Fentanyl Addiction Explained
Opioids abuse has reached epidemic levels – and this problem has become significantly more catastrophic as a result of the emergence of an incredibly potent opioid which is now taking many thousands of lives each year: fentanyl.
What Is Fentanyl?
Fentanyl is an opioid (technically, a drug acting on opioid receptors in the brain to produce morphine-like effects) used medically in the treatment of pain and recreationally because of the very strong euphoric “high” it produces in users. First synthesised in 1960 by Belgian scientist Paul Janssen (founder of Janssen Pharmaceuticals), fentanyl has been used medically since 1968. However, it has become increasingly infamous since the turn of the millennium thanks to the role it has played in thousands of deaths, especially in the United States where it is considered a major element of the ongoing opioid epidemic.
Fentanyl is approximately 100 times as strong as morphine (while analogues such as carfentanyl are considered to be up to 1,000 times as strong) [1]. Because of this extreme potency, it only takes a comparatively tiny amount of fentanyl to cause an overdose in users. Indeed, it is so strong that people have been known to die from having a small amount of fentanyl come into contact with their skin. However, the comparative ease with which it can be manufactured, and its low cost, has seen fentanyl become established as a substance of choice for drug dealers who can cut fentanyl into other substances.
This makes the substances more cost-effective but also as vastly more dangerous, especially to users who are unaware that their drugs contain fentanyl. These dealers would also sell it directly to users seeking extremely strong opioids.
As well as the danger of overdose it poses, fentanyl is staggeringly addictive. It is considered to have a very high dependence liability, meaning that its medical use must be extremely strictly controlled. Even a few instances of recreational use can cause addiction and dependence.
Fentanyl Brand and Street Names
Fentanyl is sold around the world under various brand names, including Subsys, Fentora, Abstral, Actiq, Duragesic, Instanyl, Haldid, Durogesic, Sublimaze, Matrifen, Onsolis and Lazanda. The recent proliferation of fentanyl producers, especially China-based, means that a multitude of other brand names may also be encountered. Meanwhile, on the street, fentanyl may be provided under a variety of names including Fent, Friend, Goodfella, Jack, Jackpot, Murder 8, TNT, China Girl, Dance Fever, Apache, Freddie, Fox, White Fox and more.
Medical Uses of Fentanyl
Fentanyl’s extremely strong analgesic (painkilling) properties mean that it is primarily used to treat acute and chronic pain. It is also an ingredient in several anaesthetics.
In 2018, fentanyl was used for the first time as an ingredient in cocktail of drugs used to perform capital punishment in the United States [2]. The use of fentanyl in executions is a now a matter of significant controversy in America.
Fentanyl is also believed to have been an ingredient in the incapacitating gas used by Russian authorities to end the 2002 Moscow theatre hostage crisis. Approximately 130 of the 850 hostages died as a result of the use of the gas.
Legal Status of Fentanyl
In the United Kingdom, fentanyl is categorised as a class-A controlled substance according to the Misuse of Drugs Act 1971 [3].
The maximum penalties are seven years’ imprisonment and an unlimited fine; life imprisonment and an unlimited fine could be received for possession and supply respectively.
Fentanyl addiction and abuse in the UK
So far, United Kingdom has not been as subjected to the devastating wave of fentanyl abuse and associated deaths which has hit the United States and elsewhere. However, recreational fentanyl use is growing in the UK, as are the number of fatalities associated with it: in 2017, there were 75 deaths in England and Wales caused by fentanyl, an increase of 29% from the previous year. Carfentanyl, a much stronger analogue of fentanyl, was mentioned for the first time on UK death certificates in 2017, featuring in 27 deaths that year. [4]
Fentanyl use in the UK has been driven at least in part by the increasing ease with which the drug can be obtained via the dark web from foreign manufacturers – in particular those based in China, which is estimated to be the source of at least 80% of the fentanyl found in Britain. Nevertheless, police and customs seizures of fentanyl remain few and far between: the National Crime Agency (NCA) said in 2019 that seizures of fentanyl had been at “very low levels” for the previous 18 months.
Routes of Administration
When taken recreationally, fentanyl is usually either smoked, injected or snorted. When provided medically, however, fentanyl comes in various different forms depending on the circumstances in which it may be required and the physiology of the patient receiving it.
