FENTANYL

OFFICIAL NAMES: Fentanyl

STREET NAMES: Brand names include Actiq, Alfenta, Duragesic, Oralet, Sublimaze, and Sufenta. Street terms include Apache, China girl, China town, China white, dance fever, friend, goodfellas, great bear, He-man, jackpot, king ivory, Mexican brown, murder 8, P-dope, Persian white, P-funk, poison, synthetic heroin, Tango & Cash, TNT, tombstone

DRUG CLASSIFICATIONS: Schedule I or II, narcotic analgesic

OVERVIEW

Fentanyl is a very powerful synthetic opioid analgesic routinely used legally for anesthesia. The amount of fentanyl that could fit on the head of a pin is enough to kill ten people. It is a member of the narcotic analgesic class of drugs that reduce pain. Today it is used in 70% of the surgeries performed in the United States. It has been administered since the early 1970s for prenatal use. Since 1991 it has also been used to treat chronic pain associated with cancer or other terminal diseases. Because it takes effect quickly and has few undesirable side effects when controlled by a physician, it is revered by the medical community. Fentanyl is used in the treatment of all ages, from children to the elderly.

Fentanyl was first abused by medical professionals who were able to obtain the legally produced opioid from drug companies. Today, it is a designer drug that black market chemists in clandestine laboratories with high levels of expertise and equipment manufacture in home labs. As a street drug, it can be several hundred to three thousand times more potent than morphine. Sometimes it is sold as heroin to unsuspecting users.

Fentanyl and its derivatives are opioid narcotics similar to heroin and are consumed on the street in many of the same ways. These opioids work through receptors in the brain and spine, mimicking naturally present peptides commonly known as endorphins, enkephalins, and dynorphins. The type of receptor that fentanyl predominately bonds with is the mu receptor.

The number of synthetic drugs that can be derived from the fentanyl molecule is almost limitless. Variations of fentanyl devised in street labs continue to appear, making it even more difficult to track the drug. Adding to the difficulty of tracking fentanyl is the fact that it takes multiple tests to recognize it in a user's system. It does not appear in common urine analysis, so most users are not detected until they overdose.

History

Fentanyl is a relatively new drug and still under testing. It is a completely synthetic drug first made in Belgium in the late 1950s. Fentanyl is the name given to the synthetic molecule by its creators, Janssen Parmaceutica, of Belgium. It was originally marketed by Janssen under the trade name Sublimaze. Sublimaze was introduced into clinical practice in the 1960s as an intravenous anesthetic.

According to Newsweek, the pharmaceutical market doubled between 1996 and 2000. As a whole, it generates $45 billion annually. Painkillers such as the legally produced fentanyl account for $1.8 billion of this figure. According to the National Institute on Drug Abuse (NIDA), 1.6 million people abused prescription drugs in1998. These figures represent only the legally produced drugs and do not include designer drugs sold on the street.

Fentanyls first appeared on the streets under the name China white in the late 1970s. It was viewed as a "safe" alternative to heroin because it was a derivative of a prescription drug. Furthermore, fentanyl is virtually undetectable in a person's system by a drug screening urinalysis. Users were thus attracted to it as a way to get around the law. However, analogs, drugs that differ slightly in chemical structure but are similar to other drugs, were added to the list of controlled substances by the United States Drug Enforcement Administration (DEA) in 1984 and 1986. This meant that the street variations of fentanyl were made illegal to possess or produce.

China white was popular on the West Coast of the United States in the early 1980s and was estimated at 6,000 times the potency of morphine. In the late 1980s, fentanyl was introduced into the club scene in New York, and designer variations were spawned. In the 1990s fentanyl was introduced as a lollipop for young cancer patients to treat their pain and suffering. In this form it entered into all-night raves and club parties.

CHEMICAL/ORGANIC COMPOSITION

Fentanyl is a completely synthetic molecule. Its actual chemical name is N-(1-phenethyl-4-piperidyl) propionanilide. Most of the derivatives of fentanyl are more powerful than the molecule itself. To date there have been dozens of fentanyl derivatives designed. Today, any derivative of fentanyl is commonly referred to as fentanyl, though each is given its own chemical name. For example, the drug that was sold under the name of China white in the 1980s was given the name alpha-methylfentanyl. Other common medical derivatives are fenzylfentanyl, fluorofentanyl, thiofentanyl, carfentanil, and sufentanil.

