Fentanyl
Fentanyl, also spelled fentanil, is a powerful opioid used as a pain medication and, together with other medications, for anesthesia. It is also used as a recreational drug, sometimes mixed with heroin, cocaine, or methamphetamine. Its potentially deadly overdose effects can be neutralized by naloxone. Fentanyl is commonly used to create counterfeit drugs marketed as OxyContin, Xanax, Adderall, and other pills. It has a rapid onset and its effects generally last under two hours. Medically, it is used by injection, nasal spray, or skin patch, or absorbed through the cheek as a lozenge or tablet. Common side effects of  fentanyl include nausea, vomiting, constipation, itching, sedation, confusion, and injuries related to poor coordination. Serious side effects may include respiratory depression, hallucinations, serotonin syndrome, low blood pressure, or development of an opioid use disorder. Fentanyl works primarily by activating μ-opioid receptors. It is around 100 times stronger than morphine and about 50 times stronger than heroin. Some fentanyl analogues such as carfentanil are up to 10,000 times stronger than morphine. Fentanyl was first made by Paul Janssen in 1960 and approved for medical use in the United States in 1968. In 2015, were used in healthcare globally. , fentanyl was  the most widely used synthetic opioid in medicine; in 2019, it was the 278th most commonly prescribed medication in the United States, with more than 1million prescriptions. It is on the World Health Organization's List of Essential Medicines. Starting around 2013, fentanyl disrupted the North American market for illegal drugs, capitalizing on pre-existing demand for opiates such as heroin and prescription pharmaceuticals. In 2016, fentanyl and fentanyl analogues were the most common cause of overdose deaths in the United States at more than 20,000, about half of all opioid-related deaths. Most of these overdose deaths were due  to illegally-made fentanyl. There is concern that the growing demand may prove highly attractive to organized crime and aspiring criminals, especially those operating in areas around the Golden Triangle in Southeast Asia, e.g. Shan State in Myanmar, where production of synthetic drugs has expanded dramatically since the late 2000s. Compared to heroin, it is more potent, has higher profit margins, and, because it is compact, has simpler logistics. It can be cut into, or even replace entirely, the supply of heroin and other opiates. Medical uses. Anesthesia. Intravenous fentanyl is often used for anesthesia and to treat pain. To  induce anesthesia, it is given with a sedative-hypnotic, like propofol or thiopental, and a muscle relaxant. To maintain anesthesia, inhaled anesthetics and additional fentanyl may be used. These are often given in 15–30 minute intervals throughout procedures such as endoscopy and surgeries and in emergency rooms. For pain relief after surgery, use can decrease the amount of inhalational anesthetic needed for emergence from anesthesia. Balancing this medication and titrating the drug based on expected stimuli and the person's responses can result in stable blood pressure and heart rate throughout a procedure and a faster emergence from anesthesia with  minimal pain. Regional anesthesia. Fentanyl is the most commonly used intrathecal opioid because its lipophilic profile allows a quick onset of action (5–10 min.) and intermediate duration of action (60–120 min.). Spinal administration of hyperbaric bupivacaine with fentanyl may be the optimal combination. The almost immediate onset of fentanyl reduces visceral discomfort and even nausea during the procedure. Obstetrics. Fentanyl is sometimes given intrathecally as part of spinal anesthesia or epidurally for epidural anaesthesia and analgesia. Because of fentanyl's high lipid solubility, its effects are more localized than morphine, and some clinicians prefer to use morphine to get a  wider spread of analgesia. However, it is widely used in obstetrical anesthesia because of its short time to action peak (about 5 min.), the rapid termination of its effect after a single dose, and the occurrence of relative cardiovascular stability. In obstetrics, the dose must be closely regulated in order to prevent large amounts of transfer from mother to fetus. At high doses, the drug may act on the fetus to cause postnatal respiratory distress. For this reason, shorter acting agents such as alfentanyl or remifentanil may be more suitable in the context of inducing general anaesthesia. Pain management. The  bioavailability of intranasal fentanyl is about 70–90%, but with some imprecision due to clotted nostrils, pharyngeal swallow, and incorrect administration. For both emergency and palliative use, intranasal fentanyl is available in doses of 50, 100, and 200 µg. In emergency medicine, safe administration of intranasal