Fentanyl (nasal)

Nasal Fentanyl is a narcotic medication taken nasally, as a mist or spray, that acts on the central nervous system for pain management.

Overview

Fentanyl is classified as an opioid because of its ability to act on opioid receptors. The main application of all opioids is pain relief by acting on the central nervous system, hindering its ability to interpret stimuli. These medications are also used in combination with other medications for anesthesia during surgery.

Once taken, the effects of this medication set in rapidly and generally less than an hour or two depending on the dosage. Nasal Fentanyl has been approved by the US for medicinal use since 1968 and as of 2017 has become the most widely used synthetic opioid in medicine throughout the world.

This medication is typically used to help relieve sudden onset medical problems resulting in extreme pain, such as cancer. This medication should not be used for mild or short-term pain because of the extensive side effects, risk of harm, and potential for abuse.

Intranasal Fentanyl doses can be imprecise because of the variables involved such as clotted nostrils, incorrect administration, and pharyngeal swallow (the pharynx reflex to swallow initiated by touch or stimulation in the back of the mouth). The bioavailability (amount of medication that enters the bloodstream to become available for the body to use) for intranasal application is somewhere between 70-90%.

This form of fentanyl has been created with the intent of being absorbed by the mucous membrane in the nose. Attempting to absorb this medication in any other way may result in serious side effects.

Brand names for this medication include: Sublimaze, Actiq, Duragesic, Fentora, Matrifen, Haldid, Onsolis, Instanyl, Lazanda and Subsys.

Condition Treated

  • Pain

Type Of Medicine?

  • Painkiller
  • Anesthetic
  • Opioid Analgesic
  • Narcotic

Side Effects

Some side effects are likely to be present as the body adjusts to the new medication. If these effects persist, or worsen, you should consult with your medical physician:

Some steps can be taken to lessen these effects. To reduce the chance of constipation while on this medication, users should drink plenty of water, eat an adequate amount of fiber and get as much exercise as you are able to promote healthy bowel movements. You may also ask a pharmacist about pairing your medication with laxatives or stool softeners.

When rising from a sitting position, it is important to stand slowly, allowing blood pressure to change gradually in the body to prevent dizziness.

Some side effects may be the result of an unwanted reaction in the body to the fentanyl dose. If any of these side effects occur, check with your doctor immediately before deciding to continue with your dose.

 

  • Black/tarry stools
  • Blurred vision
  • Chest pain
  • Confusion
  • Convulsions
  • A cough
  • Decreased urine
  • Labored breathing
  • Dry mouth
  • Increased thirst
  • Irregular heartbeat
  • Lightheadedness
  • Lower back or side pain
  • Mood changes
  • Nausea or vomiting
  • Pale skin
  • Pounding in the ears
  • Sneezing
  • A sore throat
  • Sunken eyes
  • Swelling of the hands/feet or lower legs
  • Tightness in the chest
  • Ulcers, sores or spots in the mouth
  • Wrinkled skin

Some side effects are to be expected and managed by a physician, while others pose a more serious risk. Some of the more serious side effects may include:

  • Agitation
  • Confusion
  • Hallucinations
  • Severe stomach/abdominal pain
  • Difficulty urinating
  • Lowered heart rate
  • Loss of appetite
  • Lethargy
  • Weight loss

If any of these symptoms appear it is important to seek physician consultation right away. Do not start or stop this medication without speaking to a pharmacist or physician.

Users will need to contact emergency medical services if any of the following side effects are present. These effects may be the result of an allergic reaction.

  • Fainting
  • Seizure
  • Slow/shallow breathing
  • Diarrhea
  • Twitching
  • Swollen head/neck/face/tongue
  • Unresponsiveness
  • Hives/rashes
  • Itching

The side effects of Fentanyl are very serious, and in some cases, extreme. Physicians will weigh the benefits against the risks for each patient on a case-by-case basis and prescribe what is most beneficial. This medication is rarely prescribed for pain management, aside from patients suffering from terminal cancer.