Because fentanyl is so much more potent than heroin or other opioids, it must be diluted before it can be consumed. Clandestine chemists often use powdered sugar, baby powder, baby laxative, or antihistamines to dilute the street drug. Because the designer drugs can contain a variety of different diluting materials and are many times more powerful, these drugs are more dangerous than legally produced opioids.

INGESTION METHODS

Fentanyl is administered by medical personnel in several ways. Originally it was developed and used primarily as an anesthesia administered through an intravenous (IV) hookup. It is still used in this form during surgery, it is not used in this way for chronic pain because it entails either having a constant IV drip or repeated shots throughout the day. Today it is also administered by epidural, which is a shot administered directly into the spine. For a local anesthetic during surgery, fentanyl is administered via needle directly into a muscle.

Oral ingestion of fentanyl is the most common way it is used to relieve chronic pain today. This is achieved primarily in a lollipop or lozenge that allows for a slow ingestion into the body. Most of the lollipops and lozenges are cherry flavored; for children in cancer wards, this is the preferred method of administration because they seldom view the "treats" as medication. Rectal administration is sometimes used as well if the patient cannot receive oral medication or if they have a strong nausea reaction to the fentanyl. This method is used only as a last resort, and few patients opt for it.

Fentanyl is also available in a patch form (much like a nicotine patch used for smoking cessation) that can also be used for long-term treatment. This form of administration is referred to as transdermal fentanyl and is sold under the trade name Duregasic. The fentanyl is absorbed directly into the skin from the patch and enters the bloodstream, which carries it to the mu receptors. This form of administration appears much easier than it is. When applying the patch, much caution is needed in making sure that the side with the fentanyl does not come in contact with the applier's hands. The sweat on our palms speeds the absorbtion of fentanyl into the bloodstream, and more of the drug is taken in than is desired at one time.

The street versions of fentanyl are ingested in the same ways as heroin. It is usually sold in a powder form and either smoked, snorted, or injected into a vein. Since fentanyl is water-soluble, the powder form can be coldstirred into a solution and does not need to be boiled like other opioids. However, injection is the most common method used for ingestion on the street. It is so much more potent than heroin that in many of the overdose deaths, the user is found with the needle still in an arm, in some instances with plunger not fully compressed. Some of the designer fentanyl today is made into pill form, but in this form of ingestion, more time elapses before the user feels its effects.

The transdermal patches and lollipops are also stolen and sold on the streets. Instead of wearing the patch as intended, users will get the fentanyl out to either inject or inhale the drug. Lollipops and lozenges are used on the street in high dosages and generally in connection with other drugs. Rather than letting the lozenges dissolve in the mouth, street users may crunch several at a time.

THERAPEUTIC USE

Fentanyl is still a new drug. Research is ongoing on its applications and benefits. It is expected that future fentanyl derivatives will be of even greater therapeutic use and importance. Fentanyl is used in 70% of surgeries today. Many anesthesiologists view fentanyl as a superior anesthetic because it acts only on specific nerve receptors that are primarily in the central nervous system. These sites are primarily linked with pain sensation, respiration control, and physical dependence. In contrast, general anesthetics affect the whole body and render the patient unconscious. Because fentanyl acts primarily on the central nervous system, the patient is able to remain awake throughout surgery.

Fentanyl is primarily used alone, but sometimes it is combined with other opiates such as Licodaine, Bupivacaine, or morphine in epidural administration or in some IVs. However, one of the more appealing virtues of fentanyl is that, unlike other opioids, it has a very mild effect on the emetic trigger zone of the medulla. For this reason, patients have less nausea and no vomiting when fentanyl is used. With other drugs, such as morphine, this unwanted side effect can be intense. Fentanyl also does not cause the release of histamine, which makes it safer for the cardiovascular system than morphine.

Fentanyl is widely used in epidurals for women in delivery. This is called a continuous infusion epidural analgesia (CIEA). In this method, a needle is inserted into a woman's spinal cavity, where it offers a continuous drip of the drug throughout the birthing process. The benefit is that it lessens the pain associated with delivering a baby while still allowing the woman to have an active role in the birthing process. When administered in the lower spinal area, it is very short-acting and does not completely numb the lower body. Morphine and Demerol, which have been used more frequently in the past, render the lower extremities completely numb, making it more difficult for the patient to participate in the delivery. Thus, because the woman is able to be more active when using fentanyl, the delivery process is quicker.

