Selected topics: ToxicologyFentanyl Intoxication Caused by Abuse of Transdermal Fentanyl
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.
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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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