To report side effects to the FDA, patients may call 1-800-FDA-1088, or report to www.fda.gov/medwatch

Dosage

The dose of Fentanyl will be determined by a physician and prescribed differently for all patients. It is vital to follow the doctor's directions on the label of the medication for use. The most common doses and prescribed dosage intervals for cancer patients are as follows:

  •  For new users, 100 mcg (micrograms) or 1 spray-into one nostril during an episode of breakthrough pain.
  •  Maximum dosage of 800 mcg (or 1 spray of 400 mcg into each nostril)
  •  Patients should never use more than 4 doses, at 400 mcg, per 24 hours
  •  Patients should wait at least 2 hours before treating breakthrough pain with fentanyl again
  •  If relief of the pain has not been achieved within 30 minutes of taking the fentanyl dose, a rescue medication may be suggested by the physician
  •  All doses should be recorded by patients to ensure overdose does not occur.

Any dose given to pediatric patients should be overseen by a physician and determined by a doctor.

As with all pain medications, fentanyl is best used at the first sign of pain. If a patient waits until their pain has worsened in severity, the medication may not work as quickly, or as efficiently.

Steps to taking Nasal Fentanyl

To receive the proper dosing of nasal fentanyl, users should follow these 11 steps. If you have any questions concerning these instructions, follow up with a physician or pharmacist. If your instructions received from your physician differ from these steps, follow your doctor's orders.

  •  If you have a runny nose, gently blow your nose clean of debris.
  •  Take the bottle of fentanyl from the child-resistant container. Remove the cap protecting the tip of the bottle. Place the bottle upright in your dominant hand so that the tip is between your first and second finger, with your thumb underneath.
  •  If this is a new bottle, it will need to be primed in order to administer the correct dose. The bottle may be primed by spraying 4 sprays into the pouch that came with the medication following the instructions for the medication guide in the box.
  •  Sit upright and place the nozzle of the bottle about ½ an inch into one nostril. Place your finger over the other nostril to seal it closed.
  •  Press down onto the platform of the finger grips on either side of the bottle tip. You may not feel anything when the spray is administered. When the nozzle is depressed far enough, it will sound 'a click' to let the user know the dose has been administered. If you are unsure the spray was released, you may refer to the dose counter to ensure it has counted down.
  •  Breathe in gently through your nose and mouth after the medication has been dispensed. Do not snort or sniff the medication during or after the spray has been administered.
  •  If your dose requires two sprays, repeat steps 4-6 in your other nostril.
  •  When the number in the countdown window indicates there are only 8 doses left, do not use the bottle again.  Dispose of the remaining liquid into the disposal pouch as indicated by the disposal guide.
  •  Remain seated for at least a minute after administering the fentanyl nasal spray.
  •  Replace the protective cap and place the medication into the child-resistant container. Place the medication in a discreet and locked location.

Do not blow your nose for at least 30 minutes after taking this medication. Anyone administering the medication should wash their hands thoroughly with soap and water afterward to prevent any of the mist from being absorbed through their skin.

Overdose

The CDC states fentanyl is a synthetic opioid that has proven to be 50 times more potent than heroin and 100 times more potent than morphine. The death rate of synthetic opioids has risen 72% due to accidental overdose. These overdoses have been found to be due to substance abuse or misuse, and not the prescribed doses.

Patients exceeding the doctor's recommended dosage, or using fentanyl in conjunction with other medications are at high risk for overdose. If an overdose occurs, emergency services should be contacted right away. If Narcan or Naloxone is available at time of overdose, use it.

Signs of overdose are:

Severe breathing problems
Unconsciousness
Very slow breathing (less than 8 breaths per minute)
Drowsiness so severe patient cannot respond when spoken to
Cold, clammy skin
Lowered blood pressure
Pinpoint pupils

It is important for first-time users to have a friend, family member, or caregiver check in on them until they are adjusted to their dose and familiar with the side effects they will experience. Anyone taking this medication should not be operating heavy machinery. This medication should be kept secured in a locked storage container.

