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Fentanyl

Risk factors, physical and mental side effects, and how to start recovery and treatment

Patients who have severe pain from advanced cancer or surgery, or who need to be medically sedated, are sometimes given pharmaceutical fentanyl. Fentanyl is a synthetic opioid that’s 50 times as strong as heroin and 50 to 100 times as strong as morphine.

Illicit drugs are often laced with illegally manufactured fentanyl, which carries a high risk of adverse or even fatal effects. Fentanyl is frequently used to make counterfeit prescription opioids. In addition, it can be added to virtually any drug — including cocaine, heroin, methamphetamine, MDMA, or even cannabis. Mixing other illicit drugs with fentanyl can make them cheaper and more addictive. There are test strips that can detect the presence of fentanyl in other drugs, but they are not 100% reliable.

If you or a loved one is dependent on fentanyl, help is available. There are behavioral therapies and medications that effectively treat opioid misuse and save lives.

Recovery is possible.

Overdose signs and risk factors

Fentanyl is an extremely potent opioid. Just the smallest amount of fentanyl — an amount equal to three grains of salt, according to the Centers for Disease Control and Prevention (CDC) — can be hazardous. Sometimes referred to by dealers as Apache, Friend, or Goodfella, illicit fentanyl can be inhaled as a nasal spray, eaten in candy form, or injected with a needle. In addition, virtually any other illicit drug can have fentanyl added to it.

The drug has contributed to record numbers of drug overdose deaths. In 2021, there were an estimated 107,622 drug overdose deaths in the United States; most of these fentanyl or other synthetic opioids.

Someone experiencing an overdose from an opioid such as fentanyl may have small pupils, lose consciousness, breathe slowly or stop breathing, make gurgling sounds, go limp, or have cold or discolored skin. If you see these signs or symptoms, call 911 immediately and then administer naloxone if you have it. Try to keep the person awake and place them on their side so they don’t choke.

Certain risk factors make it more likely that you or a loved one could misuse or become dependent on any opioid, including fentanyl, whether the drug is prescribed by a health professional or obtained illegally. These include:

Age, lifestyle, and medical history. Dependence is more likely if you use or have used other drugs, have an untreated mental illness, or live in a situation that enables drug misuse. You may be at greater risk of overdosing on prescription opioids if you are over age 65 or have a health condition such as sleep-disordered breathing, end-organ dysfunction, or lung disease. Meanwhile, the rate of nonmedical opioid use is highest among people ages 18 to 25, and most people who misuse prescription opioids start using the drug in their early to late 20s. Prescription opioid overdose deaths occur mostly among people aged 25 to 54.

Long-term use. Using opioids for even a few days raises your risk of becoming dependent and experiencing side effects. An estimated 1 in 4 people receiving prescription opioids long term in a primary care setting become dependent, according to research summarized by the CDC.

High dosage. Taking a higher dose comes with a greater risk of dependence than taking a lower dose does, but even taking a low dose is risky, according to CDC prescribing guidelines.

Extended-release formulations. Dependence is more common with drugs that act over a longer period than with those that act more immediately, CDC guidelines say.

More than other opioids, fentanyl is associated with fatal and nonfatal overdoses. To avoid serious harm and even death, be aware of these additional risks:

  • If you don’t test drugs to know what else might be in them, you may accidentally take a fatal dose of fentanyl.
  • If you use drugs when you are alone and overdose, there may be no one around who can administer naloxone.
  • If you recently experienced a nonfatal overdose, you are at heightened risk of overdosing again.
  • You are in grave danger of overdosing if you mix opioids with other substances, especially those that make you drowsy (e.g., alcohol; benzodiazepines such as Xanax or Valium; muscle relaxants like Soma; and sleep aids such as Ambien).
  • If you inject drugs such as fentanyl, you increase your chances of contracting hepatitis B or C, HIV, and tetanus.

Until you’ve fully recovered from opioid dependency, carry fentanyl test strips and naloxone, an over-the-counter nasal spray that can reverse an opioid overdose. Note that fentanyl test strips are not 100% reliable in detecting trace amounts of fentanyl in other drugs. If you suspect someone is experiencing a fentanyl overdose, call 911 and administer naloxone, if available. Keep the person awake and lying on their side until first responders arrive. Learn more.

