Selected topics: Toxicology
Fentanyl Intoxication Caused by Abuse of Transdermal Fentanyl

https://doi.org/10.1016/j.jemermed.2007.10.075Get rights and content

Abstract

Fentanyl has an analgesic effect 100 times greater than that of morphine; therefore, transdermal administration of fentanyl has been widely used to control pain. Due to misconceptions regarding the proper use of fentanyl, its simple method of administration, and the absence of regulatory rules regarding its use, both medical providers and non-medical providers have abused fentanyl. We report on three cases of fentanyl intoxication and suggest solutions to prevent its abuse in the future. Three patients were intoxicated by transdermal fentanyl, which resulted in respiratory depression. Two of these cases were attributed to non-medical use of the drug and the other occurred while using fentanyl as directed by medical personnel. Physicians should use transdermal fentanyl only to control chronic pain, and rules should be established to prevent abuse of fentanyl that occurs due to its ease of use and the absence of any established policy regarding the prescription and disposal of this drug.

Introduction

Fentanyl acts primarily as a pure and selective opioid μ receptor agonist that relieves pain with fewer adverse effects and a more potent analgesic effect than morphine. Fentanyl is administered via intravenous, epidural, transdermal, and transmucosal routes.

Transdermal fentanyl is composed of a protective peel strip and four functional layers containing fentanyl. The drug reservoir contains 2.5 mg fentanyl/10 cm2 of patch size, which is delivered via passive diffusion to systemic circulation. Because this transdermal delivery offers improved administration and enables continuous systemic application of fentanyl that produces a constant serum concentration similar to a continuous infusion, it has been widely used since it was first produced in 1991. Due to its pharmacokinetic features, transdermal fentanyl has been used to control chronic pain in patients who cannot control their pain using less potent opioids, but it is not useful for controlling acute pain. However, both medical providers and non-medical personnel have abused fentanyl, and fatal cases have occasionally been reported. We report here on three cases of fentanyl intoxication caused by transdermal fentanyl. We also analyze the pharmacokinetic features of transdermal fentanyl and suggest causes and solutions for the abuse of transdermal fentanyl.

Section snippets

Case 1

A 76-year-old female monk was admitted to our Emergency Department (ED) exhibiting a drowsy mental state that had developed 3 h previously. She had no known medical problems. She had experienced nausea and vomiting for 1 day, and she was in an altered mental state. She was initially taken to a public primary health center, where a computed tomography (CT) scan of the brain and laboratory blood tests were conducted. The CT scan of the brain was normal. An initial arterial blood gas (ABG)

Discussion

Fentanyl is a pure and selective opioid μ receptor agonist that is 80–100 times more potent than morphine (1). Fentanyl is administered via intravenous, epidural, transmucosal, and transdermal routes. Because it is a highly lipophilic drug, 98.6% of the injected dose is redistributed to highly vascular tissues, such as the brain and heart, within 1 h of intravenous administration, and elimination from the vascular tissue is rapid (2). Therefore, the duration of fentanyl's action is short and it

Conclusions

In conclusion, this article describes three cases that demonstrate the adverse effects of transdermal fentanyl, two of which involved abuse of transdermal fentanyl by non-medical personnel, and the other that was the result of a mis-prescription by medical personnel. Based on these cases, we make the following two suggestions: first, physicians should use transdermal fentanyl to control only chronic pain, and a decreased dose has to be considered for patients who are opioid-naïve or have a

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    The main side effects reported with the use of transdermal fentanyl are nausea and respiratory depression. The severity may increase with the patient age, decline in pulmonary function in older age and the use of other sedative drugs [405]. In one study all the older participants (n = 10) had to remove their patches due to respiratory depression, nausea and vomiting [406].

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