Interactions

Interactions may occur with over-the-counter medications, herbal supplements, and food and drink as well as other prescription medications. It is the responsibility of the patient, pharmacist, and doctor to ensure the prescribing physician is aware of all substances currently being used by the patient to prevent interactions. Patients should not start, stop or change the dose of any medications or herbal supplements unless first discussing changes with a pharmacist or physician.

Some products that will interact with nasal fentanyl are:

  • Decongestant nasal sprays (oxymetazoline)
  • Pentazocine
  • Nalbuphine
  • Butorphanol
  • Naltrexone

Other medications may alter the body's ability to remove fentanyl, causing a build-up in the system including:

  • Azole antifungals (such as itraconazole, ketoconazole)
  • Cimetidine
  • Calcium channel blockers (diltiazem, verapamil)
  • HIV Protease inhibitors (nelfinavir, ritonavir)
  • Macrolide antibiotics (erythromycin, nefazodone)
  • Rifamycins (rifabutin)
  • Some seizure medications (carbamazepine, phenytoin)

MAO inhibitors may cause severe or fatal interactions. MAO inhibitors should be avoided up to two weeks before beginning a fentanyl therapy. Some MAO inhibitors include:

  • Isocarboxazid
  • Linezolid
  • Methylene blue
  • Moclobemide
  • Phenelzine
  • Procarbazine
  • Rasagiline
  • Safinamide
  • Selegiline
  • Tranylcypromine

Medications that cause drowsiness may increase the patient's risk for severely slowed heart rate, respiration rate, drowsiness, dizziness or unconsciousness. Some of these medications are:

  • Cough relievers (codeine, hydrocodone)
  • Alcohol
  • Marijuana
  • Drugs for sleep or anxiety (alprazolam, lorazepam, zolpidem)
  • Muscle relaxers (carisoprodol, cyclobenzaprine)
  • Antihistamines (cetirizine, diphenhydramine)

Nasal fentanyl also poses a risk of serotonin syndrome. This is caused by taking drugs that increase the levels of serotonin along with fentanyl. Some of these medications are:

  • Street drugs (ecstasy/MDMA)
  • SNRIs (duloxetine, venlafaxine)

The threat of serotonin syndrome are higher when patients are beginning, or changing the dosage of their medication.

Overall, nasal fentanyl has been found to have major interactions with 380 drugs. Moderate interactions have been found with 533 drugs, and minor interactions have been found with 12 drugs.

Below are medications that are not recommended for use with fentanyl. However, in some circumstances, a doctor may prescribe both if the advantages outweigh the risk. Ensure your doctor knows if you are on any of the following medications:

