Fentanyl versus morphine: Which of these addictive opioids is more dangerous?
Morphine is a strong opioid. It is still used in many hospitals as a pain medication. Intravenous morphine is used to provide analgesia for cancer patients, and it is used to treat acute postoperative pain.
When a patient presents to a hospital emergency room with severe pain, the ER doctor may start an IV PCA pump filled with morphine. The patient with acute pain can press a button to administer a dose of morphine to provide immediate pain relief.
Oral morphine has been prescribed for decades in medical pain management clinics, though oxycodone became more widely prescribed during the past two decades. There are the long-acting morphine sustained release tablets, and morphine immediate release tablets for breakthrough pain.
Chronic pain with a high pain score may be due to an injury, or it may be neuropathic pain. An opioid pain reliever often has less adverse effects than many non-opioid drugs, though there is a significant risk of patients developing an opioid addiction.
Outpatient use of high potency opioids was once mainly for cancer pain, but has been used more for chronic pain in recent decades. Pharmaceutical pain med products have been promoted for chronic pain by their manufacturers, because it is better for their profit-driven business to sell more opioids to patients with a longer lifespan.
To know more about morphine addiction, read out the blog: How Addictive Is Morphine Compared To Other Opiates?
Morphine and fentanyl are products used in healthcare, and they are also known to be drugs of abuse.
In recent years, other prescription opioids have displaced morphine as being preferred by pain management doctors. Intravenous fentanyl is used in hospital operating rooms for surgeries, and fentanyl patches are prescribed for ongoing pain control.
While both morphine and fentanyl have been diverted from hospitals to be abused by opioid addicted people, the abuse of these pharmaceutical products is not very widespread at this time. These drugs are highly regulated and controlled, so diversion happens less frequently.
Heroin, on the other hand, is an opioid often involved in drug abuse, because it is widely sold on the streets by drug dealers. Heroin is in the morphine group of drugs in that it is a close relative of morphine.
When a drug user shoots up heroin, it converts in their blood stream to morphine. Heroin quickly metabolizes to morphine in the body.
In recent years, heroin has been displaced on the streets by an ominous synthetic opioid, which is closely related to fentanyl. We call it fentanyl, but it is not exactly the same as pharmaceutical fentanyl.
Fentanyl is, by far, the more potent opioid, compared to morphine.
Fentanyl, a synthetic opioid, is a much more potent opioid than morphine. In fact, it is 80-100 times the potency of morphine, where heroin is only four times the potency of morphine.
When fentanyl is given to patients in the hospital, the potency is not a major issue. Fentanyl is administered carefully by anesthesiologists, or it is measured in micrograms in fentanyl patches.
On the other hand, when fentanyl is used on the streets, instead of heroin, the potency becomes a major issue. Handling of street drugs by illicit labs and dealers is imprecise. When the drugs are more potent, it is easier to make an error and have the drug supply be much more potent than expected.
So, in a controlled, medical setting, the opioid drug is diluted appropriately for handling. For example, fentanyl intended for IV infusion in the operating room will be measured in micrograms per milliliter.
The Duragesic patch, a transdermal fentanyl product, which contains fentanyl, is also measured in micrograms. The patches release 25-100 micrograms per hour, depending on which strength is prescribed.
Morphine, on the other hand, is measured in milligrams, rather than micrograms. A vial of IV morphine may contain 10 mg per milliliter. Morphine IR tablets may have 15 mg or 30 mg per tablet.
Fentanyl’s higher potency becomes an issue when it is diverted from the healthcare system.
The super high potency of fentanyl does occasionally present itself as a problem in hospitals. This problem occurs in instances when pharmaceutical fentanyl is diverted, or stolen, from the hospital.
In a hospital operating room, there are tight controls and extensive oversight over narcotics. In order to provide adequate anesthesia and pain control during surgery, anesthesiologists must have access to the most potent opioid drugs available.
Where a nurse on the hospital floors, or in the emergency department, may be giving out morphine injections, percocet tablets, or dilaudid IV PCA pumps, the anesthesiologists in the OR work with fentanyl and sufentanil.
Sufentanil is a synthetic opioid that is far more potent than fentanyl. In fact, it is thousands of times stronger than morphine.
You may have heard of carfentanil, the veterinary painkiller for large animals, such as elephants. Sufentanil is just under half the potency of carfentanil, and is probably the most potent opioid in the fentanyl group used in human medicine.
When an anesthesiologist prepares for a surgical procedure, they must have all the anesthesia drugs available and ready to administer. This includes having vials of fentanyl, or the less often used sufentanil.
Each milliliter used from the vial must be accounted for. Whatever fentanyl remains in the vial that does not go into the patient’s IV must go back into a locked cabinet.
Oversight of fentanyl and other opioids in a healthcare setting is important to help prevent diversion and abuse.
Who watches these medical doctors who administer anesthesia in hospital operating rooms to make sure that they are not stealing controlled drugs for their own use? Is there even a concern about doctors risking many years of training to destroy their career, stealing opioids from the hospital?
Surprisingly, opioid abuse is fairly common among anesthesiologists. This includes anesthesia doctors in training, during their residency.
The job of being an anesthesiologist can be high pressure and stressful. They are responsible for making certain that each patient wakes up from surgery and resumes breathing after being on a ventilator during surgery.
Each day, they feel the pressure of their career being on the line with each surgical case. Like airline pilots, many will take on this stress with a calm, assured attitude that comes with years of experience.
Yet, others will feel intense stress, and some are even resentful of their treatment in the healthcare system. They complain that other doctors believe that they have it easy, just sitting at a desk, “passing gas.”
