Fentanyl is a laboratory-made (synthetic) opioid drug. It belongs to a class of drugs called narcotic (opiate) analgesics. Call our helpline for help in dealing with fentanyl addiction for you or a loved one.

Substance Overview: Fentanyl

Legality

Legal under prescription only

Cost

c. $40 per patch on street

Annual deaths

31,000 from synthetic opioids

Side effects

Drowsiness, stomach pain, heartburn, weight loss, vision changes

Also known as

China Girl, friend, dance fever, apache, china white, jackpot

What is Fentanyl?

Like morphine, fentanyl is used to treat patients with severe pain. Fentanyl is a synthetic opioid, meaning it does not contain opium but works on the same receptors in the brain as opioids. However, fentanyl is 80-100 times more powerful than morphine. The difference between the amount of fentanyl it takes to get high and the amount that can kill you is equivalent to a few grains of salt. 1

Because it is cheaper to manufacture and provides a more powerful high than heroin, fentanyl has become a common substitute for heroin or other opioid painkillers. Even drugs sold as heroin often contain fentanyl. Because fentanyl is so much more powerful than heroin and other opioids, it is much more likely to lead to a fatal overdose.

The DEA has classified fentanyl as a Schedule II prescription drug. This means that while fentanyl is known to have medical use for controlling pain, it also has a very high risk for abuse and addiction. 2

Because of its powerful opioid analgesic properties, fentanyl is often diverted for abuse. People abuse fentanyl because it produces a short, intense high, temporary feelings of euphoria, pain relief, and relaxation. Fentanyl is available illegally on the street under various names, such as China Girl, Friend, Dance Fever, Apache, China White, Jackpot, Goodfellas, Tango & Cash, and Murder 8.

How is Fentanyl Made?

Most addictive painkilling drugs are sourced from opium derived from the poppy plant, the same substance also used to create heroin. Fentanyl is synthetically made, meaning it does not contain opium. Instead, it is chemically formulated to mimic the effects of heroin and other opioids in the brain.

Fentanyl is available in the United States by prescription under various brand names, such as Duragesic, Actiq, Abstral, Lazanda, Fentora, Onsolis and Sublimaze. 3 Fentanyl comes in various forms, including lozenge, skin patch, nasal spray, film or pouch that can be dissolved or absorbed in the mouth. 4

Because there are such strict regulations on the prescribing of fentanyl, the majority of fentanyl sold on the street is not made by pharmaceutical companies. Instead, illegal labs in Mexico and China produce the majority of the fentanyl being sold in the US. Unlike other drugs, fentanyl is easy to disguise and ship, making it easier to import.

Understanding Fentanyl Addiction

Fentanyl is a habit-forming drug. It can be more addictive than other opioids because of its high potency. Even a person who takes fentanyl by prescription from a doctor can develop a dependence on it. When someone misuses fentanyl (uses more than prescribed) or abuses fentanyl (uses it to get high), it can lead to fentanyl addiction.

One of the first steps in addiction is the development of tolerance. When a person uses a drug like fentanyl, heroin, or other opioids regularly, the drug loses some of its effectiveness. As a person develops a tolerance, they often take higher doses to get the same effects. When they do, they become much more likely to develop a physical addiction.

When a person becomes physically addicted to fentanyl (or similar drugs), they will experience painful symptoms of withdrawal when the drug is no longer in their system. Withdrawals can start even hours after the last dose and are so uncomfortable and unpleasant that many users will dose again just to avoid them. 5

When someone is addicted to fentanyl, they continue abusing it despite health problems, breakdown in relationships, and problems at work or school. Continued use despite these consequences progresses the disease of addiction, and symptoms become more severe.

Why is Fentanyl Prescribed?

Normally, fentanyl is only prescribed to people with severe or terminal illnesses, and usually only when other painkillers have been ineffective. It was originally created to help patients with cancer manage their pain. Because fentanyl is so powerful, it is normally only prescribed to people who have already developed a high tolerance to other opioid painkillers.

Fentanyl is also used as a sedative in intubated patients and as pre-medication for procedures with anticipated discomfort. It is also used to treat severe pain in patients with kidney failure because unlike other painkillers, fentanyl is primarily eliminated from the body by the liver.