Fentanyl is also used in treating people who suffer from pain associated with long-term illnesses such as cancer. It is not, however, the most inexpensive method. Transdermal fentanyl costs roughly three times what an equivalent amount of sustained-release morphine sulfate, which has similar effects on the patient, would cost. For this reason it is not used as often as other forms of pain relief unless other avenues have failed. However, some health professionals believe fentanyl offers greater benefits in helping people cope with pain. Transdermal fentanyl is faster acting than other options and lasts up to 72 hours per application. Transdermal fentanyl is considered most beneficial for people who have a consistent pain with few momentary increases in the pain. This is because there is a steady release of fentanyl into the body with no variation. It is also suitable for people who cannot swallow or open their mouths for oral medication. However, it is recommended that patients on transdermal fentanyl be given a prescription for another opiate such as morphine, hydromorphine, or oxycodone for temporary pain relief when there is a temporary increase in their suffering.

For people with ongoing pain who desire oral doses, who cannot wear a patch, or who have moments of higher pain, fentanyl is given in a lozenge or lollipop. The raspberry-colored lozenges are quickly absorbed through the buccal mucosa in the mouth and more slowly through the gastrointestinal tract. The onset of analgesia is usually within 15 minutes by this method, and one dosage lasts one to two hours. After a patient begins feeling the effects of the fentanyl and the pain is subsiding, he or she should remove the lozenge from the mouth. This reduces the intake of the drug and slows the rate at which the patient becomes tolerant of the drug

Recently fentanyl has been tested on AIDS patients. The drug is useful in blocking pain receptors, which helps patients cope with their pain. It also helps AZT to cross the blood-brain barrier. When used alone, AZT also has several side effects that early testing has shown to be reduced when fentanyl is added to the treatment.

USAGE TRENDS

Scope and severity

Fentanyl abuse among non-medical personnel has come in waves as new derivatives are discovered. However, the problem is growing in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA) states that 576 people were treated in emergency rooms for fentanyl abuse in 2000. This is higher than the 337 recorded instances in 1999. Figures from 2001 are incomplete, but at least 512 people were treated in emergency rooms in the first six months of the year. Since fentanyl is difficult to detect, these figures are believed to be lower than actual cases.

It is known that the abuse of prescription fentanyl is on the rise, but the degree of increase is difficult to distinguish. Doctors are increasingly wary of turning down requests for pain medication for fear of lawsuits if the patient truly is in a lot of pain. Determining how much pain a patient feels is nearly impossible for the doctor, so they must rely on what the patient tells them. This has led to an increase of people illicitly getting pain relievers for personal use or distribution. Some patients lie to their doctors about their conditions in order to get painkillers; others have gone to several doctors to get several prescriptions.

There are also a growing number of doctors wanting to supplement their income and do so by writing prescriptions for people who do not need them. Doctors who do this are referred to as "script writers." These script writers can generally double their salary by selling the prescriptions for large sums of money. Middle-class drug users are increasingly viewing this route of acquisition as preferable because there are fewer stigmas attached to buying from a doctor and there is less risk of a drug deal turning violent. As demand for the pharmaceutical versions of designer drugs increases, the business of dispensing bogus prescriptions becomes even more profitable.

Age, ethnic, and gender trends

According to the American Society of Anesthesiologists, it is rare for an anesthesiology department not to have someone, at some point, need treatment for a chemical dependency. Anesthesiology has the highest incidence of chemical dependency among medical specialists. It is hypothesized that this is because they daily administer these drugs to others and are lulled into believing that they are less dangerous than they are. These professionals also have a high amount of accessibility to addictive drugs and seem to have a greater curiosity of the effects of drugs than other doctors. Due to its ready accessibility and difficulty of detection, fentanyl has long been the drug of choice to abuse by anesthesiologists.

Other than anesthesiologists, many professionals within the medical community abuse fentanyl. However, the majority of these are considered to be less skilled healthcare workers, rather than the pharmacists or doctors who abuse other drugs. Namely, abusers who steal fentanyl from hospitals are usually nursing aides and uncertified healthcare providers.

On the street, users tend to fall into one of three categories. The first group are those that view fentanyl as safer than heroin. Users in this category tend to be white, upper-middle class, male, educated at or above the college level, and ignorant to drug use. This group generally involves novice drug users who often are the ones who die from overdoses. There is not the same stigma attached to designer drugs as there seems to be with heroin, so people in this group view them as social drugs. Fentanyl is also attractive to this group because it is soluble through the skin. When ingested by directly absorbing the drug through the skin, users do not require a needle which can leave "track marks."