Transdermal patch
Fentanyl transdermal (“through the skin”) patches are most commonly used in the management of chronic pain. Fentanyl patches release the drug slowly through the skin into the bloodstream, typically over a period of between 48 and 72 hours. Because fentanyl transdermal patches typically take between 12 and 24 hours to take full effect, they are often provided along with a faster-acting opioid such as morphine or oxycodone. [5]
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Nasal spray
Fentanyl nasal spray is used in both emergency medicine and palliative care, for the treatment of moderate to severe pain. It is comparatively frequently given to children suffering severe pain.
Injection
Fentanyl is commonly provided intravenously for the treatment of severe pain. Intravenous fentanyl takes effect extremely quickly. However, those effects typically do not last as long as other routes of administration, making it primarily useful for especially severe episodes, including breakthrough pain and intense periods of pain caused by cancer. Fentanyl is also injected as an anaesthetic, typically alongside other substances including hypnotics; and as a sedative, often in combination with a benzodiazepine.
Fentanyl can also be injected intrathecally (into the spinal column) as an epidural anaesthetic.
Lozenge
Fentanyl lozenges are a solid formulation of fentanyl, typically berry-flavoured, placed on a stick in the form of a lollipop. They are sucked and wiped on to the surface of the cheeks, tongue and gums, usually dissolving within around 15 to 20 minutes. The fentanyl absorbed through the mouth takes effect quite quickly, while most – around 75% – of the drug is swallowed and absorbed in the digestive system, taking effect more slowly, allowing for both rapid and protracted pain relief. Fentanyl lozenges are commonly used by medics in wartime situations, and in the treatment of opioid-tolerant patients suffering from chronic pain, especially breakthrough cancer pain.
Pharmacological Actions of Fentanyl
As with other opioids, fentanyl binds to opioid receptors in the brain and central nervous system. In particular, to the mu (μ) receptor (MOR), and also the delta (DOR) and kappa (KOR) opioid receptors. This process initiates the inhibition of the release of nociceptive (relating to the sensation of pain) neurotransmitters. This inhibition changes the perception of pain in the affected individual, causing analgesic effects.
Chemical formula
Fentanyl has the chemical formula C22H28N2O.
Fentanyl Addiction and How It Develops
Addiction is fundamentally a disorder of the brain’s reward system. Repeatedly engaging in rewarding behaviour, such as consuming fentanyl and experiencing its effects, conditions the reward centres in the brain to produce an increased quantity of chemicals. These include dopamine, associated with pleasure and motivational salience. Thus, the person in question begins to feel compelled to repeat the behaviour further in order to feel those pleasurable sensations. Similarly, not engaging in the behaviour in question will cause a deficiency of reward-related chemicals in the brain, causing unpleasant sensations and emotions which the individual will feel the impulse to try to drive off by returning to that behaviour.
Like other opioids, fentanyl use can also cause physical dependence. Dependence is related to addiction and often conflated with or mistaken for it. It is a condition whereby the system of an individual taking a particular substance regularly over time becomes used to the presence of that substance, and subsequently comes to rely on it for normal functioning. When the substance is suddenly withdrawn from the system, the brain and body of the affected individual may begin functioning abnormally. This may happen, for example, if a fentanyl-dependent individual suddenly stops taking the drug. Any of a host of unpleasant and potentially dangerous symptoms (collectively known as withdrawal syndrome) could manifest until the system readjusts to the long-term absence of the substance, and renormalises (achieve homeostasis).
There are various ways in which someone who does consume the drug may go on to develop a fentanyl addiction. For example, they may first be given fentanyl in a medical setting, and be provided with it frequently and for long enough to become addicted, driving them to continue to seek out and consume fentanyl after their treatment is concluded. Others may begin to engage in recreational fentanyl use and quickly go on to become addicted and dependent. Others still may start out by consuming other opioids, develop a tolerance to them and move up to fentanyl because of its greater potency.
Tolerance is when someone consuming a substance over time becomes used to a certain dosage. As their system adjusts to the regular experience of dosage, its effects become less and less pronounced, thus driving them to take larger and larger doses in order to feel same desired effects as previously.
Why Is Fentanyl Addictive?
Fentanyl is highly addictive for two main reasons. Firstly, its extreme potency compared with most other opioids (themselves considered very “strong” and “hard” drugs compared with most other recreational substances) means that the “high” fentanyl can produce in users is typically extremely intense and pleasurable. Therefore, it is highly “rewarding” in the sense of driving repeated engagement. Recreational drug users seeking out that particular type of euphoric and sedative high may gravitate towards fentanyl despite an awareness of its dangers because of the sheer intensity of the experience, which may make other opioids – even heroin – much less intense by comparison.
