Prescription drug abuse is a massive health care concern in America: 16,235 people died as a result of overdoses of prescription opioids in 2013, according to the Centers for Disease Control (and quoted by Forbes magazine).
There are many reasons why patients misuse prescription drugs, but a desperate relief from pain ranks very highly on the list, and that’s where fentanyl abuse comes in. But with fentanyl abuse comes fentanyl withdrawal, and people who overuse their prescriptions play a very dangerous game with their health.
Eighty Times the Strength of Morphine
Fentanyl’s popularity among patients and abusers is partly due to the punch it packs when compared with other painkillers. As an opioid, fentanyl causes euphoria and induces powerful states of relaxation in users; as it binds to the opioid receptors of the brain that control pain and emotions, it depresses the central nervous system and dulls the patient’s awareness of physical distress. While this is a desired state for patients who are undergoing moderate to severe pain, it is also a source of concern. In their susceptible states, patients may take it on themselves to up their dosage, believing that this will make their pain go away sooner.
The concept of “sooner” is key, and this is where fentanyl distances itself from other opioids. As the Annals of Palliative Medicine journal reports, fentanyl is up to 80 times the strength of morphine. This makes fentanyl a popular choice for diagnosis in cases of rapid-onset or breakthrough pain, where patients are swiftly and devastatingly laid low by attacks of pain even as they are on mild to moderate analgesics. The journal describes fentanyl itself as a “rapid onset opioid”, which is music to the ears of suffering patients. The Journal of Pain Symptom Management says that fentanyl tablets are more effective treatments for breakthrough cancer pain than morphine), but also to people who want to experience the intense (and immediate) rush of a fentanyl trip.
As their dependence on fentanyl increases, they start finding more and more reasons to take the drug: to alleviate any form of physical discomfort, not just what their physician prescribed them fentanyl for; to help them sleep; to make stressful situations seem less bothersome; or to simply help them get through the day.
Eventually, fentanyl becomes the only source of comfort for the patient. Prescriptions are often forged or illegally obtained, pain levels are lied about, and finances are diverted, all in order to secure more and more fentanyl.
A Drug of Abuse
Because of this – and because of the powerful withdrawal effects fentanyl can exact on its users and patients who attempt to abruptly discontinue their intake – the effects of opioids like fentanyl are what the New Zealand Drug Foundation calls psychologically addicting. It is enough for the U.S. Drug Enforcement Administration to include fentanyl as an example of a Schedule II drug, a substance that has legitimate medical value, but that can cause severe physical or psychological dependence in its users.
The Centers for Disease Control put it quite simply: “[Fentanyl] is a drug of abuse.”
Withdrawal: Causes, Effects and Length
One of the facets of abuse is that discontinuing intake of the particular substance is not easy, and any attempt to cease consumption causes a wide range of negative physical and psychological effects in the patient. These effects are known as drug withdrawal, a process whereby several of the body’s long-suppressed systems are suddenly deprived of a substance upon which they had come to (unhealthily) depend. As devastating as an addiction can be on its own, the gauntlet of withdrawal effects adds to the nightmare.
Generally speaking, opioid withdrawal effects assume recognizable forms:
- Uncontrollable trembling
- Nausea and vomiting
- Craving for more drugs
- Muscle cramping
- Depression, anxiety, agitation, and similar mood changes
In extreme cases, where the fentanyl has been taking for an excessively long period of time or in inadvisably large doses, withdrawing can even cause hallucinations and seizures.
The withdrawal effects usually start to take hold between six and 36 hours after the last dose of fentanyl, for a duration of one to two days, although the actual length of withdrawal depends on a few factors:
- How long the patient has been taking fentanyl
- The average dosage and the dose of the last intake
- The patient’s medical history
- General tolerance level for pain and pain medication (i.e., how much medication has to be taken before an effect is felt)
The symptoms are at their most excruciating around the 48-hour mark, after which they gradually start dissipating. Patients in the throes of withdrawal may be tempted to take more fentanyl (or some other substance) in order to alleviate the severe distress of their symptoms; and given the potency of fentanyl as described above, relapsing at this point can drastically deepen the addiction, even to the point of death.