The second group of people consists of addicts of other opiates who use fentanyl predominately only when their personal drug of choice is unavailable. Those in this group will generally choose other opiates because they tend to "shoot" the drug and many have complained of a burning sensation after injecting fentanyl. In a survey among opiate users in a Contra Costa County, California, treatment clinic, users in this category do not like to use fentanyl as much as heroin. These users felt that heroin gave them a more euphoric feeling.

The third group of people includes those at raves who experiment with a wide variety of designer drugs. The fentanyl used by this group is manufactured in clandestine laboratories. Users in this group are generally white, middle class, and in their teens or twenties. For the most part, users in this group are female. However, males in this group frequently take whatever drug the females are using.

MENTAL EFFECTS

Generally speaking, fentanyl acts on the central nervous system and the gastrointestinal tract. Because of this, most of the effects of the drug are physical. It also causes many of the same effects as heroin, including euphoria and drowsiness. However, some research shows that the effects of heroin are more euphoric, and fentanyl is more analgesic.

During surgery fentanyl is used as an analgesic. Analgesia by definition is an absence of pain. Therefore, fentanyl causes the brain to not feel pain. Or, clinically speaking, analgesia refers to a reduction in the intensity of pain perceived. It is the goal of the anesthesiologist to make the pain as tolerable as possible without undue respiratory depression of the patient. Analgesia may be induced by interrupting the nociceptive process at one or more points between the peripheral nociceptor and the cerebral cortex. In this respect, fentanyl tricks the mind. It imitates natural peptides found in the body (such as endorphins) and stimulates a cellular response.

The receptor most affected by fentanyl is the mu receptor in the brain, which is substantially involved with addiction potential. This is why fentanyl can be so addictive to some people.

Rarely, high amounts of fentanyl have also been known to cause hallucinations. This does not happen in prescribed doses. However, people who misapply the transdermal patch and get large amounts of the drug on their hands without immediately washing them can have hallucinations. The patch can also sometimes release erratic levels of the drug into the system due to poor adhesion of the patch or exposure to too much of the drug in one location. For this reason, wearers of the patch need to rotate the patch often, but the patch can be difficult to accurately affix due to sweating and hair follicles.

Hallucinations often occur from street forms of the drug. This is because users usually take larger dosages and have less tolerance. Also, users of the designer drugs generally inhale or inject the drug, so larger quantities hit the receptors at one time.

PHYSIOLOGICAL EFFECTS

The major physiological effects of fentanyl are euphoria, drowsiness, respiratory depression, decreased gastrointestinal mobility, nausea, and muscular rigidity. People build up a tolerance to fentanyl the more they use it, causing them to need more to obtain the same effects they once received from a smaller dose. The "high" of fentanyl can last 10–72 hours, depending on the ingestion method, the fentanyl derivative used, and the amount taken.

Harmful side effects

Fentanyl acts on the heart rate, blood pressure, and respiratory system. It can decrease the heart rate by as much as 25% in a controlled setting and even more if too much is ingested too quickly. In a clinical setting, this is less dangerous due to monitors that can alert staff to these changes and machines that control breathing and heart rate. However, in the streets, these side effects can quickly cause death. Experienced drug users who use fentanyl often have a supply of cocaine or methamphetamine with them, thinking that if they experience the respiratory failure sometimes associated with fentanyl, they can then use the stimulant to keep from dying. It is possible for just one patch combined with other depressants to kill a user.

Designer heroin, or street-made fentanyl, adds many side effects due to the impurities added to the drug. Aside from allergic reactions from additives unknown to the user, street chemists are often unaware of the potency of the drug they are creating. Clandestine laboratories may not dilute the drug enough, causing too much of the drug to be ingested. This can cause immediate death. Reports have also shown that irreparable harm can be done to the receptors of a user's brain from a single use of "designer heroin."

The effects that the drug has on the gastrointestinal tract are quite severe. Fentanyl use, whether clinical or recreational, will cause constipation in the user. It is recommended that patients always take laxatives or stool softeners when using fentanyl. At least one bowel movement every two to three days is recommended. Longer periods of time between movements can result in damage to the colon, intestines, and stomach. If it has been longer than three days since the last bowel movement, patients are instructed to contact their physician, who may suggest an enema or suppository to encourage bowel release.

