Facts About Fentanyl

Given the recent increase in overdose deaths attributed to synthetic opioid analogs, it is critical to update the medical community on the current epidemiology and exposure patterns as well as pharmacology of fentanyl, analogs, and xylazine and how it impacts approach to treatment for opioid use disorder and patients chronically using fentanyl or other substances. In recent years the landscape of available opioids for use in the United States has shifted with increasing fentanyl and fentanyl analog availability. In some regions, ‘heroin’ is almost completely fentanyl or analog and contains either no or very little heroin. This presentation will describe those epidemiological changes, especially in light of the recent COVID-19 pandemic. We will describe the recent changes in exposure to fentanyl and analogues, xylazine, fentanyl presence in stimulants (cocaine and methamphetamine) and in pressed pills such as oxycodone and alprazolam. The availability of drug testing and the clinical management of patients with opioid use disorder has also undergone changes due to the COVID- 19 pandemic. We will describe the updated strategies for drug testing in new settings such as telemedicine- based care and use of harm reduction testing strategies including fentanyl test strips as well as touch upon the utility of testing for fentanyl in relation to clinical management. Furthermore, we will identify which analogs the tests identify and whether chronicity of abuse affects the length of time that fentanyl is present in the urine. We will discuss the distribution, elimination half-life, and lipophilicity of specific fentanyl analogues. Strategies to manage patients with opioid use disorder who predominantly use fentanyl will be described. Some believe patients must be in more severe withdrawal before starting a buprenorphine induction to avoid precipitated withdrawal and we will use the available medical literature to examine that belief. We will explore the existing literature and discuss our clinical experience as it relates to buprenorphine induced precipitated withdrawal in patients that use fentanyl or fentanyl analogs as compared to other opioids. Additionally, there are concerns that substantial amounts of naloxone are necessary to reverse an overdose due to fentanyl or analogs and we will discuss the use of naloxone, including dosing strategies, in patients following an overdose. This interactive didactic will use didactic content, case-based narrative and panel discussion by expert addiction medicine and medical toxicology faculty to improve the participants knowledge of fentanyl, fentanyl analogue, and xylazine epidemiology, to understand how fentanyl predominant opioid use disorder affects the occurrence of overdose and precipitated withdrawal, current laboratory diagnostics available and strategies for application of drug testing to clinical management given limited resources.