Safe Use of Fentanyl

There are some legitimate uses of fentanyl. It can be a safe and effective medication when used in a monitored medical setting for an isolated procedure or an acute condition. However, fentanyl addiction is very likely to occur when the medication is used long-term. Patients who have been prescribed fentanyl should take the following precautions to avoid developing a fentanyl addiction: 6

  • Do not take larger doses of fentanyl than prescribed.
  • Do not take more frequent doses of fentanyl than prescribed.
  • Do not take fentanyl for a longer period than prescribed.
  • Do not switch from one fentanyl product to another without consulting your doctor.
  • Do not eat grapefruit or drink grapefruit juice while on fentanyl as this can affect fentanyl elimination.

Also, patients should inform their prescribing physician about any other medications they are taking. The use of certain medications simultaneously with fentanyl can increase the risk of developing life-threatening breathing problems, sedation, and coma.

Fentanyl should be prescribed only by physicians who have experience in treating cancer pain with opioids. Every patient who receives fentanyl must be enrolled in a special program and have the prescription filled at a pharmacy that is enrolled in the program.

Doctors should be aware that patients are at greater risk of abusing fentanyl if they have had problems with alcohol, or overused prescription medications or other drugs in the past.

The accidental use of fentanyl by a child or adult who has not been prescribed this drug can lead to death. Partially used fentanyl products may contain enough medication to be harmful. Fentanyl should always be stored and disposed of in a secure way to protect a pet, child, or other person from accidental ingestion.

How Do People Abuse Fentanyl?

Drug addicts abuse fentanyl for its heroin-like euphoric effects. 7 Most cases of fentanyl-associated harm in the United States, including drug overdose deaths, are linked to fentanyl made in clandestine laboratories and sold through illegal drug markets.

Fentanyl is often mixed with or sold as heroin, cocaine, MDMA or other drugs. It offers a cheap way for dealers to increase profits while still ensuring the user gets high. In many cases, users are unaware that the drug they are buying contains traces of fentanyl.

Fentanyl addicts sometimes use discarded fentanyl patches that still contain a significant amount of the drug. Abusers remove the gel and place it under the tongue, inject it, or smoke it to get high. Synthetic fentanyl is often sold illegally as a powder, pills, dropped on blotting paper, or put in nasal sprays or eye droppers.

Why Do People Abuse Fentanyl?

Fentanyl and other opioids travel through the bloodstream to the brain where they attach to special proteins called opioid receptors, specifically mu-opioid receptors in the case of fentanyl. Opioid receptors regulate many vital functions, including emotions like pleasure, reward, and pain. 

The activation of opioid receptors by fentanyl triggers processes in the brain that are similar to feelings of pleasure associated with activities like eating and sex. 8 These effects create strong incentives to continue using the drug.

Fentanyl exerts its effects by increasing the levels of dopamine in the brain. Dopamine is a neurotransmitter (chemical) that creates a feeling of euphoria and is largely responsible for the high users experience. Dopamine is also closely linked to addiction. The majority of addictive drugs cause the release of dopamine in the brain.

When a dopaminergic drug like fentanyl is used, the brain creates a lasting record or memory that associates fentanyl use with pleasure and positive emotions. These rewarding experiences and positive associations lead to addiction pathways forming in the brain. 9

Once formed, these pathways cause strong drug cravings and make it harder for a person to stop using a drug. Drugs like fentanyl also cause physical addictions to form to the drug, making it even harder to stop without experiencing painful physical withdrawals.

Adverse Effects of Fentanyl

Fentanyl is a potent synthetic opioid and its use can lead to addiction. The misuse or abuse of fentanyl can cause several side effects, many of which can be dangerous or even fatal. The most common adverse effects of fentanyl include:

  • Drowsiness
  • Stomach pain
  • Nausea
  • Weight loss
  • Vision changes
  • Fainting or dizziness
  • Difficulty urinating
  • Anxiety and depression
  • Sleep disturbance
  • Painful sores in the mouth (cheek area where the drug is placed)

Also, more dangerous side effects of fentanyl include changes in heartbeat, hallucinations, agitation, and seizures. Fentanyl may cause decreased libido (sexual desire), erectile dysfunction (inability to get or keep an erection), and irregular menstruation. It can also cause hives, itching, and rash.
The most dangerous risk for fentanyl users is the risk of overdose. Accidental overdoses are incredibly common in fentanyl users, and synthetic opioids are responsible for the majority of overdose deaths in the US. The following signs and symptoms can indicate an overdose and warrant immediate medical attention:

  • Extreme drowsiness
  • Shallow, slow breathing
  • Difficulty breathing or swallowing
  • Dizziness, fainting, confusion
  • Loss of pallor (i.e. looking pale or blue lips or fingers)
  • Loss of consciousness
  • Unresponsiveness
  • Small “pinpoint” pupils

Because fentanyl is often combined with other drugs, the risk to users is greatly increased. The concurrent use of fentanyl and other drugs creates a complex, multi-layered clinical picture that makes it difficult for physicians to manage fentanyl addiction.

