In Spain, fentanyl has been used as a large-scale analgesic for half a century in cancer patients and to control some types of pain, says Kiko Toja, a hospital pharmacy specialist. Toja recognizes the risk of addiction, but insists that it is very difficult for the United States scenario to be seen here due to greater health control. Although you have to be alert.
What is fentanyl?
It is an opioid drug. A derivative of opiates such as morphine or heroin. It is mainly used as a large-scale analgesic when we do not have another one available. In our country it is used in pills, in transdermal patches that are applied to the skin and release the drug for prolonged periods or in forms of rapid mucosal absorption. There is also intranasal administration. And we have intravenous formulations that are mainly used to produce analgesics in the operating room in the induction of anesthesia before operations.
Has it been used for a long time?
Yeah. It has been on the market for around 50 years. It was synthesized by looking for something that could fill this gap that we were missing to treat those uncontrollable pains that could not be treated with anything else. And it is a drug with a generally safe profile that is used daily and commonly in the hospital and outpatient setting.
For what type of pain is it most recommended?
In Spain, rapid forms of administration are restricted to treat oncological and disruptive pain that no longer responds to other analgesics. Sometimes it can be used in other types of nerve pain or post-surgical pain for interventions that cause pain to patients, but these are more isolated cases. In cancer patients, sometimes the pain is very great and we are not able to alleviate their pain with other types of drugs. Fentanyl has to be signed for an inspection visa. Everything is very rigorously controlled. A therapeutic step is used and, when the other medications do not work, these drugs are discontinued.
Could there be a risk of addiction?
The addictive potential of fentanyl is a reality. The risk exists. But in our country or even in Europe it is a risk that we have greatly reduced given the control we have. We do not commonly treat other types of pain with these types of drugs as happens in the United States. There, while 90% of people who undergo surgery are discharged with an opioid prescribed to treat pain, in the rest of the world it is only 1%. It is a problem that the United States has from the system itself. When you treat so many people with opioids, with fentanyl or with oxycodone, which is another drug widely used in the United States, the potential for addictive risk is very high.
What is done if addiction is found?
In that case, there are addictive behavior units that have protocols and are activated when a potential addiction can be detected either by the prescriber or by primary care. An attempt is made to replace this drug with others with less addictive potential. And at the same time it is treated with other drugs that reduce the effects. In the case of people addicted to fentanyl, we administer naloxone, which is the antidote to fentanyl, at the same time with these drugs so that the effect of fentanyl is not so great and therefore this addiction decreases over time.
Is there a way to dispense fentanyl that causes more risk of addiction?
The most addictive forms are the quick-acting oral forms, which are taken in pill form or absorbed through the mucosa (sticks that are sucked). And those that generate the most tolerance because patients end up needing higher doses. They are drugs that reach the central nervous system very quickly. On the other hand, transdermal patches do not produce such rapid effects.
Can the control be done by a family doctor?
Yes, in principle he is qualified. But it is true that I believe that in our country in general there is a lack of training when it comes to prescribing these drugs. Because sometimes they are used for indications for which we should not try, at least at first.
Could you give an example?
Mainly for pain that is not oncological, post-surgical pain. But they are pains that may not be controlled with other analgesics. There are very isolated cases in which it is prescribed when another type of analgesia would be enough to control the pain. We would talk about post-surgical patients, nervous pain due to underlying diseases. But many times when you have a patient in front of you who is suffering from pain, the easiest thing to do is to remove it immediately. And in that we sin because we are human. The consumption of opioids or fentanyl has also increased over time not because we are doing worse, but because the population is living longer and, therefore, chronic diseases that cause pain are more prevalent. And that is why the consumption of fentanyl increases.
What warning signs can warn us of a state of addiction?
Yes. You have to know how to distinguish that when an opiate is prescribed over time it can become tolerant and require more doses to alleviate the same pain that you had before. In that case we must know how to interpret if, on the one hand, a tolerance has been generated and therefore requires more doses. If it occurs within a short period of time, we should perhaps be thinking about the drug being potentially addictive. The health system tries to start reducing the doses of the drug when acute pain is treated for a period of time. It is not usually withdrawn suddenly so as not to cause withdrawal syndrome, because although a person is not considered physically addicted to the drug, the body is accustomed to receiving it and therefore withdrawing it abruptly can cause symptoms such as sweating or tachycardia.
Is it progressively withdrawn and is any medication given to counteract the effects of this addiction?
Another analgesic that is not as powerful as fentanyl is usually added to the therapy, for example tramadol, which is also a derivative of opiates. And as you remove one, you progressively increase the other. It is true that in patients with cancer pain it is very difficult to withdraw these drugs while their underlying process does not subside or in the case of patients in whom their underlying process will not subside if it is always used long term.
Excluding these more extreme cases, is it relatively common that after a person is given fentanyl, they end up having withdrawal symptoms?
We cannot do without fentanyl. The right to not feel pain is a fundamental right. The population should not be scared by what is happening. It has a very safe profile and is not always going to generate addictions, especially with the control we have here. We do not have the entry of drugs adulterated with fentanyl, which is the main problem that the United States has, nor do we have the lack of control that they have in the dispensation of opiates. Now they are trying to fix it, but there they took oxycodone like someone taking ibuprofen here in Spain. Although we must talk about the dangers so that the same thing does not happen to us because obviously if we get confused the same thing could happen.