Because of how powerfully fentanyl can hook a patient into an addiction, weaning them off dependence has to be done carefully and methodically. Psychotherapy will address the issues of psychological dependence, but the supervised administration of anti-anxiety and anti-convulsant medication will cover the physical aspect of the problem.
Methadone and Fentanyl Withdrawal
Methadone is popular in detoxification programs because it reduces withdrawal symptoms in people who have opioid dependency, without causing the same high feelings as that of other opioids. It works by binding to the opioid receptors in the brain, WebMD explains, in much the same way that other narcotics and opioids do; but in doing so, it also blocks those other narcotics and opioids from causing the euphoric high that makes them so addictive.
Medscape reports on a study of 22 children that used methadone to speed up the process by which fentanyl could be discontinued and withdrawal symptoms prevented. As a background to the study, researchers found that patients who received fentanyl for more than a week were at an increased risk of developing withdrawal symptoms – or, as they put it, “opioid abstinence syndrome” – specifically mentioning movement and behavioral disorders as a result of the continued exposure to fentanyl.
For patients who had received up to nine days of fentanyl infusion, the chances of experiencing opioid abstinence syndrome was 100 percent.
The study’s researchers discovered that administering methadone one or two days before scaling down the patient’s fentanyl allowed for the complete discontinuation of fentanyl in only two days. The method was effective even for patients who had been on fentanyl for more than nine days. However, since methadone can itself be abused for its analgesic properties (like fentanyl, it is a Schedule II Drug in the United States and can only be obtained from certified pharmacies), the dosage of methadone to help treat a fentanyl addiction has to be sufficiently low.
Methadone also causes a number of other side effects, and it can cause adverse reactions in patients who have certain medical conditions or histories. For as effective as methadone is in combating a fentanyl addiction, it should not be taken without medical supervision, as a patient would otherwise run the risk of replacing the fentanyl dependency with a methadone problem.
Nonetheless, the researchers in the study concluded that oral administration of methadone was an option for commencing the discontinuation of fentanyl and reducing the risk of fentanyl withdrawal and opioid abstinence syndrome.
Detoxing from Fentanyl
Fentanyl detox and withdrawal control is usually done at rehab facilities, hospitals or specialized clinics. Certain facilities provide the option of outpatient detox, where the patient self-reports to the clinic to receive the methadone infusion, and then can go home. As PsychCentral explains, this allows patients to continue their daily routines and meet familial and professional obligations while simultaneously managing their fentanyl withdrawal. However, even patients who are part of an outpatient detox program will still have to check in with some form of aftercare support, such as a 12-Step group, individual counseling, family therapy, etc. It is vital that even for people who have the freedom of movement that outpatient detox provides do not detox alone.
Inpatient, or residential, treatment is best suited for patients for whom the risk of relapsing is too high to entrust them with the responsibility of leaving the protection of a treatment center. Here, the detox process is closely monitored to ensure that the withdrawal symptoms are always controlled, with staff on hand to administer methadone at the right times and in the right doses, to make the opioid abstinence syndrome more bearable for the patient. Once the patient makes it through withdrawal, he can begin a course of psychotherapy to help address the issues of psychological dependence that his fentanyl abuse caused. Through a combination of individual and group therapy, the patient will learn skills and strategies to cope with the recurring temptation to use fentanyl again, and understand how he can steer his thoughts and behavior away from the feelings and triggers that once precipitated his fentanyl abuse, into something more positive and productive.
Overcoming a dependence on prescription medication and starting a new life is possible. At FRN, we understand the frustration of how something that was meant to help you recover can become a source of pain and stress itself. That’s why we have trained admissions coordinators standing by right now, who can take your call, answer your questions, and tell you how you can make the first steps to overcoming your fentanyl dependence.
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David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.
Reviewed by: Kim Chin and Marian Newton