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Manufactured in clandestine laboratories or diverted through fraudulent prescriptions or pharmacy thefts, fentanyl is a powerful opioid drug that is commonly abused for the mellowing feelings and intense rush of euphoria it produces. According to the National Survey on Drug Use and Health (NSDUH), over 4 million people over the age of 11 in the United States were considered to be currently abusing prescription painkillers like fentanyl at the time of the 2014 survey.
Prescribed licitly for constant, chronic, and breakthrough pain, fentanyl is a Schedule II controlled substance by the Drug Enforcement Administration(DEA) that may be regularly abused as a dangerous substitute for heroin. The journal The Primary Care Companion for CNS Disorders publishes that fentanyl is hundreds of times more potent than heroin, however, meaning that fentanyl abuse can easily and quickly lead to overdose and many other adverse side effects, including drug dependence.
In 2011, the Drug Abuse Warning Network (DAWN) reported that more than 20,000 individuals received emergency department (ED) treatment for a negative reaction to fentanyl. The drug is considered highly addictive and perpetuated abuse can create drug tolerance that leads to physical dependence. Opioid drugs like fentanyl bind to opiate receptors in the body and brain, blocking pain receptors and increasing levels of pleasure-inducing dopamine. When a dependence on fentanyl is established, brain chemistry and circuitry are altered, and significant withdrawal symptoms may occur when the drug wears off or use is stopped.
Fentanyl comes in several formulations: tablet form (Fentora), in lozenges (Actiq) often called “lollipops,” in injectable form, and as a transdermal patch (Duragesic). Depending on the release mechanism and manner in which the drug is used or abused, the drug is metabolized and absorbed at different rates.
The patch is meant to release fentanyl in a time-release fashion through the skin for 48-72 hours, per the US Food and Drug Administration (FDA) labeling information for Duragesic. The FDA reports that patch formulations of fentanyl have an average half-life of 17 hours while intravenous (IV) fentanyl formats have an average half-life of seven hours. Fentanyl patches may be cut up and chewed, swallowed, smoked, or injected. Altering the extended-release mechanism of the drug sends all of it into the bloodstream more quickly, increasing the potential for an overdose as well as shortening the half-life. A drug’s half-life refers to the amount of time it takes for it to be half as active in the bloodstream. A longer half-life means longer duration of action and shorter method of action. Injecting, snorting, or smoking fentanyl may cause the drug to produce its effects sooner and wear off more quickly than ingesting it or letting it be absorbed through the skin. Once fentanyl stops being active in the body, in around 14-30 hours, withdrawal symptoms can start.
Opioid withdrawal generally occurs in two main phases: early and late withdrawal. In some cases, a third phase known as protracted acute withdrawal syndrome (PAWS) may be present as well.
Early fentanyl withdrawal: This usually starts 14-30 hours after the last dose of fentanyl and lasts around 2-3 days. Symptoms include:
Late fentanyl withdrawal: Also called acute withdrawal, this starts about 2-3 days after the last dose and can last 3-10 days, depending on the level of dependence. Symptoms include:
Protracted withdrawal syndrome: This doesn’t occur in all cases, but it can start about a week to 10 days after the last dose and last for several weeks or even months, according to the Substance Abuse Treatment Advisory. Symptoms include:
Withdrawal severity and duration are directly related to a person’s level of dependence on fentanyl. The more dependent on the drug a person is, the more intense and long-lasting the side effects may be. Any co-occurring mental health and/or medical disorders can impact drug dependence, as can genetic and biological factors, high stress levels, and environmental factors. Polydrug abuse, or the abuse of multiple drugs at the same time, can also impact the withdrawal intensity, length, and range of side effects.
Since fentanyl withdrawal can be both psychologically and physically difficult and uncomfortable, it is not recommended to stop taking it suddenly or without the help of a healthcare professional. Medical detox is required.
Stopping fentanyl use or abuse “cold turkey” can be potentially dangerous. It can lead to cardiac and respiratory issues and even possibly cause seizures and serious mood alterations. For this reason, medical detox in a specialized facility, that can provide 24/7 monitoring of vital signs, mental health support, and medications to manage withdrawal symptoms, is considered the optimal method of stopping and detoxing from fentanyl.
Medical detox typically lasts between 5-7 days, on average. Fentanyl may also be tapered off slowly in order to keep the more intense symptoms of withdrawal at bay. Oftentimes, individuals are switched to another opioid-based medication, such as buprenorphine, and then weaned off that over time. Weaning off opioids slowly can be less shocking to the system than stopping them suddenly.
Buprenorphine, as published by SAMHSA, comes in two main formulations when used for the treatment of opioid dependence: the partial opioid agonist buprenorphine by itself (generic transmucosal products and Subutex) and buprenorphine combined with the opioid antagonist medication naloxone (Bunavail, Suboxone, and Zubsolv). The agonist portion helps to engage opioid receptors and keep withdrawal from being as intense. The antagonist component remains dormant unless the medication is abused. If abused, it then induces withdrawal symptoms, thus helping to ensure treatment compliance.
Since fentanyl is a central nervous system (CNS) depressant, when it is removed, the CNS can become hyperactive, speeding up respiration, heart rate, body temperature, and blood pressure. Dopamine stores are depleted with chronic fentanyl abuse, and significantly lower levels cause the extreme emotional lows that may accompany withdrawal.
Medications targeting specific symptoms during medical detox can help to regulate brain chemistry and CNS functions to manage withdrawal symptoms. Antidepressants, mood stabilizers, anti-nausea medications, and sleep aids can all be helpful during detox and in managing withdrawal from fentanyl. Medications like clonidine, which is technically a blood pressure medication, can be used off-label to minimize some of the overactivity of the autonomic CNS functions. Supplements can replace some of the depleted vitamins, minerals, and essential nutrients and help to restore a healthy physical balance.
In addition to medications and pharmaceutical methods, supportive care is also important during fentanyl detox. Substance abuse and mental health professionals can provide encouragement and support as well as a safe and controlled environment. Medical detox is the safest way to smoothly process a toxin such as fentanyl from the body, allowing the brain to heal and a level of physical stabilization to be reached before entering into a comprehensive substance abuse treatment program.