1. Fentanyl and California's
Physician Diversion
Program
10/12/12 1

2. 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
10/12/12 2

3. 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
10/12/12 3

4. 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
10/12/12 4

5. 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)
10/12/12 5

6. 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
10/12/12 6

7. 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
10/12/12 7

8. 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
10/12/12 8

9. Common Side Effects
 ACh Effects
 Confusion
 Orthostatic Hypotension – light
headedness or fainting spells
 Nervousness or restlessness
 Mood swings, irritability
10/12/12 9

10. Drug interactions with
Fentanyl Injection
 MAOI’s
 Fluoxetine
 Herbal Products, including St.
John’s Wart
 Anti-convulsants
 Alcohol
 Barbituates
 Antihistamines
10/12/12 10

11. 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
10/12/12 11

12. 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
10/12/12 12

13. 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
10/12/12 13

14. 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
10/12/12 14

15. 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
10/12/12 15

16. 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
10/12/12 16

17. 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!
10/12/12 17