fentanyl with a low rate of side effects and a promising pain-reducing effect was demonstrated in a prospective observational study in about 900 out-of-hospital patients. In children, intranasal fentanyl is useful for the treatment of moderate and severe pain and is well tolerated. Chronic pain. It is also used in the management  of chronic pain including cancer pain. Often, transdermal patches are used. The patches work by slowly releasing fentanyl through the skin into the bloodstream over 48 to 72 hours, allowing for long-lasting pain management. Dosage is based on the size of the patch, since, in general, the transdermal absorption rate is constant at a constant skin temperature. Each patch should be changed every 72 hours. Rate of absorption is dependent on a number of factors. Body temperature, skin type, amount of body fat, and placement of the patch can have major effects. The different delivery systems used by different  makers will also affect individual rates of absorption. Under normal circumstances, the patch will reach its full effect within 12 to 24 hours; thus, fentanyl patches are often prescribed with a fast-acting opioid (such as morphine or oxycodone) to handle breakthrough pain. It is unclear if fentanyl gives long-term pain relief to people with neuropathic pain. Breakthrough pain. Sublingual fentanyl dissolves quickly and is absorbed through the sublingual mucosa to provide rapid analgesia. Fentanyl is a highly lipophilic compound, which is well absorbed sublingually and generally well tolerated. Such forms are particularly useful for breakthrough cancer pain episodes , which are often rapid in onset, short in duration, and severe in intensity. Palliative care. In palliative care, transdermal fentanyl patches have a definitive, but limited role for: When using the transdermal patch, patients must be careful to minimize or avoid external heat sources (direct sunlight, heating pads, etc.), which can trigger the release of too much medication and cause potentially deadly complications. Combat medicine. USAF Pararescue combat medics in Afghanistan used fentanyl lozenges in the form of lollipops on combat casualties from IED blasts and other trauma. The stick is taped to a finger and the lozenge put in  the cheek of the person. When enough fentanyl has been absorbed, the (sedated) person generally lets the lollipop fall from the mouth, indicating sufficient analgesia and somewhat reducing the likelihood of overdose and associated risks. Dyspnea. Fentanyl can also be used for patients in which morphine is not tolerated, or whose breathlessness is refractory to morphine. Fentanyl is especially useful for concomitant treatment in palliative care settings where pain and shortness of breath are severe and need to be treated with high strength opioids. Other. Some routes of administration such as nasal sprays and inhalers generally result in a faster  onset of high blood levels, which can provide more immediate analgesia but also more severe side effects, especially in overdose. The much higher cost of some of these appliances may not be justified by marginal benefit compared with buccal or oral options. Intranasal fentanyl appears to be equally effective as IV morphine and superior to intramuscular morphine for the management of acute hospital pain. A fentanyl patient-controlled transdermal system (PCTS) is under development, which aims to allow patients to control administration of fentanyl through the skin to treat postoperative pain. Adverse effects. Fentanyl's most common side effects, which  affect more than 10% of people, include nausea, vomiting, constipation, dry mouth, somnolence, confusion, and asthenia (weakness). Less frequently, in 3-10% of people, fentanyl can cause abdominal pain, headache, fatigue, anorexia and weight loss, dizziness, nervousness, anxiety, depression, flu-like symptoms, dyspepsia (indigestion), shortness of breath, hypoventilation, apnoea, and urinary retention. Fentanyl use has also been associated with aphasia. Despite being a more potent analgesic, fentanyl tends to induce less nausea, as well as less histamine-mediated itching, than morphine. The duration of action of fentanyl has sometimes been underestimated, leading to harm in a medical context. In 2006 , the U.S. Food and Drug Administration (FDA) began investigating several respiratory deaths, but doctors in the United Kingdom were not warned of the risks with fentanyl until September 2008. The FDA reported in April 2012 that twelve young children had died and twelve more made seriously ill from separate accidental exposures to fentanyl skin patches. Fentanyl has a therapeutic index of 270. Respiratory depression. The most dangerous adverse effect of fentanyl is respiratory depression, that is, decreased sensitivity to carbon dioxide leading to reduced rate of breathing, which can cause