In regular users of fentanyl, dry mouth is common. It is suggested that patients chew sugarless gum, suck on hard candy, and most importantly, drink plenty of water. Dehydration can occur if fentanyl users fail to consume more water than they normally do. A regular user of fentanyl must make sure to tell their doctor if they are having surgery. The added fentanyl in their system from the anesthesia can cause death.

Some other rare side effects from fentanyl include breathing difficulties, wheezing, cold and clammy skin, seizures, slow or fast heartbeat, severe rash, and unusual weakness. A physician should be notified immediately if any of these symptoms occur. It is more common for patients to experience confusion, fainting spells, and nervousness or restlessness; any of these also need medical attention. Some side effects that do not require immediate medical attention but can be reported if bothersome include itching, blurred vision, clumsiness, difficulty urinating, headache, and nausea.

According to the American Association of Pediatrics, clinical use of fentanyl is considered safe for pregnant and nursing mothers. Other organizations have deemed the results of studies to be inconclusive. Some of the drug will pass into the baby from a nursing mother, so constipation, dry mouth, and drowsiness can be expected. Babies born to mothers who abused fentanyl during pregnancy can be expected to have an addiction to fentanyl at birth.

Long-term health effects

As with any narcotic, fentanyl is addictive. Because it interacts with the mu receptor, which has an effect on addiction, it is highly addictive. Fentanyl users also build a tolerance to the drug's effects, thus needing more of the drug to reach the same euphoric experiences. Building up a tolerance to the drug can be harmful to the user. As the user continues to consume more and more of the drug to achieve the same effects, an overdose becomes likely.

Even though fentanyl is habit-forming, addiction can only be experienced by those using the drug for recreational or pleasure purposes. According to the SAMSHA, users who are being treated for extreme pain cannot be addicted to their medication because they have a physical, not psychological, need for the medication. They may become tolerant to the drug, though, and should not stop treatment without a doctor's supervision.

The more of the drug that is used, the more dangerous the effects of the constipation can be. Long-term constipation left untreated can be very dangerous to the user, so doctors may suggest a change of diet. Patients are encouraged to include more fiber and bran in their diets to help offset the consequences of the constipation. This is especially important in elderly patients, who often have problems with constipation that are unrelated to fentanyl use.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

One of the side effects of fentanyl is drowsiness, so any other medication that causes drowsiness can greatly increase this effect in a user. For this reason, users of fentanyl must not consume alcoholic beverages, because a user can fall asleep quickly and possibly depress the user's respiratory system even more. Some medications to be avoided include barbiturates, antidepressants, tranquilizers, muscle relaxants, and antihistamines used in some cold medicines.

It is very important that anyone using fentanyl, either pharmaceutical or clandestine, let their health care professional know of their use prior to surgery or when being prescribed other medications. As was discussed earlier, high dosages of fentanyl are deadly. Because it is used in 70% of surgeries today, any additional use of fentanyl during surgery can lead to complications or death.

According to the makers of Duragesic, it is important not to also use slow-release forms of morphine or oxycodone while using the patch. This would include switching between the two forms of medication or using both at the same time. Other medications that can react negatively with fentanyl use include medicines for high blood pressure and seizures.

Patients taking naltrexone (trade name Trexan) must tell their health care professional because the two drugs will cancel any effects that the other has. Some other medications that reduce the effects of fentanyl are buprenorphine, dezocine, nalbuphine, and pentazoncine. These medications also can cause side effects in people who have become physically dependent on fentanyl.

TREATMENT AND REHABILITATION

Most hospitals in the United States today are aware of the trend of abuse among anesthesiologists. In recent years, hospitals have stepped up efforts to help personnel realize when coworkers might be abusing various drugs, including fentanyl. Due to necessity, anesthesiology staffers have become especially adept at observing signs of addiction in their coworkers. Assistance is covered under most hospital healthcare insurance plans. This is due to the high number of addicts within the hospital community and the harm that can come to patients if a doctor's addiction is left untreated.

Addiction requires a user to get help from professionals. A person is considered an addict if they continue using a drug despite adverse consequences or if they cannot go without the drug. There are numerous opiate detoxification programs in the United States that can treat abusers, though their methods vary. The traditional method for treating opiate addiction is by detoxification. This means clearing the body of the drug and giving small amounts of methadone to help curb some of the desire for the drug. When the desire is diminished to abuse drugs and the withdrawal symptoms have subsided, the person can be released. This is a very long and tenuous process. Some have questioned its success rate as many "rehabilitated users" return to abuse.

