Characteristics of opioid‐maintained clients smoking fentanyl patches: The importance of confirmatory drug analysis illustrated by a case series and mini‐review

Abstract

The increase in opioid prescribing in many European countries over the last decade has raised concerns about associated diversion, overdose, and mortality. Fentanyl is one of these synthetic opioids that is typically prescribed as a transdermal patch for pain that requires continuous pain relief and has been the focus of investigation due to reports of overdose and death. We report a case series of 14 drug addiction treatment entrants, who entered treatment in a service located in the region of Southern Denmark from August 2015 to December 2015 for smoking fentanyl patches. Clients presented with difficulties breathing and pains in the lungs. The clients had a history of past opioid use, including heroin. Relapses resulted in treatment disengagement. Immunoassays for fentanyl were used in the service. In some cases, false negative results occurred. Clients' urine samples were subsequently analysed in a collaborating laboratory. Seven clients tested positive for fentanyl. One client was positive for both fentanyl and heroin. Analyses were also positive for other opioids and metabolites in 6 clients, predominantly codeine and oxycodone. Results from confirmatory analysis contributed to clearer insights into clients' drug histories, which facilitated personalised care plans consisting of opioid agonist therapy informed by confirmed drug use. In Denmark, prescription levels of fentanyl are high, which has been accompanied by observations of diversion and smoking in a smaller population. In addition to revision of inappropriate prescribing to reduce diversion, we recommend increased reliance upon confirmatory drug analysis in the addiction treatment sector in Denmark.

Systematic review on intentional non-medical fentanyl use among people who use drugs

“…The search resulted in 4437 studies after de-duplication, 132 were selected for full-text review, and 41 were included ( Figure 1 ). Of the 41 studies included, 23 were in the United States ( 13 – 35 ); seven in Canada; ( 36 – 42 ) two in Sweden; ( 43 , 44 ) one each in Australia, ( 45 ) Germany, ( 46 ) Denmark, ( 47 ) France, ( 48 ) Estonia, ( 49 ) the UK, ( 50 ) and Turkey. ( 51 ) Two studies were done online with no note of specific country involvement ( Table 1 ) ( 52 , 53 ).…”

Rapid and Highly Sensitive Detection of Fentanyl and its Analogs by a Novel Chemiluminescence Immunoassay

“…It should be noted that as low as 3 ng/mL fentanyl in blood may cause loss of protective airway reflexes and deaths [34,35], and while most of the fentanyl is rapidly cleared from the body in an hour, only 10% is excreted in the urine [36,37]. From this perspective, many drug users or front-line workers may have been exposed to pharmacologically effective or even dangerous levels of fentanyl with urine samples screened negative by the current screening immunoassays [38]. It is reasonable to postulate that overdose caused by more potent fentanyl analogs like carfentanil may lead to even higher rate of false negatives by these assays, and there is an emerging need to adopt more sensitive immunoassays for synthetic opioids [39].…”

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

“…The perceived ineffectiveness of CWE procedures did not always prevent consumption of the extracted codeine amongst the participants using CCM and heroin. However, amongst the participants who only used CCM, there were comments suggesting that all the steps required for CWE such as from collecting codeine boxes from multiple pharmacies to crushing them up, dissolving them in water and completing the filtration presented as a barrier to using CWE 4,5 . Considering that pharmacies are allowed to only dispense one box per day per customer, scouring enough boxes would require visits to more than one pharmacy on the same day [9].…”

“…In comparison, the price of 1 bag of heroin is estimated to £10 in the UK (although the weight may be reduced or unknown to sellers and buyers) [34]). 5 To produce 1300 mg free-base codeine from CWE (maximum achievable dose without exceeding the upper limit of ibuprofen), participants would require three boxes of OTC CCM (or around 96 tablets containing 12.8 mg codeine and 200 mg ibuprofen).…”

“…Reports of harm following intravenous injection of crushed oxycodone and morphine tablets highlight the risk of pulmonary granulomatosis from deposition of talc and other fillers used in the manufacturing of medicines [3,4]. Smoking of fentanyl patches (either whole patches or smaller pieces) have been reported amongst people seeking addiction treatment, setting new demands for services to negotiate severe withdrawal symptoms amongst their clients [5]. Studies have also shown that tablets are crushed and snorted [6], including tampering-resistant formulations which were released onto the market to make it harder to crush, snort and inject psychoactive medicines [7].…”