anoxic brain injury or death. This risk is decreased when  the airway is secured with an endotracheal tube (as during anesthesia). This risk is higher in specific groups, like those with obstructive sleep apnea. Other factors that increase the risk of respiratory depression are: Sustained release fentanyl preparations, such as patches, may also produce unexpected delayed respiratory depression. The precise reason for sudden respiratory depression is unclear, but there are several hypotheses: Another related complication of Fentanyl overdoses includes the so-called wooden chest syndrome which quickly induces complete respiratory failure by paralyzing the thoracic muscles, explained in more detail in the Muscle rigidity section below. Muscle rigidity. If high  boluses of fentanyl are administered quickly, muscle rigidity of the vocal cords can make bag-mask ventilation very difficult. The exact mechanism of this effect is unknown, but it can be prevented and treated using neuromuscular blockers. Wooden chest syndrome. A prominent idiosyncratic adverse effect of fentanyl also includes a sudden onset of rigidity of the abdominal muscles and the diaphragm which induces respiratory failure; this is seen with high doses and is known as wooden chest syndrome. The syndrome is believed to be the main cause of death as a result of fentanyl overdoses. Wooden chest syndrome is reversed  by naloxone and is believed to be caused by a release of noradrenaline which activates α-adrenergic receptors and also possibly via an activation of cholinergic receptors. Wooden chest syndrome is unique to the most powerful opioids—which today comprise fentanyl and its analogs—while other less-powerful opioids like heroin produce mild rigidity of the respiratory muscles to a much lesser degree. Overdose. Fentanyl poses an exceptionally high overdose risk in humans, due to having an extremely unpredictable fatal dosage when mixed with other drugs. In its pure form, overdoses are only moderately unpredictable, with most overdose deaths occurring  at serum concentrations of between 150 and 250 ng/mL. But when mixed with other drugs, overdoses can occur with as little as 0.1 ng/mL. Over 85% of overdoses involved at least one other drug, and there was no clear correlation showing at which level the mixtures were fatal. The dosages of fatal mixtures varied by over three magnitudes in some cases. This extremely unpredictable volatility with other drugs makes it especially difficult to avoid fatalities. Naloxone can completely or partially reverse an opioid overdose. In July 2014, the Medicines and Healthcare products Regulatory Agency (MHRA) of the UK  issued a warning about the potential for life-threatening harm from accidental exposure to transdermal fentanyl patches, particularly in children, and advised that they should be folded, with the adhesive side in, before being discarded. The patches should be kept away from children, who are most at risk from fentanyl overdose. In the US, fentanyl and caused over 29,000 deaths in 2017, a large increase over the previous four years. Most of the recent increases in fentanyl deaths do not involve prescription fentanyl but are related to illicitly-made fentanyl that is being mixed with or sold as heroin. Death  from fentanyl overdose continues to be a public health issue of national concern in Canada since September 2015. In 2016, deaths from fentanyl overdoses in the province of British Columbia averaged two persons per day. In 2017 the death rate rose over 100% with 368 overdose-related deaths in British Columbia between January and April 2017. Fentanyl has started to make its way into heroin as well as illicitly-manufactured opioids and benzodiazepines. Fentanyl contamination in cocaine, methamphetamine, ketamine, MDMA, and other drugs is common. A kilogram of heroin laced with fentanyl may sell for more than US$100,000, but  the fentanyl itself may be produced far more cheaply, for about US$6,000 per kilogram. Fentanyl was often produced in China and exported illegally to the U.S. The UK illicit drug market is no longer reliant on China, as domestic fentanyl production is replacing imports. As of 2018, fentanyl was the most commonly listed opioid in overdose drug deaths, surpassing heroin. From 2013 until 2016, overdose deaths involving fentanyl were increasing by 113% per year. In 2021, the Public Health Agency of Canada noted that 87% of accidental apparent opioid toxicity deaths involved fentanyl. The intravenous dose causing 50% of  opioid-naive experimental subjects to die () is "3 mg/kg in rats, 1 mg/kg in cats, 14 mg/kg in dogs, and 0.03 mg/kg in monkeys." The LD in mice has been given as 6.9 mg/kg by intravenous administration, 17.5 mg/kg intraperitoneally, 27.8 mg/kg by oral administration. The LD in humans is unknown, but a lethal dose for the average person is estimated