There are a small but growing number of institutions that are beginning to use an ultra-rapid opiate detoxification program. It is still considered an experimental practice with techniques varying from site to site. However, there are three main differences between traditional and ultra-rapid opiate detoxification. In traditional programs, a patient attempts to function normally while fighting the heavy withdrawal symptoms. In ultra-rapid detoxification, the user is put under anesthesia and is thus able to sleep through the pains of withdrawal. The amount of time varies between institutions, but usually lasts a day or two. A drug called naltrexone is given, which accelerates the onset of withdrawal. Some doctors believe that naltrexone only be given to a patient who has been free of opiates for seven days, which means that a user still must face severe withdrawals. Opiate blockers are given upon release of the program, which has been found to suppress both desire for the drug as well as some lingering withdrawal symptoms.

The first three days of the treatment are the most difficult for the abuser due to the highly intensive withdrawal pains. During this time approximately 30% of opiate-dependent abusers in a traditional detoxification program quit the program. Some of the withdrawal symptoms the user faces include runny nose, tearing, sneezing, insomnia, loss of appetite, depression, irritability, severe abdominal cramps, pain in the muscles and bones of the back, sweating, nausea, tremors, increased heart rate and blood pressure, and weight loss due to dehydration.

Removing the drug from the user's system is only the first step in an ongoing process regardless of which technique is used. For an addict, the drug has become a part of his or her lifestyle. That lifestyle must change in order for that person to remain clean. Twelve-step programs such as Narcotics Anonymous have proven very helpful to many in the everyday battle to avoid relapse.

This creates a very difficult situation for anesthesiologists who are recovering from an addiction to fentanyl. Since it is used so often in their work, they must handle and administer the drug that they have abused. This is why the risk of relapse is especially high among opiate-addicted anesthesiologists who decide to return to their profession. Among those who do have a relapse, the incidence of death from overdose is high.

In a May 2001 newsletter, the American Society of Anesthesiologists offers seven questions that an anesthesiologist who is a recovering fentanyl addict should ask themselves before trying to return to their jobs. An abbreviated list follows: If you were a freshman in college and could choose any profession with the wisdom you have now, what would you consider pursuing? If you could not be in anesthesiology, what other possibilities would you consider? What are some positives and negatives of practicing anesthesia? What is stressful for you in the practice of anesthesia? Since the relapse rate is so high, why would you put yourself and your patients at risk? How does your significant other feel about the risk you would be talking returning to anesthesiology? What safeguards would you put in place to avoid a relapse?

Depending on recovering addict's honest answers to these questions, it is often suggested that they find a different field. However, former abusers are allowed to return as long as they are not currently using.

PERSONAL AND SOCIAL CONSEQUENCES

Teenagers and young adults are often introduced to designer drugs through peer pressure and their social environment. They often segregate themselves from non-users and surround themselves with those who view their choice as acceptable. This limits their exposure to those who scorn their lifestyle. However, society in general views designer drugs and their users negatively, so someone who abuses can face difficulty finding a job or keeping non-abusing friends.

As discussed earlier, anesthesiologists who abuse fentanyl often have difficulty keeping the job for which they have trained and studied for years to obtain. Even those who undergo treatment can have a hard time finding a new position in a different field because they will have to be retrained. Other white-collar workers in the middle to upper-middle class who abuse fentanyl can also lose their jobs, families, and friends when their addiction comes to light.

People who use fentanyl for chronic pain often try to hide their use. They often believe that others will think less of them for needing something to help them deal with their pain. Since fentanyl is only prescribed to those who are in extreme pain and need to block the receptors in their brain that signals pain, patients should not be viewed as drug "users" who are trying to get high. This constitutes the difference between medicinal and recreational uses of fentanyl.

LEGAL CONSEQUENCES

According to the DEA, fentanyl and its analogs are Schedule I and II narcotics. This means that anyone who possesses fentanyl without a legal prescription can face criminal charges. Whether the drug is Schedule I or II depends on how much of the drug is possessed or sold. It is important to remember that when the weight of the drug is determined, anything that is part of the substance is included. This means that an entire fentanyl lollipop is weighed, not just the amount of fentanyl in the lollipop. This is especially of concern to street users who buy the designer drug already dissolved in water, because water is much heavier than the drug.

