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Fentanyl and California's Physician Diversion Program

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History of Fentanyl

Illicit use of pharmaceutical fentanyl first appeared in mid 1970’s in the medical community

Biological effects indistinguishable from heroin-EXCEPT that fentanyl may be hundreds of times more potent

Most commonly used by intravenous administration, but like heroin, may be smoked or snorted

First synthesized in Belgium in late ’50’s as a synthetic narcotic

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History of Fentanyl

Approved by FDA in 1968 Introduced into clinical practice in

’60’s as an IV anesthetic (Sublimaze)

Thereafter Alfenta and Sufenta introduced

Today extensively used for anesthesia and chronic pain management

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DESCRIPTION

Only used in hospital or clinical setting

Especially prone to creating dependency early on

Used to aid induction and maintenance of general anesthesia and to supplement regional and spinal anesthesia

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DESCRIPTION

May be administered IV, IM, transdermally, epidurally, or in lozenge/lollipop form

Drug of abuse of choice by anesthesiologists, for myriad reasons, including availability, often undetectable in less sophisticated urine sample screens, and personality characteristics unique to many physicians (Vaillant, 1972)

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PHARMACOLOGY OF FENTANYL

An opioid analgesic, lipid soluble, metabolized in liver

Fentanyl interacts with the m-receptor, sites that are distributed in the brain, spinal cord, and other tissues

Exerts primary pharmacologic effects on CNS

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PHARMACOLOGY OF FENTANYL Increases toleration of pain, decreases

perception of suffering, produces alterations in mood, EUPHORIA, dysphoria and drowsiness

Stimulatory effect is result of “disinhibition” as the release of inhibitory neurotransmitters, such as Dopamine, acetylcholine, norepinephrine, and substance P are blocked

Exact process of how opioid agonists cause both inhibitory and stimulatory processes not well understood

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PHARMACOLOGY OF FENTANYL Side effects myriad, but include

respiratory depression, gastrointestinal motility, and physical dependence

Significant drug-drug interactions Metabolites and unchanged drug are

excreted in urine, which can take several days

Residual fentanyl from one dose can potentiate the effect of subsequent doses, such as serious respiratory complications

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Common Side Effects

ACh Effects Confusion Orthostatic Hypotension – light

headedness or fainting spells Nervousness or restlessness Mood swings, irritability

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Drug interactions with Fentanyl Injection

MAOI’s Fluoxetine Herbal Products, including St.

John’s Wart Anti-convulsants Alcohol Barbituates Antihistamines

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CALIFORNIA’S PHYSICIAN DIVERSION PROGRAM Known as one of best in nation for

record of rehab in peer group setting-alcohol abuse, drug abuse, mental disorders (NOT sexual misconduct)

Identification, diagnosis, treatment and recovery of chemically dependent physicians since 1980

Offers confidentiality to protect career of impaired docs, providing there’s no evidence of patient harm/Board action pending

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Anesthesiologists, Diversion and Fentanyl Anesthesiologists are 5 percent of

licensed physicians in the state of CA, yet represent 17.4 percent of the physicians in the Diversion Program

Factors contributing to high incidence of abuse in anesthesia include ready availability of drug, constant handling, a predisposing personality, stress, long hours, and family issues

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Anesthesiologists, Diversion and Fentanyl Continued Diversion program regularly monitors, random

urine tests at least twice weekly over this period, establishes when a doctor may return to work and monitors re-entry conditions, and requires participation in peer group and self-help groups for three to five years, at the discretion of a Diversion Committee,

Diversion Evaluation Committees: 5 throughout state, composed of three physicians and 2 public members (volunteer experts): assess docs for entry to program, determine when ready to graduate and deal with non-compliance

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Anesthesiologists, Diversion and Fentanyl Continued Group Facilitators: 11 throughout state- recruited

by sending notices to licensed therapists, responsible for groups ranging from 6 to 12 docs-pd directly by participants

Despite improved control of O.R. meds and increased education, the rate of substance abuse among anesthesiologists remains unchanged (2003, Duke University): often a “revolving door”

Underlines need for systemic approach rather than the medical model used by Diversion Program

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Impaired Physicians…

Do especially well at hiding addiction problems: strong denial mechanisms, sophisticated knowledge of symptoms and ways to “beat the system” re urine monitoring, med wastage, etc

Colleagues often don’t recognize the signs of chemical dependency or fear reporting suspicions: Conspiracy of Silence

Usually begin tx late in the course of their condition

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Most Common Methods for Acquisition May order more of drug than is needed

for a case Skim off the unused medication for later

use Also, since the drug can be infused

continuously during a surgical case, the abusing doc may “pocket” leftover med and unused portion saved to be used for euphoric recreation later

Most common way these substance-abusing doctors discovered is by fentanyl overdose

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TEACHING ON ADDICTION ISSUES Sorely lacking in

medical schools Resulting in under

diagnosed and inadequately treated patients with alcohol or drug problems as well as within own ranks

PHYSICIAN: HEAL THYSELF!