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Fentanyl

Fentanyl is an opioid analgesic, first synthesized in Belgium in the late 1950s, with an analgesic potency of about 80 times that of morphine. It was introduced into medical practice in the 1960s as an intravenous anesthetic under the trade name of Sublimaze. Fentanyl has an LD50 of 3.1 milligrams per kilogram in rats. The LD50 in humans is not known. Fentanyl is a Schedule II drug. more...

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Analogues

The pharmaceutical industry has developed several analogues of fentanyl:

  • Alfentanil (Alfenta), an ultra-short acting (5–10 minutes) analgesic,
  • Sufentanil (Sufenta), a potent analgesic (15 to 10 times more potent than fentanyl) for use in heart surgery.
  • Remifentanil, currently the shortest acting opioid, has the benefit of rapid offset, even after prolonged infusions.
  • Carfentanil (Wildnil) is an analogue of fentanyl with an analgesic potency 10,000 times that of morphine and is used in veterinary practice to immobilize certain large animals.

Therapeutic use

Today, fentanyls are extensively used for anesthesia and analgesia. Duragesic, by Janssen Pharmaceutica, is a fentanyl transdermal patch used in chronic pain management. In the past few years, this compound has gone generic and is available for lower cost. Duragesic is manufactured in five patch sizes. They are 12.5 mcg/hr, 25 µg/h, 50 µg/h, 75 µg/h, and 100 µg/h. Dosage is based on the size of the patch, since the transdermal absorption rate is generally constant at skin temperature.

Actiq, by Cephalon, is a recently-developed solid formulation of fentanyl citrate on a stick that dissolves slowly in the mouth for transmucosal absorption. Actiq is intended for opiate-tolerant individuals and is effective in treating breakthrough cancer pain. It is also useful for breakthrough pain for those suffering bone injuries, severe back pain, neuropathy, arthritis, and some other examples of chronic nonmalignant pain. The unit is a berry-flavored lozenge on a stick which is swabbed on the mucosal surfaces inside the mouth - under and on the tongue and gums—to release the fentanyl quickly into the system. It is most effective when the lozenge is consumed in 15 minutes. The drug is practically ineffective if swallowed, absorption from the alimentary tract being negligible. Actiq is available in 6 dosages, from 200 µg to 1,600 µg (There are no 1,000 µg or 1,400 µg doses)in 200 µg increments.

Fentanyl is frequently given intrathecally as part of spinal anesthesia or epidurally for epidural anesthesia and analgesia.

Illicit use

Illicit use of pharmaceutical fentanyls first appeared in the mid-1970s in the medical community and continues to be a problem in the United States. United States authorities classify fentanyl as a narcotic. To date, over 12 different analogues of fentanyl have been produced clandestinely and identified in the U.S. drug traffic. The biological effects of the fentanyls are indistinguishable from those of heroin, with the exception that the fentanyls may be hundreds of times more potent. Also, fentanyl has a shorter duration than heroin does. Fentanyls are most commonly used by intravenous administration, but like heroin, they may also be smoked or snorted. One common street name for fentanyl is china white. This is not always accurate, as it was originally given to alpha-methyl-fentanyl, although in recent years this terminology has faded somewhat. AMF has longer metabolism than fentanyl because the methyl group retards metabolism.

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Do patients prefer transdermal fentanyl or sustained-release oral morphine for treatment of chronic non-cancer pain?
From Journal of Family Practice, 10/1/01 by Amanda J. Heidemann

Allan L, Hays H, Jensen N, et al. Randomized crossover trial of transdermal fentanyl and sustained release oral morphine for treating chronic non-cancer pain. BMJ 2001; 322:1154.

* BACKGROUND Recent public and legislative focus on pain management practices has led to scrutiny of guidelines for the role of opioids in pain therapy. A survey by the World Health Organization in 1998 revealed that 22% of patients seeing primary care physicians reported persistent pain. Better, more acceptable methods of pain control are needed. This study compared 2 methods of administering potent opioids to patients to determine which method produced better results

* POPULATION STUDIED A panel of 256 adult patients (age range = 26-82 years) was drawn from specialist pain clinics in Europe, Canada, and South Africa. Many of these patients (70%) had previous therapy with opioids for chronic non-cancer pain. Patients (N=24) were excluded who had previous exposure to morphine and had rated it "bad" or "very bad." Sixty patients withdrew, leaving 196 patients to complete the study. Duration of pain ranged from less than 1 year to 50 years, with a mean duration of 9 years.

* STUDY DESIGN AND VALIDITY The researchers of this randomized multicenter open label crossover trial enrolled patients with nociceptive and/or neuropathic pain. As the method of administration of the 2 drugs is different, patients were aware of the change in therapy. Patients received doses of opioid equivalent to their pre-study requirements. The study compared fentanyl patch (25, 50, 75, or 100 [micro]g/hr) and sustained-release oral morphine (10-, 30-, 60-, 100-, or 200-mg tablets). One group received 4 weeks of fentanyl followed by 4 weeks of morphine; the other received the drugs in reverse sequence. Medication dosage was fixed and not titrated to achieve pain control. This is perhaps the most important study limitation, because empiric dosage conversions are based on opioid equivalents determined in populations and often do not predict individual response.

The patients were assessed by evaluating pain control and quality of life at the completion of each period of therapy. At either the time of study completion or withdrawal, subjects stated whether they "preferred" or "very much preferred" one of the therapies. They elaborated on this preference by evaluating pain relief, adverse events, and convenience.

The patients invited to participate were chronically opioid-requiring and may have encountered study medications before the study; however, only preexisting experiences with morphine (194 participants) were mentioned. Although the study duration was likely long enough to assess the desired outcomes, the lack of blinding in pain studies is a limitations.

* OUTCOMES MEASURED Overall, patient preference was assessed, as well as feelings regarding convenience, adverse events, and pain relief. Pain control was evaluated through intensity of pain (scale of 0-100) and need for a rescue drug. Quality of life was evaluated using the Medical Outcomes Study 36-item short form quality-of-life instrument. Safety-related outcomes included the rate of nausea, constipation (using a bowel function questionnaire), and hypoventilation.

* RESULTS A preference for one product over another could not be assessed in 39 patients (15%). The 212 remaining patients (65%) either "preferred" or "very much preferred" transdermal fentanyl, compared with 28% preferring sustained-release oral morphine (P [is less than] .001.) Seven percent expressed no preference. Patients in the fentanyl group had lower pain intensity with a mean rating of 57.8 mm (range=33.1-82.5 mm), compared with a mean rating of 62.9 mm (range = 41.2-84.6 mm; P [is less than] .001). Pain control was rated "good" or "very good" by 35% of the patients while receiving fentanyl, but only by 23% of the patients while taking morphine (P=.002.) They also reported higher quality-of-life scores during fentanyl therapy than during sustained-release oral morphine use, with scores in the categories of bodily pain, vitality, social functioning, and mental health being significantly different. The incidence and proportion of adverse events was similar; fentanyl, however, produced higher rotes of nausea (26% vs 18%) but less constipation (16% vs 22%).

RECOMMENDATIONS FOR CLINICAL PRACTICE

Patients with chronic pain not due to cancer who were treated with both oral morphine and transdermal fentanyl were more likely to report less pain, greater satisfaction with treatment, and a better quality of like while treated with the transdermal product. However, nausea was more common with the patches, and the cost of the patches is approximately twice that of fentanyl patches. Patients requiring continuous opioid therapy who experience difficulty taking oral morphine should receive a trial of transdermal fentanyl.

COPYRIGHT 2001 Appleton & Lange
COPYRIGHT 2001 Gale Group

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