era. J Addict Med. 2022 Jan 11. doi: 10.1097/ADM.0000000000000952. Epub ahead of print. PMID: 35020693.
Thakrar AP. Short-Acting Opioids for Hospitalized Patients With Opioid Use Disorder. JAMA Intern Med. 2022 Mar 1;182(3):247-248. doi: 10.1001/jamainternmed.2021.8111. PMID: 35099508.
Thakrar AP, Kleinman RA. Opioid withdrawal management in the fentanyl era. Addiction. 2022 Apr 4. doi: 10.1111/add.15893. Epub ahead of print. PMID: 35373864.
Varshneya NB, Thakrar AP, Hobelmann JG, Dunn KE, Huhn AS. Evidence of Buprenorphine-precipitated Withdrawal in Persons Who Use Fentanyl. J Addict Med. 2021 Nov 23:10.1097/ADM.0000000000000922. doi: 10.1097/ADM.0000000000000922. Epub ahead of print. PMID: 34816821; PMCID: PMC9124721.
Volkow ND. The epidemic of fentanyl misuse and overdoses: challenges and strategies. World Psychiatry. 2021 Jun;20(2):195-196. doi: 10.1002/wps.20846. PMID: 34002497; PMCID: PMC8129846.
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