New data from an enhanced surveillance program for opioid overdose deaths has prompted the Centers for Disease Control and Prevention (CDC) to alert clinicians to a 'dramatic rise' in deaths from synthetic opioids including fentanyl and its analogs.
Seven of the 10 US states involved in the CDC-funded surveillance program reported that more than half of all opioid overdose deaths tested positive for fentanyl or fentanyl analogs (e.g., 3-methylfentanyl, carfentanil) in the period July 2016 to June 2017. One factor behind the increasing availability of fentanyl and its analogs has been via the widespread adulteration of cocaine.
The CDC has advised healthcare providers that fentanyl and its analogs are potent opioids; patients being treated for an overdose may require the administration of multiple doses of naloxone. Other commentators cited by the CDC have advised that some patients exposed to long-acting or very potent opioids (e.g., fentanyl, 3-methylfentanyl, carfentanil) may need naloxone by continuous infusion.  See Management: approach See Management: treatment algorithm
The patient's history from bystanders/friends/family can assist diagnosis.
Signs include central nervous system and respiratory depression, miosis, and apnea.
Initial treatment consists of ensuring adequate ventilation followed by administration of the opioid antagonist naloxone.
Monitor patients for resedation and repeat antidote dose if necessary.
An opioid is any synthetic or natural agent that stimulates opioid receptors and produces opium-like effects. Opiates are opioids naturally derived from the opium poppy, Papaver somniferum , and include morphine and codeine. Opioids are used in the treatment of pain but are often sold illicitly and abused for their euphoric effects. An overdose occurs when larger quantities than physically tolerated are taken, resulting in central nervous system and respiratory depression, miosis, and apnea, which can be fatal if not treated rapidly.
Consultant Physician and Clinical Toxicologist
National Poisons Information Service (Newcastle)
RT declares that he has no competing interests.
Dr Ruben Thanacoody would like to gratefully acknowledge Dr Dean Olsen, a previous contributor to this monograph. DO declares that he has no competing interests.
Northwest Cancer Specialists
Rose Quarter Cancer Center
WW declares that he has no competing interests.
Joseph Epstein Centre for Emergency Medicine Research
Western Health Sunshine Hospital
AMK has received grant funding for research into intranasal delivery of naloxone in heroin overdose.
Johns Hopkins University
AS declares that he has no competing interests.
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