to be 2 mg. Contrary to what has been reported in some media outlets, topical (via the skin) and inhalative exposure to fentanyl is extremely unlikely to cause intoxication or overdose (except  in cases of prolonged exposure with very large quantities of fentanyl), and first responders such as paramedics and police officers are at minimal risk of fentanyl poisoning through accidental contact with intact skin. Prevention Many public health initiatives have been started to prevent the misuse and overdose of fentanyl. One of the initiatives that have been started to prevent fentanyl overdose is from the CDC  . The effort has been categorized as a Health Alert Network Advisory signaled to a multitude of professionals within the health field. The advisory explains four key action points. Those points include the (a) local  need to expand the distribution and use of naloxone and overdose prevention education, (b) expand awareness, access, and availability of treatment for substance use disorders, (c) intervene early with individuals at highest risk for overdose, and (d) improve detection of overdose outbreaks to facilitate more effective response. Another initiative is a social media campaign from the United States Drug Enforcement Administration (DEA) called "One Pill Can Kill". This social media campaigns goal was to spread awareness of the prevalence of counterfeit pills that are being sold in America that is leading to the large overdose epidemic in America. This campaign  also shows the difference between counterfeit pills and real pills. This campaign also offers resources for help with drug addiction and rehabilitation. In New Jersey another initiative was started called "The Partnership for a Drug-Free New Jersey" ( PDFNJ) was created to inform the people of New Jersey the harm of taking drugs and where to dispose of expired or unneeded prescription medications. Some of this programs campaigns also focus on children and teaching children how to deal with the influence and peer pressures of these drugs. Rehab Options and resources Opioid rehabilitation is common within America and there are  many different facilities and resources that a person can reach out to if they need assistance or if someone they know needs assistance with an opioid addiction. One of these resources that a person could reach out to is the American Addiction Centers’ website. This website has many different resources like a helpline where a person could discuss treatment options for either themselves or someone else. This website also shows the locations of the facilities that the American Addiction Centers have throughout the country. They have facilities in Texas, California, Nevada, Florida, Rhode Island, Massachusetts, Mississippi, and New Jersey. This  website also offers different treatment and rehab options including drug detoxification, inpatient treatment, outpatient treatment, etc. This website also shows the types of medications that could be used to help with the rehabilitation process as well.   Another resource that could be used is the Hazelden Betty Ford Foundation which is the nations largest nonprofit treatment providers. They have llocations in California, Minnesota, Oregon, Illinois, New York, Florida, Massachusetts, Colorado and Washington. This foundation provides recources on many different types of addiction including opioids. They also provide information about signs of addiction, and how to have an intervention for the party  that is affected by the addiction. Pharmacology. Classification. Fentanyl is a synthetic opioid in the phenylpiperidine family, which includes sufentanil, alfentanil, remifentanil, and carfentanil. Structure-activity. The structures of opioids share many similarities. Whereas opioids like codeine, hydrocodone, oxycodone, and hydromorphone are synthesized by simple modifications of morphine, fentanyl and its relatives are synthesized by modifications of meperidine. Meperidine is a fully synthetic opioid, and other members of the phenylpiperidine family like alfentanil and sufentanil are complex versions of this structure. Like other opioids, fentanyl is a weak base that is highly lipid-soluble, protein-bound, and protonated at physiological  pH. All of these factors allow it to rapidly cross cellular membranes, contributing to its quick effect in the body and the central nervous system. Mechanism of action. Fentanyl, like other opioids, acts on opioid receptors. These receptors are G-protein-coupled receptors, which contain seven transmembrane portions, intracellular loops, extracellular loops, intracellular C-terminus, and extracellular N-terminus. The extracellular N-terminus is important in differentiating different types of binding substrates. When fentanyl binds, downstream signaling leads to the inhibitory effects, such as decreased cAMP production, decreased calcium