Secondly, fentanyl also has a very high physical dependence liability: dependence can develop extremely rapidly. Users who may experiment with fentanyl on only a few occasions in succession may find that they have already become dependent and need to continue to take the drug in order to avoid going into withdrawal.
Causes of Fentanyl Addiction
Although many aspects of addiction are well understood, it is still not yet totally clear what precisely causes it in any one individual, while another person in very similar circumstances may not develop an addiction. It is known that both environmental and genetic factors play a role. Fundamentally, the more fentanyl a person takes, and the more frequently they take it, the greater the likelihood that they will become addicted. On the other hand, someone who never takes fentanyl will obviously never develop a fentanyl addiction.
Genetics
Genetics are very significant factor in the development of addiction. A family history of substance abuse and addiction is one of the leading indicators that an individual will go on to develop a fentanyl addiction themselves, as is, similarly, a family history of mental health disorders. It is thought that the gene transcription factor DeltaFosB, and in particular its excessive expression in the part of the brain known as the nucleus accumbens, is a critical component in drug addiction. Research into the precise significance of DeltaFosB, and how it may be addressed in addiction treatment, is ongoing. Other genetic factors affecting the probability that fentanyl addiction will occur include the rate at which the body metabolises opioids, and the presence of any hereditary illnesses causing chronic pain.
Socio-environmental factors
Environmental and social risk factors for fentanyl addiction include: the experience of childhood trauma; coming from a low socio-economic background; experiencing significant stress and/or life challenges; associating with a peer group in which substance abuse (especially fentanyl or other opioids) is commonplace; having easy access to fentanyl; having a partner who uses and/or is addicted to fentanyl; having a history of substance abuse (especially opioid abuse); having a criminal record (especially involving imprisonment); and suffering from an injury or illness causing chronic pain and requiring repeated administration of strong analgesia.
Personality and psychological factors
The risk of fentanyl addiction is higher than average in individuals who suffer from low self-esteem, regularly engage in risk-taking behaviour, suffer from one or more mental health disorders, (especially depression and/or anxiety), are introverted and withdrawn, do not feel strong ambition or a sense of purpose, and/or feel a strong desire to fit in.
Signs and Symptoms of Fentanyl Addiction
It can be very difficult to identify the presence of an addiction even in someone very close to you, as the stigma and shame associated with addiction typically drives addicts to go to great lengths to conceal their condition. This is all the more so in the case of fentanyl, as opioid addiction is typically associated in the public mind with highly stigmatised heroin usage. After all, for years it was portrayed by government information campaigns as being dirty, dangerous, and associated with disease, crime, violence and deceit. Some addicts successfully sustain their addictions in secret for many years.
However, numerous signs and symptoms may indicate that someone is suffering from a fentanyl addiction. However, it is important to bear in mind that there may also be various other causes of each of them:
- frequent intoxication
- a preoccupation with obtaining and consuming fentanyl or other opioids
- the abuse of other opioids, including medicines
- financial troubles
- deceitful, furtive and/or manipulative behaviour
- neglecting personal and professional responsibilities
- altered eating habits
- altered sleeping habits
- changes in peer group
- new vocabulary relating to substance abuse
- a loss of interest in previously enjoyed activities
- alienation from family and friends
- involvement in criminal activity
- changes to sex drive and sexual preferences
- carrying paraphernalia related to fentanyl abuse (possibly including syringes)
- the development of a range of physical health issues
- the development of any of various mental health issues including depression and/or anxiety
- lack of care regarding personal appearance and hygiene
- anhedonia
- a loss of optimism regarding future prospects
- general apathy
- mood swings
- altered behaviour
- the manifestation of symptoms of withdrawal
Some physical and psychological signs which may indicate fentanyl consumption, possibly as an aspect of fentanyl addiction:
- major depressive disorder
- laboured breathing
- shaking
- weakness
- confusion
- dizziness
- stiff muscles
- visual hallucinations
- scratching
- sudden weight loss
- slurred speech
Health Risks from Fentanyl Addiction
Some of the health risks associated with addiction generally include those related to poor diet, low levels of hygiene, risky sexual behaviour, an increased risk of violence, a much higher risk of injury due to accident and a greater propensity to self-harm. Alongside these, fentanyl addiction specifically is associated with a number of serious risks to physical and mental health including:
- cardiac arrest
- severe confusion
- respiratory distress
- altered sense of consciousness
- seizures
- weak immune system that makes you susceptible to illness
- gastrointestinal problems, such as bowel obstruction
- risk of overdose and death
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Effects of Fentanyl Addiction
Fentanyl addiction can have a catastrophic impact upon an addict’s life, most obviously in the form of the risk of potentially fatal overdose, but no less significantly in numerous other extremely detrimental ways. An addiction to fentanyl can lead to a huge variety of serious physical and mental health issues. Many of those, such as the risk of contracting diseases such as HIV/AIDS and hepatitis C, can be fatal.