Fentanyl Addiction Statistics

The rising number of opioid overdose deaths in the United States has led to more focused attention on synthetic opioids like fentanyl. Here are some facts and figures that illustrate the scope of the fentanyl addiction problem in the US: 10 11 12

  • In the past 20 years, 750,000 people have died from a drug overdose
  • There has been a six-fold increase in opioid overdoses in the past 20 years
  • Ohio, Massachusetts and New Hampshire have the highest rates of fentanyl-related encounters with law enforcement
  • 70% of all drug overdoses in 2018 were related to an opioid
  • 2/3 opioid overdoses were caused by a synthetic opioid like fentanyl
  • From 2010 to 2015, annual opioid overdose deaths increased by 57%
  • Synthetic opioid overdose deaths (fentanyl, tramadol, Demerol) increased by 219% between 2010 and 2015.
  • Drug submissions that tested positive for illicitly manufactured fentanyl increased by 196% from 2014 to 2015.
  • The number of US forensic lab reports on fentanyl increased from 5,400 in 2014 to over 56,500 in 2017

Causes and Risk Factors for Fentanyl Addiction

There is no way to accurately predict a drug dependency like fentanyl addiction. However, certain psychological, biologic, environmental and genetic factors place some people at higher risk for addiction.13

Genetic vulnerability: Studies have shown that drug addiction can run in families. For example, a direct relationship has been observed between parental drug abuse and drug abuse in the offspring. Similarly, sons and daughters of alcoholics have a 3-4 times higher risk of developing alcoholism. The mechanism by which a family history of drug abuse confers increased genetic risk is not well understood.

Physiologic vulnerability: Metabolic variations, i.e., the ability of the body to break down and excrete fentanyl, can increase the risk of abuse and addiction. Certain enzymes, such as monoamine oxidase (MAO), are low in alcohol abusers. MAO plays an important role in the metabolism of neurotransmitters like dopamine, which is the chemical through which fentanyl exerts its effects.

Environmental and social vulnerability: Factors like access to drugs, peer pressure, and the presence of co-occurring psychiatric illnesses, can all increase the risk of fentanyl abuse. Also, familial factors, such as dealing with divorce, abuse, or stressful relationships are risk factors for substance use disorders. Social and cultural factors such as community drug use patterns also play a role.

Physical and mental health history: People with a medical history of severe pain due to a medical condition or injury are at risk of abusing analgesic medications like fentanyl to self-medicate. Having a mental health disorder or experiencing stress or trauma also increases a person’s risk for addiction, especially when these are untreated.

Signs and Symptoms of Fentanyl Abuse

When a person is abusing fentanyl or has developed an addiction to it, several physical, psychological, and behavioral changes occur. While these changes vary from person to person, some of the observable changes can include:

  • Unexplained changes in mood, levels of irritability or emotional reactivity or having more mood swings
  • Changes in a person’s routine or behavior like oversleeping, missing work, skipping meals or withdrawing from friends
  • Changes in energy levels like appearing more drowsy, nodding off, or sleeping more
  • Changes in appearance including neglecting hygiene, appearing tired or ill, or losing a lot of weight
  • Inability to pay bills or needing to borrow money
  • Being evasive, secretive or defensive about drug use or how a person is spending their time and money
  • Becoming less reliable and neglecting major responsibilities at work or home

If you are unsure if you have developed an addiction, the best course of action is to make an appointment with a licensed medical, mental health, or addiction treatment specialist. These professionals can determine whether or not you have an addictive disorder. The symptoms used to diagnose addictions include two or more of the following: 14

  • Using more often or in higher doses than intended
  • Spending a lot of time thinking about, obtaining, using and/or recovering from using the drug
  • Frequent strong drug cravings or urges to use
  • Using in situations where it is dangerous or risky (i.e. at work or while driving)
  • Experiencing conflict, tension or strain in important relationships because of drug use
  • Neglecting responsibilities, roles and routines because of drug use
  • Developing a tolerance (drug becomes less effective)
  • Experiencing adverse physical or mental health effects related to drug use
  • Experiencing physical or psychological discomfort or pain when cutting back, stopping or missing a dose (withdrawal symptoms)
  • Multiple unsuccessful efforts to stop using or cut back
  • Giving up important or previously enjoyed activities to use the drug

Fentanyl Addiction in Pregnant Women

Various studies have shown that 20-30% of women fill at least one opioid prescription during pregnancy. Opioid use can have many adverse effects on the unborn baby. 15 16 Some of the potential consequences of opioid addiction during pregnancy that have been studied include low birth weight, small for gestational age, preterm birth, and birth defects.