ion influx, and increased potassium efflux. This inhibits the ascending pathways  in the central nervous system to increase pain threshold by changing the perception of pain; this is mediated by decreasing propagation of nociceptive signals, resulting in analgesic effects. As a μ-receptor agonist, fentanyl binds 50 to 100 times more potently than morphine. It can also bind to the delta and kappa opioid receptors but with a lower affinity. It has high lipid solubility, allowing it to more easily penetrate the central nervous system. It attenuates "second pain" with primary effects on slow-conducting, unmyelintated C-fibers and is less effective on neuropathic pain and "first pain" signals through small , myelinated A-fibers. Fentanyl can produce the following clinical effects strongly, through μ-receptor agonism. It produces sedation and spinal analgesia through Κ-receptor agonism. Detection in biological fluids. Fentanyl may be measured in blood or urine to monitor for abuse, confirm a diagnosis of poisoning, or assist in a medicolegal death investigation. Commercially available immunoassays are often used as initial screening tests, but chromatographic techniques are generally used for confirmation and quantitation. The Marquis Color test may also be used to detect the presence of fentanyl. Using formaldehyde and sulfuric acid, the solution will turn purple when introduced to  opium drugs. Blood or plasma fentanyl concentrations are expected to be in a range of 0.3–3.0 μg/L in persons using the medication therapeutically, 1–10 μg/L in intoxicated people, and 3–300 μg/L in victims of acute overdosage. Paper spray-mass spectrometry (PS-MS) may be useful for initial testing of samples. History. Fentanyl was first synthesized in Belgium by Paul Janssen under the label of his relatively newly formed Janssen Pharmaceutica in 1959. It was developed by screening chemicals similar to pethidine (meperidine) for opioid activity. The widespread use of fentanyl triggered the production of fentanyl citrate (the  salt formed by combining fentanyl and citric acid in a 1:1 stoichiometric ratio). Fentanyl citrate entered medical use as a general anaesthetic in 1968, manufactured by McNeil Laboratories under the trade name Sublimaze. In the mid-1990s, Janssen Pharmaceutica developed and introduced into clinical trials the Duragesic patch, which is a formulation of an inert alcohol gel infused with select fentanyl doses, which are worn to provide constant administration of the opioid over a period of 48 to 72 hours. After a set of successful clinical trials, Duragesic fentanyl patches were introduced into medical practice. Following the patch, a flavored lollipop  of fentanyl citrate mixed with inert fillers was introduced in 1998 under the brand name of Actiq, becoming the first quick-acting formation of fentanyl for use with chronic breakthrough pain. In 2009, the US Food and Drug Administration approved Onsolis (fentanyl buccal soluble film), a fentanyl drug in a new dosage form for cancer pain management in opioid-tolerant subjects. It uses a medication delivery technology called BEMA (BioErodible MucoAdhesive), a small dissolvable polymer film containing various fentanyl doses applied to the inner lining of the cheek. Fentanyl has a US DEA ACSCN of 9801 and a 2013 annual  aggregate manufacturing quota of 2,108.75 kg, unchanged from the prior year. Society and culture. Legal status. In the UK, fentanyl is classified as a controlled Class A drug under the Misuse of Drugs Act 1971. In the Netherlands, fentanyl is a List I substance of the Opium Law. In the U.S., fentanyl is a Schedule II controlled substance per the Controlled Substance Act. Distributors of Abstral are required to implement an FDA-approved risk evaluation and mitigation strategy (REMS) program. In order to curb misuse, many health insurers have begun to require precertification and/or quantity limits for Actiq prescriptions. In  Canada, fentanyl is considered a schedule I drug as listed in Canada's Controlled Drugs and Substances Act. Estonia is known to have been home to the world's longest documented fentanyl epidemic, especially following the Taliban ban on opium poppy cultivation in Afghanistan. A 2018 report by "The Guardian" indicated that many major drug suppliers on the dark web have voluntarily banned the trafficking of fentanyl. Recreational use. Illicit use of pharmaceutical fentanyl and its analogues first appeared in the mid-1970s in the medical community and continues in the present. More than 12 different analogues of fentanyl, all unapproved  and clandestinely produced, have been identified in the U.S. drug traffic. In February 2018, the U.S. Drug Enforcement Administration indicated that illicit fentanyl analogs have no medically valid use, and thus applied a "Schedule I" classification to them. Fentanyl analogues may be