  • Acepromazine
  • Alefacept
  • Alfentanil
  • Almotriptan
  • Alprazolam
  • Amiodarone
  • Amisulpride
  • Amitriptyline
  • Amobarbital
  • Amoxapine
  • Amprenavir
  • Anileridine
  • Aprepitant
  • Aripiprazole
  • Asenapine
  • Atazanavir
  • Baclofen
  • Benperidol
  • Blinatumomab
  • Boceprevir
  • Bosentan
  • Bromazepam
  • Bromopride
  • Brompheniramine
  • Buprenorphine
  • Buspirone
  • Butabarbital
  • Butorphanol
  • Carbamazepine
  • Carbinoxamine
  • Cariprazine
  • Carisoprodol
  • Carphenazine
  • Ceritinib
  • Chloral Hydrate
  • Chlordiazepoxide
  • Chlorpheniramine
  • Chlorpromazine
  • Chlorzoxazone
  • Ciprofloxacin
  • Citalopram
  • Clarithromycin
  • Clobazam
  • Clonazepam
  • Clorazepate
  • Clozapine
  • Cobicistat
  • Cocaine
  • Codeine
  • Conivaptan
  • Cyclobenzaprine
  • Cyclosporine
  • Dantrolene
  • Darunavir
  • Delavirdine
  • Desipramine
  • Desvenlafaxine
  • Dexamethasone
  • Dexmedetomidine
  • Dextromethorphan
  • Dezocine
  • Diacetylmorphine
  • Diazepam
  • Dichloralphenazone
  • Difenoxin
  • Dihydrocodeine
  • Diltiazem
  • Diphenhydramine
  • Diphenoxylate
  • Dolasetron
  • Donepezil
  • Doxepin
  • Doxylamine
  • Dronedarone
  • Droperidol
  • Duloxetine
  • Efavirenz
  • Eletriptan
  • Eluxadoline
  • Enflurane
  • Enzalutamide
  • Ephedrine
  • Erythromycin
  • Escitalopram
  • Estazolam
  • Eszopiclone
  • Ethchlorvynol
  • Ethopropazine
  • Ethylmorphine
  • Flibanserin
  • Fluconazole
  • Flunitrazepam
  • Fluoxetine
  • Fluphenazine
  • Flurazepam
  • Fluspirilene
  • Fluvoxamine
  • Fosamprenavir
  • Fosaprepitant
  • Fosphenytoin
  • Fospropofol
  • Frovatriptan
  • Furazolidone
  • Golimumab
  • Granisetron
  • Halazepam
  • Haloperidol
  • Halothane
  • Hydrocodone
  • Hydromorphone
  • Hydroxytryptophan
  • Hydroxyzine
  • Idelalisib
  • Iloperidone
  • Imatinib
  • Imipramine
  • Indinavir
  • Iproniazid
  • Isocarboxazid
  • Isoflurane
  • Itraconazole
  • Ketamine
  • Ketazolam
  • Ketobemidone
  • Ketoconazole
  • Levomilnacipran
  • Levorphanol
  • Linezolid
  • Lithium
  • Lopinavir
  • Lorazepam
  • Lorcaserin
  • Lumacaftor
  • Lurasidone
  • Meclizine
  • Melperone
  • Meperidine
  • Meprobamate
  • Meptazinol
  • Mesoridazine
  • Metaxalone
  • Methadone
  • Methdilazine
  • Methocarbamol
  • Methohexital
  • Methotrimeprazine
  • Methylene Blue
  • Mibefradil
  • Midazolam
  • Milnacipran
  • Mirtazapine
  • Mitotane
  • Moclobemide
  • Modafinil
  • Molindone
  • Moricizine
  • Morphine
  • Morphine Sulfate Liposome
  • Nafcillin
  • Nalbuphine
  • Naphazoline
  • Naratriptan
  • Nefazodone
  • Nelfinavir
  • Nevirapine
  • Nialamide
  • Nicardipine
  • Nicomorphine
  • Nifedipine
  • Nilotinib
  • Nitrazepam
  • Nitrous Oxide
  • Nortriptyline
  • Olanzapine
  • Opium
  • Opium Alkaloids
  • Orphenadrine
  • Oxazepam
  • Oxcarbazepine
  • Oxycodone
  • Oxymetazoline
  • Oxymorphone
  • Paliperidone
  • Palonosetron
  • Papaveretum
  • Paregoric
  • Pargyline
  • Paroxetine
  • Pazopanib
  • Pentazocine
  • Pentobarbital
  • Perampanel
  • Perazine
  • Periciazine
  • Perphenazine
  • Phenelzine
  • Phenobarbital
  • Phenylephrine
  • Phenylpropanolamine
  • Phenytoin
  • Pimavanserin
  • Pimozide
  • Piperacetazine
  • Pipotiazine
  • Piritramide
  • Pitolisant
  • Posaconazole
  • Prazepam
  • Prednisone
  • Primidone
  • Procarbazine
  • Prochlorperazine
  • Promazine
  • Promethazine
  • Propofol
  • Propoxyphene
  • Propylhexedrine
  • Pseudoephedrine
  • Quazepam
  • Quetiapine
  • Ramelteon
  • Ranolazine
  • Rasagiline
  • Remifentanil
  • Remoxipride
  • Rifabutin
  • Rifampin
  • Risperidone
  • Ritonavir
  • Rizatriptan
  • Safinamide
  • Saquinavir
  • Secobarbital
  • Secukinumab
  • Selegiline
  • Sertindole
  • Sertraline
  • Sibutramine
  • Siltuximab
  • Sodium Oxybate
  • St John's Wort
  • Sufentanil
  • Sulpiride
  • Sumatriptan
  • Suvorexant
  • Tapentadol
  • Telaprevir
  • Telithromycin
  • Temazepam
  • Tetrahydrozoline
  • Thiethylperazine
  • Thiopental
  • Thiopropazate
  • Thioridazine
  • Thiothixene
  • Tilidine
  • Tizanidine
  • Tolonium Chloride
  • Topiramate
  • Tramadol
  • Tramazoline
  • Tranylcypromine
  • Trazodone
  • Triazolam
  • Trifluoperazine
  • Trifluperidol
  • Triflupromazine
  • Trimeprazine
  • Tryptophan
  • Venlafaxine
  • Verapamil
  • Vilazodone
  • Voriconazole
  • Vortioxetine
  • Xylometazoline
  • Zaleplon
  • Ziprasidone
  • Zolmitriptan
  • Zolpidem
  • Zopiclone
  • Zotepine

