Why do we have such a great need for fentanyl recovery now?
There was a time when fentanyl was a drug only known to certain medical specialists and chronic pain patients. Fentanyl has been quietly used for many years in hospital operating rooms as a key component of general anesthesia. It is also the main ingredient in some often-prescribed pain management products, including Duragesic, the fentanyl patch.
In recent years, we have seen many news stories about fentanyl laced heroin and imported fentanyl analogs. When we read about another fatal overdose, we can assume that fentanyl is likely the cause.
Fentanyl is a synthetic opioid that works by activating opioid receptors in the human central nervous system. It has a potency of about 80 times that of morphine. While it is not the most potent opioid in existence, it is the most potent opioid in common use, both in the medical field and on the streets.
Over the past decades, there have been stories of fentanyl overdoses that involved FDA-approved medical fentanyl. There was a story many years back of a man who was found dead in his apartment with several Actiq fentanyl lollipops sticking out of his mouth. Actiq was later given greater restrictions, such that doctors could only prescribe it for cancer-related pain.
Other stories involved the fentanyl patch, which is one of the best prescription opioids for cancer-related pain when the patient is unable to swallow opioid pills. Because of the high potency of fentanyl, the small amount of drug contained in a single patch is highly toxic when consumed in any manner other than as intended.
The fentanyl patch is supposed to be applied to the skin and left in place for three days at a time. After three days, the patch is discarded and replaced with a new patch.
People must be careful how they dispose of their used fentanyl patches.
Even after wearing the patch for three days and depleting the medication contained in it, the patch still may contain a deadly amount of fentanyl. A dog or child chewing on an old patch found in the garbage could lead to a tragic outcome. Hence, the manufacturers recommend disposing of used patches by flushing them down the toilet.
Fentanyl patches can be abused in several ways. One way is to apply more patches than prescribed at the same time. I once heard of someone placing as many as five fentanyl patches all over their body, including one that emergency room staff could not find at first on his inner thigh.
Other ways that the patches have been abused are much more deadly. In fact, the fentanyl patch has been referred to as “the dead man’s high.”
Some people abusing fentanyl have tried extracting the drug from a patch with a needle for the purpose of injecting it. Over time, the formulation of the patch was changed from a liquid-containing pouch to a more flat bandage-like patch. Possibly, this was to discourage extraction of the drug with a needle.
Another very dangerous way to abuse fentanyl patches, leading to many overdose deaths is to chew on the patch. The problem is that there is no way for the user to gauge how much fentanyl they are consuming.
With the high potency of the drug and the delay in effect from oral consumption, a fentanyl abuser might not realize that they have chewed the patch too much until it is too late. If there is no one nearby with a naloxone nasal spray, fentanyl overdose will occur, leading to overdose death.
How is illicit fentanyl different from medical fentanyl?
You might say that illicit fentanyl found on the streets is an entirely different animal from fentanyl found in Duragesic patches, Actiq lollipops, and vials in the operating room. Street fentanyl, found in fentanyl laced heroin and as a heroin replacement, is in some ways, very different from its clean, medically useful cousin.
It is believed that much of the illicit fentanyl analogs on the streets of the United States started out in clandestine labs in China. Wuhan, the city associated with the start of the COVID-19 pandemic, was once known as the fentanyl capital of the world.
Much of the street fentanyl finds its way into the US through Mexico and even directly to street dealers and fentanyl users through the United States Postal Service. Fentanyl analogs can be purchased on the dark web using cryptocurrency and a combination of software to make tracking sales by law enforcement very difficult.
Fentanyl analogs shipped to the US are not the same as the fentanyl used for chronic pain relief. One characteristic that might be an issue for you if you go to an addiction specialist for treatment is the way that illicit fentanyl lingers in the body for a much longer period of time than other opioids.
In my recent podcast interview with top addiction specialist, Adam Bisaga, M.D., Dr. Bisaga agreed that he was aware of the issue with long-lasting fentanyl analogs and how their actions interfere with starting medication-assisted treatment programs. The problem is that fentanyl should be a short-acting drug that leaves the system quickly.
Fentanyl analogs are making addiction treatment more challenging.
Doctors treating patients for fentanyl addiction when the fentanyl is pharmaceutical fentanyl will have no problem timing the start of treatment medication. The patient will go about 18-24 hours, report mild to moderate withdrawal symptoms, and then be able to start Suboxone or a similar buprenorphine-based drug.
With illicit fentanyl analogs found on the streets, the drug seems to get caught in the body, possibly sequestered in fat cells. It unpredictably persists, sometimes for several days. When the patient starts their Suboxone, they sometimes go into precipitated withdrawal because of the lingering illicit fentanyl.
Precipitated withdrawal is an opioid withdrawal syndrome that is triggered by taking Suboxone or Subutex too soon. Normally, it is not a problem, because doctors and patients know to wait for about a day before starting treatment. But, with fentanyl analogs, precipitated withdrawal can happen two, three, or even four to five days later.
