Paper with fentanyl and test tubes on a table.

Fentanyl (common brand names: Abstral, Duragesic, and Subsys) is an opioid drug that is synthetically produced. The primary use of fentanyl is for the control of pain.

Fentanyl is commonly prescribed in a transdermal patch form that is meant to be placed on an area of the body where a person is experiencing significant pain. The drug is extremely potent; it is often estimated to be between 50 and 100 times more potent than morphine, abused frequently, and tightly controlled.

The United States Drug Enforcement Administration (DEA) places fentanyl products in the Schedule II controlled substance category. This is the highest level of control enforced by the DEA on a drug that can be obtained with a prescription. Drugs in the next highest category (Schedule I) cannot be legally obtained for personal use under any circumstances.

Fentanyl is most commonly used to control chronic pain in people who have serious diseases, such as cancer, or for postoperative pain. Because the drug is extremely potent, it can be a very effective analgesic (pain-controlling) medication when used under the supervision of a physician. Its potency has also made it attractive to those who abuse drugs. Thus, the drug’s extreme potency is a double-edged sword, such that in therapeutic environments, it can effectively ease pain and suffering, but outside of therapeutic uses, it can be extremely dangerous.

What Is a Synthetic Opioid?

A synthetic opioid drug is a manmade substance that mimics the actions of opium, which is processed from the flowers of the poppy plant. Fentanyl is made through a long series of complex chemical reactions that requires access to restricted chemicals.

Essentially, fentanyl is a substance made from chemicals to mimic the action of opium.

Most medications also contain other substances; some may be inert and used to bind the drug into forms that allow it to be taken orally or injected. Other substances may be added to help the delivery of the drug. Different forms of fentanyl have different forms of additives. For example, the transdermal fentanyl patch includes ethanol (alcohol) or propylene glycol (an organic form of alcohol) to make the drug more soluble in order to be absorbed through the skin. Fentanyl is also offered in a sublingual lozenge form, a lollipop form, and a liquid or powder form that can be used intravenously. In many cases, the drug is diluted because of its potency.

The Effects of Fentanyl

Because fentanyl is an opiate drug, its use results in very significant physical and psychological effects that include the reduction of pain, feelings of relaxation, and feelings of sedation. Recreational users are drawn to its ability to produce mild to powerful levels of euphoria that increase as the person takes more of the drug as well as feelings of emotional numbness and dissociation (being removed from potential stressful emotions).

Complete understanding of how opiate drugs produce euphoria has not been achieved; however, these feelings are most likely due in part to the release of the neurotransmitter dopamine in the brain, which is associated with most drugs of abuse. Dopamine is released when individuals experience feelings of reinforcement or reward, and it is suggested that the release of dopamine accounts for the psychologically reinforcing effects of opiate drugs. The pain-reducing effects of opiate drugs are related to their similarity to natural painkilling substances in the brain, such as endorphins and enkephalins. These substances may also contribute to feelings of euphoria and wellbeing.

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How Is Fentanyl Cut on the Street?

Fentanyl is known by various street names, such as China girl, China white, tango & cash, and synthetic heroin. When recreational users refer to a drug being “cut,” it means that the drug is diluted with some substance that may or may not be inert in order to produce a larger volume of the drug. However, in some cases where dealers are attempting to increase the potency of low-grade drugs, fentanyl is used as an additive to heroin. Fentanyl is often passed off as heroin on the street, and because it is far more potent than heroin, it can increase the risk for a fatal overdose.

According to the National Institute on Drug Abuse (NIDA), street fentanyl can be cut with numerous substances that appear to include but are not limited to:

  • The anti-malarial drugs quinine or chloroquine
  • Other anesthetic drugs, such as procaine and dimethocaine
  • Sweeteners that can include manitol, inositol, dextrose, glucose, or even lactose
  • Starch and other substances, including laxatives

Illegally manufactured forms of fentanyl were a major problem in rising levels of overdoses on heroin and other opiate drugs. The Centers for Disease Control and Prevention (CDC) indicated that an over 400 percent increase in the use of illegal fentanyl products occurred in 2013 and 2014. The number of overdose deaths involving suspected fentanyl products rose almost 80 percent during this time period.

Fentanyl is more potent and cheaper than heroin, and this allows illicit dealers to get more money for a smaller amount of the drug. Cutting opiate drugs like heroin with fentanyl or substituting fentanyl for opiate drugs increases profits for illicit drug dealers and also results in an increased risk to users. Small amounts of fentanyl can be extremely dangerous, even in individuals who have developed tolerance to opiate drugs.

NIDA reports that illicit use of fentanyl is similar to use of heroin. Drug abusers often obtain the drug in powder form and will most often inject it. The drug can also be snorted, and sometimes, it may be smoked. Some users attempt to extract the drug from the transdermal patches by chewing it or through some other means. The lozenges or lollipop forms can be ground up and used in a similar manner or be chewed.

The Risks of Fentanyl Use and Abuse

According to NIDA and the CDC, medicinal use of fentanyl is generally safe when performed under the supervision of a physician. There are numerous potential side effects of fentanyl that can often be controlled in clinical situations. In cases where fentanyl is used for postoperative pain or for very short-term periods, the side effects are not generally a major concern.

    Some of the more common side effects associated with using fentanyl medicinally are:

  • Constipation or tar-like stools
  • Decreased urine production
  • Tiredness or fatigue
  • Mental confusion, mental slowness, or loss of inhibitions
  • Decreased rate of breathing (respiratory suppression)
  • Slowed or irregular heartbeat
  • Nausea, vomiting, or muscle cramps
  • Increased thirst, loss of appetite, or problems with dry mouth
  • Muscle pains or muscle cramps
  • Lightheadedness, dizziness, or even headache
  • Numbness or tingling, pale skin, fever, or chills
  • Changes in mood, such as mood swings, anxiety, or depression

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    Some of the rarer side effects that may occur with medicinal use include:

  • Significantly decreased heart rate or breathing rate that can be dangerous
  • Trembling, shakiness, or even potential seizures in very rare cases
  • The development of hallucinations in very rare instances
  • Significant problems with motor coordination or balance
  • Significantly decreased mental awareness, responsiveness, and confusion

As mentioned above, in controlled situations where the drug is being used for medicinal reasons, physicians can address side effects by either discontinuing the drug or using other medications to control the adverse effects. However, when individuals abuse fentanyl, the side effects are often not addressed. Because the drug is extremely potent, and very small doses of fentanyl can lead to the risk for overdose, additional serious side effects from abuse of fentanyl include:

  • Severe issues with respiratory suppression and decreased heart rate
  • The potential for coma, which can lead to severe brain or other organ damage and even death
  • Significantly decreased issues with judgment and reasoning that can result in the potential for serious accidents or other mishaps

Like all opiate products, the risk to develop physical dependence on fentanyl is extremely high, particularly for individuals who abuse the drug. The development of physical dependence results in significant tolerance (needing more of the drug to get the effects that were once obtained at lower doses), which can increase the risk for overdose. The withdrawal syndrome associated with discontinuing fentanyl is not believed to be potentially fatal, but individuals can become very confused, disoriented, and desperate. This can lead to a significant potential for serious problems due to dehydration from nausea and vomiting, accidents, and overdose.