This list is only a sample of some of the medications that cause major interactions. For a complete list, speak to a pharmacist or physician.

Warnings

The effects of this medication will become more potent when mixed with other CNS depressants such as alcohol, antihistamines, sedatives, sleeping medications, anesthetics or cold medicines.

Fentanyl is habit forming and should only be used with the consent and supervision of a doctor. If you feel this medication is not working well, do not use more of it. Instead, refer to your doctor or pharmacist for instructions on how to proceed.

This medication will need to be continuously monitored by a physician. It is essential that any patients taking this medication attend regular laboratory tests.

Before completing any laboratory tests, it is important for users to let their lab technician know before the test begins. Especially for lab tests utilizing methylene blue.

Never share this medication with anyone else. Even if a friend or family member has the same symptoms, this medication can be very dangerous or fatal for some people. Fentanyl is a controlled substance and sharing the prescription is illegal.

This medication may cause reactions similar to withdrawal when a patient discontinues use after using fentanyl regularly, or in high doses. Withdrawal symptoms should be reported to your physician immediately. It is possible to prevent, or lessen, withdrawal symptoms by coming off the fentanyl nasal spray slowly. Symptoms of withdrawal include:

  • Restlessness
  • A runny nose
  • Nausea
  • Sweating
  • Watery eyes
  • Muscle aches

It is possible for a patient to build up a tolerance to this medication, causing its pain-relieving effects to lessen. If this occurs a user may notice more 'breakthrough' pain. This is a normal response to long-term doses. Speak to your doctor about how to proceed with your treatment. Rule of thumb for this medication is if you have more than four episodes of 'breakthrough' pain in one day you should consult your physician.

Do not eat grapefruit or drink grapefruit juice while taking this medication. Grapefruit juice may change the way this medication is absorbed into the body causing your doses to become too potent, or too weak.

Do not start or stop any medications without first consulting with your physician. Even over-the-counter medications (especially cold medications, and St John's Wort) may alter fentanyl in your system.

Fentanyl is not safe for all consumers. Patients with pre-existing conditions should ensure their doctor is fully aware of their medical history and family medical history before seeking fentanyl treatment. Some pre-existing conditions may put a patient at risk when taking fentanyl. Let your doctor know if you suffer from:

Older adults tend to be more sensitive to the side effects of this medication including dizziness, confusion, heartbeat irregularity, drowsiness and shallow breathing.