Dr. Bisaga recommends that Suboxone doctors consider starting their patients on very low doses of Suboxone in the beginning and increase very gradually over time. This is similar to the Burnese Method, a treatment protocol used in countries such as Canada to start medication-assisted treatment while a patient is unable to quit their heroin.
What are the signs and symptoms of fentanyl addiction?
When a person is addicted to fentanyl, they will act similarly to people who are addicted to other opioids. They may appear to be sleepy, sedated, with poor mental functioning. I remember having lunch with a group of friends where one person in the group was believed to be relapsing on opioids.
During lunch, he did not engage in conversation and he moved very slowly in handling his food. At times, his head would start to fall as if he was suddenly falling asleep at the table. As his chin fell towards his chest, he would catch himself and quickly lift his head, opening his eyes to try to appear more awake.
When a person high on opioids does this movement with their head, it is called “nodding off” or simply, “nodding.” Unfortunately, this person, who had been to multiple rehab programs and recovery meetings, finally ended up dying from an overdose.
Another sign to look for is pinpoint pupils. While other drugs may cause noticeably enlarged pupils, opioids cause the pupils to shrink to a very small size.
Otherwise, if you are trying to determine if someone you know is addicted to fentanyl, you might note that they are disorganized in their life regarding basic activities. Their homes and cars are a mess, they are behind on paying bills and taking care of basic daily hygiene.
Unfortunately, in many cases, family and friends of people addicted to fentanyl are in denial and may try to justify the changes occurring to their loved one who is silently suffering with active fentanyl addiction. It is not easy to confront someone about their addiction. The best way to start is by letting them know that you are available to provide help when they are ready.
Should I go to a fentanyl addiction treatment center for a medical detox?
I remember once speaking to a patient who was very angry about his rehab experience. He kept repeating that they had promised him a comfortable detox. From his story, my impression was that the staff felt that he should suffer a bit to help him remember how bad it is to come off of heroin.
Is there such a thing as a comfortable detox? There are ways to make detoxing from fentanyl or heroin more comfortable than doing it alone, without medical treatment.
In the case of that particular patient, his goal was to come off of opioids altogether. He was not interested in methadone maintenance, and his experience was in the 90s, before Suboxone was available.
Today, there are many more treatment options available compared to several decades ago. Methadone maintenance is still an option, and in many cases of opiate addiction involving illicit fentanyl, a very good option.
Residential treatment is also a possibility. When looking for a treatment program, it is important to check that they provide both medication-assisted treatment (MAT), and also various types of therapy, including treatments such as cognitive behavioral therapy (CBT).
Treatment programs are able to offer buprenorphine treatment in the form of Suboxone, ZubSolv, and monthly subcutaneous injectables, such as Sublocade and Brixadi. They can also provide naltrexone in the form of daily tablets or the monthly injection, Vivitrol. Dissolvable naltrexone implants are currently in development.
In the future, detox and rehab programs may also provide novel new medical treatments involving psychedelic drug treatment. Ibogaine and ayahuasca are plant-based substances used by the indiginous people of the American continents.
While there are questionable fly-by-night clinics popping up in Mexico and other countries where these substances might be legal, it is possible that derivatives of these plant medicines may be useful in Western medicine.
For example, 18-MC is derived from ibogaine and is a substance being studied for use in the treatment of various mental health disorders. Psilocybin is a mushroom based substance that has been synthesized and is being studied as well.
Can a Suboxone doctor treat fentanyl addiction?
Knowing about the issue of precipitated withdrawal with fentanyl analogs may scare you away from visiting a Suboxone doctor. Methadone has the advantage that it can be started the same day that you quit opioids without concern about precipitated withdrawal.
Yet, it is definitely possible to make the transition from fentanyl to Suboxone with a treatment plan provided by a local Suboxone doctor. Treatment can even be performed over a telemedicine visit with careful guidance from an experienced Suboxone treatment provider.
Treatment involves careful monitoring of withdrawal symptoms as well as careful induction with buprenorphine. Comfort medications, such as clonidine, Lucemyra, and others can help ease the transition.
While going to the methadone clinic may seem like the easiest solution, methadone maintenance is a tightly controlled program that requires daily visits to the clinic every morning. Suboxone treatment, on the other hand, can be provided on a weekly or monthly basis.
Suboxone therapy works better for many people’s lifestyles. You are able to relax on the weekends with your family and even go away on vacations without having to find a methadone clinic at your destination.
So, if you are willing to work closely with an experienced concierge Suboxone doctor to get through the sometimes challenging first few days of treatment induction, you will be able to enjoy significantly greater freedom compared to other options. Concierge MAT provides easy access to your doctor as well as the freedom to live your life without being chained down to an oppressive treatment program.
Fentanyl addiction treatment works and there is no reason to continue with fentanyl abuse. The dangers of opioid overdose are serious. The first step in overcoming fentanyl addiction is to ask for help and get started right away on a medical treatment plan.