Fentanyl is a highly potent synthetic opioid of the piperidine family, used primarily as pain medication. It is 50 to 100 times more potent than morphine. Its primary clinical use is in pain management for cancer patients and those recovering from surgery. Fentanyl is also used as a sedative for intubated patients. Fentanyl has a short duration of action. Fentanyl works by activating μ-opioid receptors. Brand names include Actiq, Duragesic, and Sublimaze, among others. Fentanyl was first synthesized by Paul Janssen in 1960 and was approved for medical use in the United States in 1968. In 2015, 1,600 kilograms (3,500 pounds) were used in healthcare globally. As of 2017, fentanyl was the most widely used synthetic opioid in medicine; in 2019, it was the 278th most commonly prescribed medication in the United States, with more than a million prescriptions. It is on the World Health Organization's List of Essential Medicines. The effects of fentanyl are similar to those of other opioids, causing sedation and analgesia at clinical doses. The most common adverse effects are respiratory depression, emesis, and asthenia. Bradycardia and apnea are uncommon side effects but are serious and can lead to death outside of clinical settings. Fentanyl exerts its actions as an agonist of the μ-opioid receptor and κ-opioid receptor. The μ-receptor agonism is responsible for the respiratory depression and generalized analgesia whilst the κ-receptor agonism is responsible for sedation and spinal analgesia. Fentanyl is a potent μ-receptor agonist but has less affinity for the κ-receptor. Fentanyl is contributing to an epidemic of synthetic opioid drug overdose deaths in the United States. From 2011 to 2021, overdose deaths involving prescription opioid (natural and semi-synthetic opioids and methadone) per year remained stable, while synthetic opioid (primarily fentanyl) associated overdose deaths per year increased from 2,600 overdoses to 70,601. Fentanyl was involved in the most drug overdose deaths in the United States in 2018. The United States National Forensic Laboratory estimates fentanyl reports by federal, state, and local forensic laboratories increased from 4,697 reports in 2014 to 117,045 reports in 2020. Fentanyl is often mixed, cut, or ingested alongside other drugs, including cocaine and heroin. Fentanyl has been reported in pill form, including pills mimicking pharmaceutical drugs such as oxycodone. Mixing with other drugs or disguising as a pharmaceutical makes it difficult to determine the correct treatment in the case of an overdose, resulting in more deaths. Emerging adulterants have further complicated the evolving fentanyl supply. In an attempt to reduce the number of overdoses from taking other drugs mixed with fentanyl, drug testing kits, strips, and labs are available.
Medical uses
Anesthesia Intravenous fentanyl is often used for anesthesia and as an analgesic. To induce anesthesia, it is given with a sedative like propofol or thiopental. To maintain anesthesia, inhaled anesthetics and additional fentanyl may be used. These are often given in 15–30 minute intervals throughout procedures such as endoscopy and surgeries and in emergency rooms. For pain relief after surgery, using fentanyl can decrease the amount of inhalational anesthetic needed for emergence from anesthesia. Balancing this medication and titrating the drug based on expected stimuli and the person's responses can result in stable blood pressure and heart rate throughout a procedure and a faster emergence from anesthesia with minimal pain.
Regional anesthesia Fentanyl is the most commonly used intrathecal opioid because its lipophilic profile allows a quick onset of action (5–10 min) and intermediate duration of action (60–120 min). Spinal administration of hyperbaric bupivacaine with fentanyl may be the optimal combination. The almost immediate onset of fentanyl reduces visceral discomfort and even nausea during the procedure.
Obstetrics Fentanyl is sometimes given intrathecally as part of spinal anesthesia or epidurally for epidural anesthesia and analgesia. Because of fentanyl's high lipid solubility, its effects are more localized than morphine, and some clinicians prefer to use morphine to get a wider spread of analgesia. It is widely used in obstetrical anesthesia because of its short time to action peak (about 5 minutes), the rapid termination of its effect after a single dose, and the occurrence of relative cardiovascular stability. In obstetrics, the dose must be closely regulated to prevent large amounts of transfer from mother to fetus. At high doses, the drug may act on the fetus to cause neonatal withdrawal. For this reason, shorter-acting agents such as alfentanil or remifentanil may be more suitable in the context of inducing general anesthesia.
Pain management
The bioavailability of intranasal fentanyl is about 70–90% but with some imprecision due to clotted nostrils, pharyngeal swallow, and incorrect administration. For both emergency and palliative use, intranasal fentanyl is available in doses of 50, 100, 200, or 400(PecFent) μg. In emergency medicine, safe administration of intranasal fentanyl with a low rate of side effects and a promising pain-reducing effect was demonstrated in a prospective observational study in about 900 out-of-hospital patients. In children, intranasal fentanyl is useful for the treatment of moderate and severe pain and is well tolerated. Furthermore, a 2017 study suggested the efficacy of fentanyl lozenges in children as young as five, weighing as little as 13 kg. Lozenges are more inclined to be used as the child is in control of sufficient dosage, in contrast to buccal tablets.
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