Addiction can be devastating to relationships including marriages and is a factor in many family break-ups. It can also permanently compromise professional and academic prospects, including resulting in unemployment. It can cause permanent reputational damage, can lead to a criminal record and can result in an overall long-term diminution of life prospects, optimism for the future, and self-worth. Fentanyl addiction specifically can require a very substantial financial outlay, potentially leading to high levels of debt and even destitution. Opioid addiction is a factor in a high proportion of cases of homelessness.
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Short-term and long-term effects of fentanyl
In the short term – i.e., as consequences of only one or a few instances of fentanyl consumption – the greatest risks associated with fentanyl are death or permanent impairment through overdose. Another devastating risk is death a result of an accident caused by intoxication. We may also contract blood-borne diseases such as HIV/AIDS through intravenous fentanyl use. Those risks do not disappear over the long term.
As fentanyl consumption becomes more frequent, they are joined by many more dangers including the growing likelihood of addiction and dependence and an increased risk of permanent physical health issues. These include neurological damage (due to frequent hypoxia resulting from respiratory depression) and damage to the cardiovascular, digestive and respiratory systems, and the liver. Users are also exposed to mental health issues including depression, anxiety, impaired cognitive functioning, loss of memory, and anhedonia.
Co-Occurring Disorders with Fentanyl Addiction
Substance use disorders often occur alongside other mental health issues, and fentanyl addiction is no different. The relationship between addiction and mental health issues is a profound and complex one: mental health disorders can be both a cause of addiction (as individuals self-medicate or seek escapism through substance abuse, and/or are unable to control their drug consumption) and a consequence of it (due to both the direct effects of substances of abuse upon the brain, and the secondary effects of addiction).
When a substance use disorder co-occurs with a mental health disorder, the problem is described as dual diagnosis. In cases of dual diagnosis, addiction treatment is usually significantly more complex than would be the case when treating addiction alone, as both disorders need to be treated simultaneously. Specialist care is typically required.
Polydrug Use Disorders
Many drug users suffering from an addiction to fentanyl may also abuse other substances and become addicted to those simultaneously. In the case of polydrug disorders, addiction treatment is often more complicated, partly because of the different effects caused by different substances and the way these affect the user psychologically, and the way that potentially dangerous interactions between substances of abuse and certain medications can affect and impede any pharmaceutical treatment which might otherwise be provided.
Fentanyl users suffering from polydrug use disorder most commonly abuse other opioids. This happens because their effects are similar and they can help to stave off withdrawal symptoms. In fact, treatment in these cases is typically similar as it is addressing the same underlying opioid dependence. However, fentanyl users frequently also abuse a broad range of other drugs, especially including alcohol, cocaine (crack cocaine in particular) and amphetamines, as well as nicotine. Addiction to these substances does typically render treating a simultaneous fentanyl addiction significantly more challenging.
Fentanyl Overdose Explained
Overdose occurs when an individual takes too much of a given substance for their system to be able to handle effectively and safely. Fentanyl overdose in particular is extremely dangerous because it can cause various life-threatening symptoms, and comparatively commonplace because of the very small quantities of fentanyl required to constitute an excessive dosage. A dangerous factor is fentanyl’s presence in other substances, possibly unbeknownst to the user.
A fentanyl overdose, as with other opioid overdoses, is typically indicated by the presence of the “opioid overdose triad”: respiratory depression (decreased levels of breathing, or no breathing at all), decreased consciousness or unconsciousness, and pinpoint pupils. Other prominent symptoms include muscle spasms and seizures. If you observe any individual displaying these symptoms whom you know to have taken fentanyl, call the emergency services immediately.
Respiratory depression is the leading danger associated with fentanyl overdose. It can lead to hypoxia (a lack of oxygen to the brain), which can be fatal in only a few minutes, and can cause life-changing impairment even in individuals who survive.