Women who are pregnant, may become pregnant or are breastfeeding should discuss all risks and benefits with their doctor. This medication is not safe for an unborn baby. This medication is passed to nursing infants during breastfeeding. Fentanyl may cause nursing infants to experience slowed heartbeat, difficulty breathing, drowsiness or death.

Nasal fentanyl is absorbed through the mucous membrane in the nose. The dosage of fentanyl in a single dose (or spray) is enough to overdose a child. This medication must be locked safely away from children of all ages.

Storage

This medication is at high risk for abuse and as such it is best kept in a locked container or in a private, discreet place in the home. The storage location of this medication should be unavailable to children, as it is fatal to children in this dose.

Patients should count the number of sprays they have used, and be aware of how many sprays are left so the prescribed individual will be aware if any doses are missing.

Dispose of the nasal spray when it is no longer needed, or outdated. If 5 days have passed since you have last used your medication, the medication should be disposed of. After the bottle is prepared for use for the first time, the medication is safe to use for 14 days. Afterward, the medication should be disposed of.

The fentanyl nasal spray comes with a disposal pouch used for disposal as well as instructions on how to dispose of it safely. If the pouch is not intact, or otherwise unavailable, the medication may be disposed of at any fire station, police station, hospital, pharmacy or doctor's office.

Summary

Nasal fentanyl is an opioid pain medication in the form of a nasal spray that acts on the nervous system to control pain. It is most often used in the case of 'breakthrough' pain for cancer patients.

This medication is highly addictive and at high risk for abuse. While this should not keep any patients requiring pain management from using this drug, patients should remain conscientious of this and keep the medication in a locked or discreet location.

This form of fentanyl is typically prescribed in doses of 100 mcg for new users, with the maximum dose reaching 800 mcg. Patients should not use more than 800 mcg in a day unless otherwise specified by their physician.

Nasal fentanyl has a sedating effect on the body and should not be used in conjunction with other medications that may contribute further to the sedating effect unless otherwise prescribed by their physician. Fentanyl may cause serotonin syndrome when paired with other medications that also alter the amount of serotonin in the brain.

The risk for overdose is high with medications that work on the nervous system. Symptoms of overdose include severe breathing problems, unconsciousness, very slow breathing (less than 8 breaths per minute) drowsiness so severe the patient cannot respond when spoken to, cold or clammy skin, lowered blood pressure, and pinpoint pupils. If an overdose occurs, and a caregiver has Narcan available, use it. Afterwards, call the emergency response services.

First-time users are encouraged to ensure a friend, family member or caregiver can check-in on the patient until they are familiar with how their body will respond to the medication. Users of this medication should not operate heavy machinery.

The bioavailability of this medication in this form is around 70-90%. To ensure the proper dose is acquired, the medication comes with a user guide that includes the steps for proper use.

Once the bottle is primed for first use, the remainder of the medication should be disposed of within 14 days following. If the medication has gone unused for 5 days or more, the remaining amount should be disposed of.

This medication does pose a risk for major interactions with over 350 other drugs. It is vitally important that any patient fully disclose any current medications including over-the-counter medications, vitamins, supplements, herbal treatments or topical creams to their physician prior to receiving or taking this medication.

This drug is not safe for use for everyone. Ensure your doctor is aware of any pre-existing conditions, and predispositions in your medical history. Women who are pregnant, may become pregnant or are breastfeeding should consult with their doctor before taking this medication. Nasal fentanyl is passed on from the mother to unborn children and nursing infants.

It is typical for long-term users of this medication to experience a loss of effectiveness after an extended period of use. Patients experiencing four or more episodes of breakthrough pain in a day should consult with their physician about potentially raising their dose. Patients should not raise their dose unless it has been approved by a physician to avoid overdose.

Proper disposal of this medication is paramount because of its susceptibility to abuse and overdose. It is for this reason this medication comes with a disposal pouch and directions. If for any reason a consumer is unable to use this pouch, proper disposal may be achieved by returning any unused or expired medication to their doctor's office, pharmacy, fire station, police station or clinic.