hundreds of times more potent than heroin. Fentanyl is used orally, smoked, snorted, or injected. Fentanyl is sometimes sold as heroin or oxycodone, sometimes leading to overdoses. Many fentanyl overdoses are initially classified as heroin overdoses. Recreational use is not particularly widespread in the EU except for Tallinn, Estonia, where it has largely replaced heroin. Estonia has the  highest rate of 3-methylfentanyl overdose deaths in the EU, due to its high rate of recreational use. Fentanyl is sometimes sold on the black market in the form of transdermal fentanyl patches such as Duragesic, diverted from legitimate medical supplies. The gel from inside the patches is sometimes ingested or injected. Another form of fentanyl that has appeared on the streets is the Actiq lollipop formulation. The pharmacy retail price ranges from US$15 to US$50 per unit based on the strength of the lozenge, with the black market cost ranging from US$5 to US$25, depending  on the dose. The attorneys general of Connecticut and Pennsylvania have launched investigations into its diversion from the legitimate pharmaceutical market, including Cephalon's "sales and promotional practices for Provigil, Actiq and Gabitril." Non-medical use of fentanyl by individuals without opioid tolerance can be very dangerous and has resulted in numerous deaths. Even those with opiate tolerances are at high risk for overdoses. Like all opioids, the effects of fentanyl can be reversed with naloxone, or other opiate antagonists. Naloxone is increasingly available to the public. Long acting or sustained release opioids may require repeat dosage. Illicitly synthesized fentanyl  powder has also appeared on the United States market. Because of the extremely high strength of pure fentanyl powder, it is very difficult to dilute appropriately, and often the resulting mixture may be far too strong and, therefore, very dangerous. Some heroin dealers mix fentanyl powder with heroin to increase potency or compensate for low-quality heroin. In 2006, illegally manufactured, non-pharmaceutical fentanyl often mixed with cocaine or heroin caused an outbreak of overdose deaths in the United States and Canada, heavily concentrated in the cities of Dayton, Ohio; Chicago; Detroit; and Philadelphia. Enforcement. Several large quantities of illicitly  produced fentanyl have been seized by U.S. law enforcement agencies. In November 2016, the DEA uncovered an operation making counterfeit oxycodone and Xanax from a home in Cottonwood Heights, Utah. They found about 70,000 pills in the appearance of oxycodone and more than 25,000 in the appearance of Xanax. The DEA reported that millions of pills could have been distributed from this location over the course of time. The accused owned a tablet press and ordered fentanyl in powder form from China. A seizure of a record amount of fentanyl occurred on February 2, 2019, by U.S. Customs and Border  Protection in Nogales, Arizona. The of fentanyl, which was estimated to be worth US$3.5M, was concealed in a compartment under a false floor of a truck transporting cucumbers. The "China White" form of fentanyl refers to any of a number of clandestinely produced analogues, especially α-methylfentanyl (AMF). One US Department of Justice publication lists "China White" as a synonym for a number of fentanyl analogues, including 3-methylfentanyl and α-methylfentanyl, which today are classified as Schedule I drugs in the United States. Part of the motivation for AMF is that, despite the extra difficulty from a  synthetic standpoint, the resultant drug is more resistant to metabolic degradation. This results in a drug with an increased duration. In June 2013, the United States Centers for Disease Control and Prevention (CDC) issued a health advisory to emergency departments alerting to 14 overdose deaths among intravenous drug users in Rhode Island associated with acetylfentanyl, a synthetic opioid analog of fentanyl that has never been licensed for medical use. In a separate study conducted by the CDC, 82% of fentanyl overdose deaths involved illegally manufactured fentanyl, while only 4% were suspected to originate from a prescription. Beginning in 2015, Canada  has seen a number of fentanyl overdoses. Authorities suspected that the drug was being imported from Asia to the western coast by organized crime groups in powder form and being pressed into pseudo-OxyContin tablets. Traces of the drug have also been found in other recreational drugs including cocaine, MDMA, and heroin. The drug has been implicated in multiple deaths from the homeless to young professionals, including multiple teens and young parents. Because of the rising deaths across the country, especially in British Columbia where 1,716 deaths were reported in 2020 and 1,782 from January to October 2021, Health Canada  is putting a rush on a review of the