Signs and Symptoms of Dependence and Withdrawal
Fentanyl dependence may be earliest identified by the manifestation of strong cravings for more fentanyl, but is most typically diagnosed through the identification of withdrawal symptoms upon cessation of use. Similarly to other opioids, withdrawal from fentanyl dependence is notoriously unpleasant, distressing and painful. Unlike some substances such as alcohol and benzodiazepines, fentanyl withdrawal is not usually considered directly life-threatening. However, it can be so unpleasant that withdrawing fentanyl users can be driven to self-harm and even suicide. It also poses a risk of overdose in individuals who relapse after a period of withdrawal and who take fentanyl in quantities to which they were previously accustomed, but which their systems can now no longer handle effectively.
Early fentanyl withdrawal symptoms
Depending on the severity and the duration of the addiction, fentanyl withdrawal can begin to manifest from a few hours after the last dose, but typically begins between 12 and 24 hours afterwards. Early symptoms include cravings, anxiety, sweating, drowsiness and fatigue, insomnia, muscle pain, clammy skin and flulike symptoms.
Protracted fentanyl withdrawal symptoms
Some fentanyl users will go on to develop post-acute (or protracted) withdrawal syndrome (PAWS), with symptoms which may last months or even years. These symptoms are typically psychological in nature – with cravings, depression and anxiety especially prominent – but could feasibly include any of the symptoms associated with withdrawal syndrome.
Fentanyl detox process
Fentanyl Addiction Treatment Strategies
One silver lining to the current proliferation of opioid abuse is the growth in the number of high-quality treatment centres across the UK treating fentanyl addiction.
Inpatient and outpatient treatment
Residential rehabilitation (rehab) facilities commonly provide both inpatient and outpatient treatment. Inpatient stays typically last between one and three months and consist of an initial detoxification phase followed by therapy. Included are also other elements of a holistic addiction treatment programme such as bespoke dietary and fitness plans, all provided in a secure, relaxed and confidential setting conducive to healing and recovery.
Outpatient treatment may be appropriate for addicts who do not feel they can take the necessary time out from personal and professional responsibilities to undergo inpatient treatment. However, it can be challenging as it does not remove the addict from their daily environment of substance abuse and addiction.
Medication used during treatment and recovery
Various medicines may be provided prior to and during treatment for fentanyl addiction. Safer and legal substitute opioids such as methadone may be prescribed to wean addicts off fentanyl over time, while drugs such as buprenorphine can be used to reduce cravings and prevent the manifestation of withdrawal symptoms. Naltrexone, meanwhile, blocks the effects of opioids, disincentivising their consumption.
During withdrawal, substances such as benzodiazepines may be prescribed to alleviate some of the most challenging withdrawal symptoms, while over the longer-term antidepressants and anxiolytics may be provided to deal with persistent depression and anxiety.
Therapy for Fentanyl Addiction
Therapy is the foundation of all addiction treatment. It both reveals and tackles the psychological root causes of addiction and substance abuse. Therapy enables the addict to identify and remediate problematic behaviours, and provides them with a range of defence mechanisms against cravings and relapse. Therapy is given in a broad range of methodologies and models, and in both group and one-to-one settings.
Some of the most common forms of therapy provided in addiction treatment include:
- individual counselling
- group therapy
- dialectical behaviour therapy (DBT)
- cognitive behavioural therapy (CBT)
- motivational interviewing (MI)
- family therapy
- acceptance and commitment therapy
- psychodynamic therapy
- hypnotherapy
- contingency management
Fentanyl Addiction Facts and Statistics
- One gram of pure fentanyl can make up over 7,000 doses for sale on the street.
- In 2015, 1,600 kg of fentanyl were used in healthcare around the world.
- Fentanyl was a factor in the deaths of musicians Prince, Tom Petty, Lil Peep and Mac Miller.
- The wholesale cost of fentanyl in the developing world ranges between $0.08 and $0.81 per 100 micrograms.
- In the USA – currently experiencing an opioid academic – fentanyl kills over 20,000 people each year.
Ready to get Help for your Addiction?
If you have a fentanyl addiction, your life is in danger: you are abusing one of the strongest and deadliest drugs on the market. If you wish to overcome your addiction, however, help is out there in the form of high-quality treatment facilities across the country.
Get help today
The sooner you can reach out for help, the sooner you can start receiving it – so get in touch with your GP and/or an addiction specialist today to enquire about treatment options which may be appropriate for you.
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