The part about passing gas is in reference to some anesthetic agents being delivered in gas form, though in modern anesthesia, much of the medication is administered via IV. For example, propofol, a white milky substance, is commonly used, and is given by IV.
Doctors and nurses who work with potent synthetic opioids in hospitals may be at risk for becoming addicted.
What happens if a stressed out anesthesiologist decides to steal some fentanyl to take at home, to relieve the pain of being a misunderstood medical specialist? They work hard, take on huge responsibilities, and get little respect from their peers.
Fortunately, when an anesthesiologist, full doctor or resident, thinks about diverting opioids from the hospital, there is oversight to prevent them endangering their career, and their life. There are nurses who watch carefully to make sure that controlled medication records are accurate.
Hospital staff members help in tracking dangerous addictive opioids in the hospital. They watch each other to make sure that their coworkers do not give into temptation.
However, because of the high potency of fentanyl, and especially sufentanil, a tiny amount of the drug goes a long way. An anesthesiologist determined to get high on opioids from work may take a very small amount of synthetic opioid to get a powerful opioid high.
In some teaching hospitals, anesthesia residents are required to watch an educational video on the dangers of diverting and abusing synthetic opioids. One video has been described as showing a dramatization of a resident overdosed and dead in a bathtub after attempting to shoot up sufentanil.
High potency opioids are considered to be easier to divert with the intention of misuse.
The high potency makes the drug easier to steal, but much harder to carefully self-administer without risking a deadly overdose, caused by respiratory depression. If a trained doctor can accidentally kill themselves with fentanyl, what are the risks with a user on the streets buying fentanyl analogs of unknown potency?
At least the doctor in the bathtub knew the potency of what they were pushing into the self-placed IV line. The street fentanyl user does not know the strength of the powdered drug they are taking, or even what drug it is.
A user may buy heroin and get a heroin/fentanyl mix instead. In fact, the drug sold as heroin may be pure fentanyl.
With heroin being four times the potency of morphine, and fentanyl being up to 100 times the potency of morphine, it becomes clear which drug is more dangerous on the streets. When potencies are inaccurate, it is much safer to have a lower potency drug.
Do street opioid users know how many milligrams, or micrograms, of their drug they are buying? Street heroin users typically measure their usage in bags or capsules.
By developing a high opioid tolerance, the opioid addicted person has some protection from variations in potency. Yet, fentanyl is so much more potent than heroin, a small error in measurement on the part of the dealer can easily lead to many overdoses.
In an addiction treatment program, is there a difference in how morphine addiction is treated versus fentanyl addiction?
The rehab client who is addicted to fentanyl may have developed a much higher opioid tolerance, compared to the client addicted to morphine. While this may have some influence on how the facility treats them, for the most part, opioid addiction is treated similarly, regardless of the client’s level of tolerance.
When starting medication-assisted treatment for opioid dependence, the half-life of the opioid being abused is more significant than the potency. For treatments such as buprenorphine therapy or naltrexone therapy, it is important to allow time for the opioid to be cleared from the patient’s system.
While fentanyl is considered to be a short-acting opioid, the fentanyl analogs found on the streets may act very differently. Street fentanyl has been found to remain in a person’s system for many days after they stop using it.
Fentanyl analogs present a unique difficulty in starting medical treatment for opioid dependence.
The unusual long-acting nature of synthetic fentanyl analogs can make it difficult to start Suboxone treatment, because the buprenorphine in Suboxone will cause precipitated withdrawal symptoms if taken before enough fentanyl is cleared from their system. Precipitated withdrawal is a dreaded syndrome that opioid abusers want to avoid at all costs, because it is so unpleasant.
One reason for the additional training that Suboxone doctors require is to teach them about precipitated withdrawal. The reason why it is important is that when a patient suffers through precipitated withdrawal, they are less likely to return and try treatment again.
One way that medical addiction treatment experts have discovered to get around the problem posed by long-lasting fentanyl analogs is to introduce Suboxone very gradually, avoiding a full precipitated withdrawal reaction. Starting Suboxone very low, and increasing it gradually, is known as the Bernese Method.
There is another option that opioid addicted people have to avoid precipitated withdrawal, caused by a reaction of fentanyl analogs imported to the streets from Mexico or China, with Suboxone or naltrexone.
This alternate option is methadone maintenance, which can be started the same day that the fentanyl addicted client decides to quit fentanyl and start methadone. Methadone is a potent opioid which will not cause precipitated withdrawal, even for a client shooting up fentanyl analogs being sold as heroin on the streets.
Is treating an opioid overdose different for fentanyl vs morphine?
Naloxone is the standard drug used to reverse an opioid. This harm reduction drug has saved many lives, when it has been available, on site, when an opioid user is overdosing. Naloxone is sold under the brand-name Narcan.
Narcan is available as an injection and as a nasal spray. There is also Evzio, a talking naloxone auto-injector, and now, a high potency naloxone injection, Zimhi.
Zimhi has been released in response to the issue of Narcan-resistant overdoses. Because of the high potency of street fentanyl, a spray of Narcan nasal spray is often not enough to get an overdosing individual breathing and awake again.
As a result, the helpful bystander must administer more Narcan, and hop for the best. With Zimhi, a single injection is likely to awaken any overdosing subject, even if they have taken a large amount of fentanyl analog.
As you can see, in a healthcare setting, the difference in potency of morphine versus fentanyl is not so important. However, on the streets, and from the perspective of first responders, the potency difference is critical. Listen to our free recovery podcasts: Fentanyl Recovery Stories & Morphine Recovery Stories.
