Fentanyl analogue overdose: Key lessons in management in the synthetic opioid age

Authors

  • Amer Raheemullah, MD
  • Neal Andruska, MD, PhD

DOI:

https://doi.org/10.5055/jom.2019.0531

Keywords:

fentanyl overdose, fentanyl analogues, opioid overdose, acrylfentanyl, naloxone, buprenorphine start in ED

Abstract

Fentanyl overdoses are growing at an alarming rate. Fentanyl is often mixed into heroin and counterfeit prescription opioid pills without the customer’s knowledge and only detected upon laboratory analysis. This is problematic because fentanyl analogues like carfentanil are 10,000 times more potent than morphine and pose new challenges to opioid overdose management.

A 62-year-old male with an overdose from a rare fentanyl analogue, acrylfentanyl, was given two doses of intranasal 2 mg naloxone with improvements in respiratory rate. In lieu of more naloxone, his trachea was intubated and he was admitted to the intensive care unit. He subsequently developed ventilator-associated pneumonia and then a pulmonary embolism. He did not receive any opioid use disorder treatment and returned back to the emergency department with an opioid overdose 21 days after discharge.

We are encountering an unprecedented rise in synthetic opioid overdose deaths as we enter the third decade of the opioid epidemic. Thus, it is imperative to be aware of the features and management of overdoses from fentanyl and its analogues. This includes protecting against occupational exposure, administering adequate doses of naloxone, and working with public health departments to respond to fentanyl outbreaks. Additionally, fentanyl overdoses represent a critical opportunity to move beyond acute stabilization, start buprenorphine or methadone for opioid use disorder during hospitalization, link patients to ongoing addiction treatment, and distribute naloxone into the community to help curb the overdose epidemic.

Author Biographies

Amer Raheemullah, MD

Department of Psychiatry, Stanford University School of Medicine, Stanford, California

Neal Andruska, MD, PhD

Department of Internal Medicine, University of Illinois College of Medicine, Chicago, Illinois

References

Hedegaard H, Minino AM, Warner M: Drug Overdose Deaths in the United States, 1999-2017. Hyattsville, Maryland: National Center for Health Statistics, 2018. Data Brief No. 329.

Drug Enforcement Administration: Counterfeit Prescription Pills Containing Fentanyls: A Global Threat. Springfield, VA: US Drug Enforcement Administration, 2016. Issue Brief DEA-DCTDIB-021-16.

Fogarty MF, Papsun DM, Logan BK: Analysis of fentanyl and 18 novel fentanyl analogs and metabolites by LC–MS-MS, and report of fatalities associated with methoxyacetylfentanyl and cyclopropylfentanyl. J Anal Toxicol. 2018; 42 (9): 592-604.

US Drug Enforcement Administration, Diversion Control Division: NFLIS Brief: Fentanyl, 2001-2015. Springfield, VA: US Drug Enforcement Administration, 2017.

US Drug Enforcement Administration, Diversion Control Division: NFLIS Brief: Fentanyl and Fentanyl-Related Substances Reported in NFLIS, 2015-2016. Springfield, VA: US Drug Enforcement Administration, 2017.

DEA Chicago Field Division: Fake Rx in Indiana: Carfentanil and Fentanyl Found in Purported Oxycodone Pills. Chicago, Illinois: US Drug Enforcement Administration, 2016. Bulletin DEA-CHI-BUL-167-17.

Vardanyan RS, Hruby VJ: Fentanyl-related compounds and derivatives: Current status and future prospects for pharmaceutical applications. Future Med Chem. 2014; 6: 385-412.

Fairbairn N, Coffin PO, Walley AY: Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic. Int J Drug Policy. 2017; 46: 172-179.

Drug Enforcement Administration, Department of Justice: Schedules of controlled substances: Temporary placement of acryl fentanyl into schedule I. Temporary scheduling order. Fed Regist. 2017; 82 (134): 32453-32457.

Boyer EW: Management of opioid analgesic overdose. N Engl J Med. 2012; 367: 146-155.

Morgan J, Jones AL: The role of naloxone in the opioid crisis . Toxicol Commun. 2018; 2 (1): 15-18.

Drug Enforcement Administration: Fentanyl: A Briefing Guide for First Responders. Springfield, VA: US Drug Enforcement Administration, 2017.

Helander A, Stojanovic K, Villén T, et al.: Detectability of fentanyl and designer fentanyls in urine by 3 commercial fentanyl immunoassays. Drug Test Anal. 2018; 10 (8): 1297-1304.

Walley AY, Paasche-Orlow M, Lee EC, et al.: Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis. J Addict Med. 2012; 6: 50-56.

Moreno JL, Wakeman SE, Duprey MS, et al. Predictors for 30-day and 90-day hospital readmission among patients with opioid use disorder. J Addict Med. 2019; 13(4): 306-313.

Naeger S, Ali MM, Mutter R, et al.: Prescriptions filled following an opioid-related hospitalization. Psychiatr serv. 2016; 67 (11): 1262-1264.

D’Onofrio G, O’Connor PG, Pantalon MV, et al.: Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA. 2015; 313: 1636-1644.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality: The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits, 2011. Rockville, MD: SAMHSA.

Published

09/01/2019

How to Cite

Raheemullah, MD, A., and N. Andruska, MD, PhD. “Fentanyl Analogue Overdose: Key Lessons in Management in the Synthetic Opioid Age”. Journal of Opioid Management, vol. 15, no. 5, Sept. 2019, pp. 428-32, doi:10.5055/jom.2019.0531.

Issue

Section

Clinical Report