Anyone who sells or distributes fentanyl or one of its analogs, regardless of whether it is pharmaceutically or clandestinely created, can face criminal charges. This includes giving someone else some of a legally prescribed dosage. Any doctor who falsely prescribes fentanyl to someone can face criminal charges.

Anyone possessing more than 40 g of fentanyl can be prosecuted for a Schedule I offense. Possession of more than 10 g of a fentanyl analog is also a Schedule I offense. The harsher penalties for fentanyl analogs are because all analogs are illegally produced in clandestine laboratories. Possessing less than 40 g of fentanyl or less than 10 g of an analog is a Schedule II offense.

Legal history

The Controlled Substances Act of 1970 was an attempt to tightly control all potentially harmful substances. It was designed to limit the use of drugs such as fentanyl and codeine to clinical use only. Drug users found a way around this law. By designing the drug in clandestine labs, they would alter the chemical makeup just enough so that prosecutors could not charge users. However, the law was altered in 1984 to include analogs of illegal drugs. The wording was cleaned up even more in 1986, and since then, any analog of an illegal drug is also considered illegal. In fact, analogs are viewed in an inceasingly negative light; as of 2002, analogs are considered more dangerous and thus demand stiffer penalties for violators of the law.

Federal guidelines, regulations, and penalties

Fentanyl is used throughout the world. In most countries, few can legally possess the drug. However, 11 countries—including the United States—use fentanyl not only for pain associated with the effects of cancer but also for those with general chronic pain.

In the United States, fentanyl and its analogs can be considered either a Schedule I or II drug depending on the amount involved. The DEA is pushing to remove all designer drugs from the street, so makers are being targeted. Doctors who write false prescriptions are increasingly under scrutiny as well.

First-time offense violators who possess 40–399 g of fentanyl mixture can receive not less than five years or more than 40 years in prison; if death or serious injury is involved, then not less than 20 years or more than life in prison. This is in addition to a fine of not more than $2 million for an individual. The same penalties apply to 10–99 g of fentanyl analog. For a second offense, the violator can receive not less than 10 years or more than life unless serious injury or death is involved. In this case, the term becomes not less than life in prison. The fine doubles to not more than $4 million for the second offense.

First-time offenders who possess 400 g or more of fentanyl or 100 g or more of an analog can receive not less than 10 years or more than life in prison unless there is a death or serious injury. This is in addition to a maximum $4 million fine. A second offense brings a mandatory 20-year prison sentence with a maximum of life. If death or serious injury occurs in a second offense, a life sentence in prison is the minimum. A fine of not more than $8 million can accompany the prison sentence.

RESOURCES

Books

Ottomanelli, Gennaro. Assessment and Treatment of Chemical Dependency. Westport, CT: Praeger, 2001.

Polishuk, Paul V. and Henry C. Nipper. "The Neurobiology of Fentanyl and its Derivatives," edited by Ronald R. Watson. Drugs of Abuse and Neurobiology Boca Raton, FL: 2000.

Periodicals

"Anesthesiologists: Addicted to the Drugs They Administer." American Society of Anesthesiologists: Newsletter (May 2001).

"Just the Facts: Designer Drugs." Florida Alcohol and Drug Abuse Association (2000).

Oncology Nursing Forum. "A Research-Based Guideline for Appropriate Use of Transdermal Fentanyl to Treat Chronic Pain." 25, 9 (1998).

"What You Can Do About Drug Use In America." National Clearinghouse for Alcohol and Drug Information. (1991).

Other

Addiction Recovery Institute. <http://www.detox24.com> Accessed 17 July 2002.

Office of National Drug Control Policy. <http://www.whitehousedrugpolicy.gov> Accessed 17 July 2002.

United States Department of Justice Drug Enforcement Agency. <http://www.usdoj.gov/dea> Accessed 17 July 2002.

United States Food and Drug Administration. Warning against misusing of Fentanyl Analgesic Skin Patch.<http://www.fda.gov:80/bbs/topics/NEWS/NEW00459.html.> Accessed 17 July 2002.

Organizations

Narcotics Anonymous (NA), PO Box 9999, Van Nuys, CA, USA, 91409, (818) 773-9999, (818) 700-0700, <http://www.na.org>.

National Federation of Parents for Drug-Free Youth, 9551 Big Bend, St. Louis, MO, USA, 63122, (314) 968-1322.

National Institute on Drug Abuse (NIDA), National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, [email protected], <http://www.drugabuse.gov/Infofax/marijuana.html>.

Brian Clifford Sine