Opiate use during pregnancy can lead to a condition known as neonatal abstinence syndrome (NAS) in the newborn baby. This condition describes when a baby has developed an addiction to the drug the mother has been using. Babies with NAS go through withdrawals which can include irritability, excessive crying, poor sleep, increased muscle tone, skin excoriations, loose stools, tremors, sneezing, nasal stuffiness, and hyperthermia. 17

Withdrawal Symptoms in Fentanyl Addicts

People with a fentanyl addiction can have severe withdrawal symptoms when they stop using the drug. The symptoms can begin within a few hours of the last time fentanyl is taken. Fentanyl withdrawal symptoms include:

  • Muscle and bone pain
  • Nausea and vomiting
  • Diarrhea and loose stools
  • Insomnia and restless leg syndrome
  • Hot and cold flashes
  • Sweating
  • Severe drug cravings
  • Anxiety
  • Depression
  • Irritability

The uncomfortable nature of withdrawal symptoms for people addicted to fentanyl and other opioids creates a major barrier for those who want to stop using. Often, fentanyl addicts have developed such a high tolerance to the drug that they may not even experience any pleasurable effects and are only continuing to use to “feel normal” and avoid withdrawal symptoms.

Luckily, medications and treatments now exist to help people addicted to opioids quit without experiencing painful withdrawal symptoms. Medications like methadone and suboxone are some of the most widely used medications to help people stop using drugs like fentanyl. Other medications that can help a person reduce withdrawal symptoms and cravings include naltrexone and clonidine.

Fentanyl Overdose

Fentanyl overdose occurs when a person takes enough of the drug to cause serious life-threatening symptoms. It is a medical emergency. A fentanyl overdose can lead to slowed or stopped breathing, which decreases the amount of oxygen reaching the brain (a condition known as hypoxia). Hypoxia as a result of fentanyl overdose can lead to permanent brain damage, coma, and death.

In case of overdose, the fentanyl should be removed from the person’s mouth and emergency services (911) contacted. People who have been prescribed fentanyl or those who are known to be abusing the drug may be told to always keep the rescue medication naloxone on hand. Naloxone can reverse the life-threatening effects of fentanyl and other opiates. Friends and family members should be made aware of this and taught how to use naloxone since the person who is overdosing will not be able to use the rescue medication themselves. It may take more than one dose of naloxone to reverse fentanyl overdose symptoms.

Preventing Fentanyl Fatalities

Public health and safety experts recommend several ways to effectively respond to and prevent overdose deaths related to illicitly manufactured fentanyl. One of the best ways to achieve this is by expanding the use of naloxone, a safe and effective antidote to all opioid overdoses, including fentanyl.

Healthcare providers should make naloxone available to EMS first responders and law enforcement personnel as well as people with fentanyl addiction who are at high risk of overdose. Family and friends of people who are using fentanyl by prescription should also have access to naloxone in case of accidental overdose.

People should be educated that fentanyl overdose may require multiple doses of naloxone per event because fentanyl is much more potent than other opioids. Any person who uses heroin and/or fentanyl or knows people that do, should carry a naloxone kit and know how to use it.

Other ways to control fentanyl abuse and addiction include the rapid detection of fentanyl outbreaks with surveillance systems. The authorities should identify demographics and geographic concentrations of fentanyl use to better inform the public health officials in that area. This can lead to better surveillance and fentanyl overdose prevention efforts. 18

Fentanyl Addiction Treatment

Like other opioid addictions (heroin, prescription pain pills), fentanyl addiction is treated with medications and behavioral therapies. Medications like suboxone (buprenorphine) and methadone, which bind to the same opioid receptors in the brain as fentanyl, are most commonly used to reduce cravings and withdrawal symptoms. 19

Medications are only believed to be effective when combined with therapy. A variety of behavioral therapies, such as cognitive-behavioral therapy, contingency management, and motivational interviewing are used to treat the psychological aspects of addiction, teach new methods of coping, and prevent future drug relapse.

