Podcast 760: Why Fentanyl is the Worst

Contributor: Don Stader, MD

Educational Pearls:

• Fentanyl's common administration route through pills has lowered the psychological barrier of using opioid compared to injecting and smoking heroin
• Fentanyl is showing up in all illicit drugs with documented cases even in marijuana
• Testing for fentanyl is difficult and requires a send out test because UA does not show up not common in ED but can better inform our care
• Fentanyl doesn't show up on UA drug screen and requires a send out test, thus we should ask patients if they're using fentanyl specifically 
• Send any patient using an illicit drug home with Narcan to protect them from potential opioid overdoses
• Start patients on buprenorphine for opioid withdrawal in the ED
• Fentanyl is very lipophilic, thus patients require longer washout times (sometimes over 24 hours) before buprenorphine induction to avoid precipitated withdrawal

References:

Adams, K.K., Machnicz, M. & Sobieraj, D.M. Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: a systematic review. Addict Sci Clin Pract 16, 36 (2021). https://doi.org/10.1186/s13722-021-00244-8

Moustaqim-Barrette, A., Dhillon, D., Ng, J. et al. Take-home naloxone programs for suspected opioid overdose in community settings: a scoping umbrella review. BMC Public Health 21, 597 (2021). https://doi.org/10.1186/s12889-021-10497-2

*Image from NIDA

Summarized by Mason Tuttle