Withdrawal

Because fentanyl is so potent, you can easily become dependent on it. You should stop use of fentanyl under the care of a licensed medical provider, who can help you manage any withdrawal symptoms. These symptoms can begin a few hours after you stop taking fentanyl and last several days. Withdrawal from pharmaceutical fentanyl, a short-acting opioid, typically does not last longer than 10 days. However, illicit fentanyl often behaves more like long-acting opioids, substances that when stopped can cause protracted withdrawal.

Fentanyl withdrawal symptoms include cold flashes and goose bumps, watery eyes, runny nose, diarrhea and vomiting, pain in the bones and muscles, uncontrolled leg movements, severe cravings for the drug, irritability, yawning, and sleep difficulties.

Opioids and the brain: Opioids such as fentanyl enter the brain and cling to cellular proteins called opioid receptors, which are found in the brain and elsewhere in the body. Our brain’s opioid system is involved in behaviors related to mood, pain, reward, and impulsivity. Opioids stimulate the brain’s reward circuits and cause a surge in dopamine, a chemical messenger that can make us feel a pleasurable “high.” This high can also make us want to take more of the drug, increasing the likelihood of using it daily and becoming dependent.

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Treatment for misuse

Recovery from fentanyl misuse and dependence is possible for you or your loved one. There are treatments to reduce the potential for relapse and medications to manage withdrawal systems.

Therapy: A licensed medical provider may recommend medication for addiction treatment (MAT), which combines the use of prescription drugs to alleviate withdrawal symptoms with therapies such as behavioral counseling. Studies have shown that MAT reduces opioid use and related deaths. Types of counseling to treat dependence on fentanyl and other opioids include cognitive behavioral therapy; contingency management, which assigns “points” or monetary rewards for negative drug tests; and motivational interviewing, which is a form of patient-focused counseling. The Food and Drug Administration (FDA) has also authorized a mobile cognitive behavioral therapy app called reSET that can be used with MAT and other therapies; the app is available by prescription.

Medications: Specific FDA-approved opioid use treatments include buprenorphine (brand names include Suboxone and Subutex); methadone; and extended-release naltrexone (marketed as Vivitrol). The FDA has also approved the nonopioid treatments clonidine and lofexidine (sold under the brand names Catapres and Lucemyra, respectively) for managing opioid withdrawal. Use these medications with caution, as they can cause low blood pressure.

Recovery: Further manage your symptoms and promote your recovery by drinking a lot of water, getting plenty of exercise, and practicing relaxation techniques such as yoga and meditation.

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Sources

CDC Guideline for Prescribing Opioids for Chronic Pain, March 18, 2016

CDC Launches New Education Campaigns Aimed at Preventing Drug Overdose Deaths, News Release, Oct. 27, 2021

Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings, World Health Organization, 2009

Fentanyl, Alcohol and Drug Foundation, November 10, 2021

Fentanyl, Centers for Disease Control and Prevention, June 1, 2022

Fentanyl DrugFacts, National Institute on Drug Abuse, June 2021

Fentanyl Facts: The Facts About Fentanyl, Centers for Disease Control and Prevention, November 2, 2021

Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic, Centers for Disease Control and Prevention Health Alert Network, December 17, 2020

Inside Fentanyl’s Mounting Death Toll: ‘This Is Poison’, The New York Times, November 22, 2021

Opioid use disorder and the brain: a clinical perspective, Addiction, 2021

Opioid withdrawal symptoms, Australian Government Department of Health, April 2021

Overdose Deaths Reached Record High as the Pandemic Spread, New York Times, Nov. 17, 2021

Overdose reversal drugs gain support at music festivals, but not fentanyl test strips, NPR, Aug. 3, 2022

Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use, National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Washington (DC): National Academies Press (US); July 13, 2017

Policy Brief: Effective Treatments for Opioid Addiction, National Institute on Drug Abuse, November 2016

Prescription Opioids, Centers for Disease Control and Prevention, August 29, 2017

Prescription Opioids and Heroin Research Report, National Institute on Drug Abuse, undated

Prevent Opioid Misuse, Centers for Disease Control and Prevention, Nov. 20, 2020

Prevention of Opioid Overdose, New England Journal of Medicine, 2019

Risk Factors for Opioid-Use Disorder and Overdose, Anesthesia & Analgesia: November 2017, Volume 125, Issue 5, pp. 1741-1748

Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths — United States, 2013–2019, February 12, 2021

U.S. Overdose Deaths In 2021 Increased Half as Much as in 2020 – But Are Still Up 15%, CDC, May 11, 2022