Last updated: October 1, 2020

About the author

Hailey Shafir
Hailey Shafir, M.Ed., LCMHCS, LCAS, CCS

Hailey Shafir is a licensed addiction specialist and mental health counselor. She graduated from North Carolina State University with a master of education in clinical mental health counseling in 2012, and has developed deep expertise in the areas of mental health, behavioral addictions and substance abuse. She is passionate about using this knowledge to raise awareness, provide clear and accurate information, and to improve the quality of treatment for these disorders.

Hailey is an LCMHCS (license number: S9539) under the North Carolina Board of Mental Health Counselors, and an LCAS (ID: LCAS-21333) and CSS (ID: CCS-20721) under the North Carolina Addictions Specialist Professional Practice Board.

References

  1. Ramos-Matos CF, Bistas KG, Lopez-Ojeda W. Fentanyl. [Updated 2020 Apr 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459275/
  2. Drug Scheduling. Drug Enforcement Administration. Available online. Accessed August 21, 2020. https://www.dea.gov/drug-scheduling
  3. Fentanyl. National Institute on Drug Abuse. Available online. Accessed August 21, 2020. https://www.drugabuse.gov/drug-topics/fentanyl
  4. Fentanyl. U.S. National Library of Medicine. Available online. Accessed August 21, 2020. https://medlineplus.gov/druginfo/meds/a605043.html
  5. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1(1):13-20. doi:10.1151/spp021113 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
  6. Kharasch ED, Whittington D, Hoffer C. Influence of hepatic and intestinal cytochrome P4503A activity on the acute disposition and effects of oral transmucosal fentanyl citrate. Anesthesiology. 2004;101(3):729-737. doi:10.1097/00000542-200409000-00022 https://pubmed.ncbi.nlm.nih.gov/15329598/
  7. Opioid Overdose. Fentanyl. Centers for Disease Control and Prevention. Available online. Accessed August 21, 2020. https://www.cdc.gov/drugoverdose/opioids/fentanyl.html
  8. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1(1):13-20. doi:10.1151/spp021113 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
  9. Volkow, N. D, Wang, G. J., Fowler, J. S., & Tomasi, D. (2012). Addiction Circuitry in the Human Brain. Annual Review of Pharmacology and Toxicology, 52(1), 321-336.
  10. Opioid Overdose. Fentanyl. Centers for Disease Control and Prevention. Available online. Accessed August 21, 2020. https://www.cdc.gov/drugoverdose/opioids/fentanyl.html
  11. Prescription Behavior Surveillance System. Issue Brief. Available online. Accessed August 21, 2020. https://www.cdc.gov/drugoverdose/pdf/pbss/PBSS-Report-072017.pdf
  12. DEA & DOJ Drug Fact Sheet. Retrieved September 10, 2020 from https://www.dea.gov/sites/default/files/2020-06/Fentanyl-2020_0.pdf
  13. Webster LR. Risk Factors for Opioid-Use Disorder and Overdose. Anesth Analg. 2017;125(5):1741-1748. doi:10.1213/ANE.0000000000002496 https://pubmed.ncbi.nlm.nih.gov/29049118/
  14. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
  15. Yazdy MM, Desai RJ, Brogly SB. Prescription Opioids in Pregnancy and Birth Outcomes: A Review of the Literature. J Pediatr Genet. 2015;4(2):56-70. doi:10.1055/s-0035-1556740
  16. Broussard CS, Rasmussen SA, Reefhuis J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204(4):. doi:10.1016/j.ajog.2010.12.039 https://pubmed.ncbi.nlm.nih.gov/21345403/
  17. Stover MW, Davis JM. Opioids in pregnancy and neonatal abstinence syndrome. Semin Perinatol. 2015;39(7):561-565. doi:10.1053/j.semperi.2015.08.013 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628571/
  18. Prescription Behavior Surveillance System. Issue Brief. Available online. Accessed August 21, 2020. https://www.cdc.gov/drugoverdose/pdf/pbss/PBSS-Report-072017.pdf
  19. Weiss RD, Rao V. The Prescription Opioid Addiction Treatment Study: What have we learned. Drug Alcohol Depend. 2017;173 Suppl 1(Suppl 1):S48-S54. doi:10.1016/j.drugalcdep.2016.12.001