prescription-only status of naloxone in an effort to combat overdoses of the drug. In 2018, Global News reported allegations that diplomatic tensions between Canada and China hindered cooperation to seize imports, with Beijing being accused of inaction. Fentanyl has been discovered for sale in illicit markets in Australia in 2017 and in New Zealand in 2018. In response, New Zealand experts called for wider availability of naloxone. In 2020, the Myanmar military and police confiscated 990 gallons of methyl fentanyl, as well as precursors for the illicit synthesis of the  drug. According to the United Nations Office on Drugs and Crime, the Shan State of Myanmar has been identified as a major source for fentanyl derivatives. In 2021, the agency reported a further drop in opium poppy cultivation in Burma, as the region’s synthetic drug market continues to expand and diversify. Recalls. In February 2004, a leading fentanyl supplier, Janssen Pharmaceutica Products recalled one lot, and later, additional lots of fentanyl (brand name: Duragesic) patches because of seal breaches that might have allowed the medication to leak from the patch. A series of class II recalls was initiated in  March 2004, and in February 2008 ALZA Corporation recalled their 25 µg/h Duragesic patches due to a concern that small cuts in the gel reservoir could result in accidental exposure of patients or health care providers to the fentanyl gel. Brand names. Brand names include Sublimaze, Actiq, Durogesic, Duragesic, Fentora, Matrifen, Haldid, Onsolis, Instanyl, Abstral, Lazanda and others. Cost. In the United States, the 800 mcg tablet was 6.75 times more expensive as of 2020 than the lozenge. Storage and disposal. The fentanyl patch is one of a few medications that may be especially harmful, and in some cases  fatal, with just one dose, if misused by a child. Unused fentanyl patches should be kept in a secure location out of children's sight and reach, such as a locked cabinet. In British Columbia, Canada, where there are environmental concerns about toilet flushing or garbage disposal, pharmacists recommend that unused patches be sealed in a child-proof container which is then returned to a pharmacy. In the United States where patches cannot always be returned through a medication take-back program, flushing is recommended for fentanyl patches because it is the fastest and surest way to remove them  from the home to prevent them from ingestion by children, pets or others not intended to use them. State use. In August 2018, Nebraska became the first American state to use fentanyl to execute a prisoner. Carey Dean Moore, at the time one of the longest-serving death row inmates in the United States, was executed at the Nebraska State Penitentiary. Moore received a lethal injection, administered as an intravenous series of four drugs that included fentanyl citrate, to inhibit breathing and render the subject unconscious. The other drugs included diazepam as a tranquilizer, cisatracurium besylate as a muscle relaxant , and potassium chloride to stop the heart. The use of fentanyl in execution caused concern among death penalty experts because it was part of a previously untested drug cocktail. The execution was also protested by anti-death penalty advocates at the prison during the execution and later at the Nebraska capitol building. Russian Spetsnaz security forces used a fentanyl analogue, or derivative, to incapacitate people rapidly in the Moscow theater hostage crisis in 2002. The siege was ended, but some hostages may have died from the gas after their health was severely taxed during the days long siege. The Russian  Health Minister later stated that the gas was based on fentanyl, but the exact chemical agent has not been identified. Veterinary use. Fentanyl in injectable formulation is commonly used for analgesia and as a component of balanced sedation and general anesthesia in small animal patients. Its potency and short duration of action make it particularly useful in critically ill patients. In addition, it tends to cause less vomiting and regurgitation than other pure-opiate (codeine, morphine) and synthetic pure-opioid agonists (oxycodone, hydromorphone) when given as a continuous post-operative infusion. As with other pure-opioid agonists, fentanyl can be  associated with dysphoria in both dogs and cats. Transdermal fentanyl has also been used for many years in dogs and cats for post-operative analgesia. This is usually done with off-label fentanyl patches manufactured for humans with chronic pain. In 2012, a highly concentrated (50 mg/mL) transdermal solution, trade name "Recuvyra", has become commercially available for dogs only. It is FDA approved to provide 4 days of analgesia after a single application before surgery. It is not approved for multiple doses or other species. The drug is also approved in Europe.