Thursday, May 25, 2006


A drug that we use in the NICU for pain relief, fentanyl, is in the news. Allow me to stray from neonatal topics for a day.

Fentanyl is a powerful narcotic, about 80 times more potent than morphine. In some large cities in the U.S., such as New York, Philadelphia, Detroit, and Chicago, drug dealers are mixing their heroin or cocaine with fentanyl. It isn't clear why, but it might be to give a better or different high. Unfortunately, the combination can be deadly, and several people have died as a result of using the combination. This is, of course, terrible. But what caught my eye was the reaction of some family members of the deceased drug users. They were blaming the police for the deaths, saying that the police did not put out warnings soon enough that the lethal combination was on the streets. Doggone those nutty police, can't they get anything right? All we're asking is that they ensure the safety of the local illicit drug supply.

In a related story, capital punishment by lethal injection is gathering some criticism for perhaps being cruel and unusual punishment, because in some cases the punishees were given too small a dose of the drugs and may have suffered during the lethal injection procedure. Now, I'm not a fan of capital punishment, but that's a topic for some other time. What I can't figure out is why someone would ever be underdosed when undergoing lethal injection.

I am by no means an expert on lethal injection , but I understand that a combination of three drugs is given. First, a powerful analgesic and/or sedative is given, something like fentanyl, although I think they use another, similar drug for this part. Then a drug that paralyzes the person's muscles is given, to avoid having any thrashing, I guess. Finally, something like potassium chloride is given to stop the heart. Apparently, when some cases have been audited, there was concern that too small a dose of the first drug was given, leading to the person being awake and aware when the potassium chloride was given. But it's hard to know for sure, because the person is paralyzed and cannot speak or otherwise show pain or discomfort.

Here's the thing. The only reason to underdose with a drug like fentanyl is to avoid having a complication, such as respiratory depression, that could lead to death. But in the case of lethal injection, that's not really a consideration, is it, because you're killing the guy anyway. So give him (or her) a huge dose of the analgesic/sedative, one that leaves no doubt that the person is knocked out. What's the worse that can happen if you give too big a dose? The person might die?

You can't make this stuff up. It's just too crazy.

P.S. Erratum: A couple of posts ago I mentioned a six year old patient who weighed 160 pounds. My pediatrician friend, whose patient it is, told me the other day that she had been mistaken. He really weighed only 112 pounds. Sorry for the error.


Blogger Flea said...

I have a feeling the bit about underdosing may emanate from the "cruel and unusual" crowd.

I doubt it's true.



12:48 PM  
Blogger JenLo said...

In the case of the 112 lb vs 160 lb 6 yo kid, unless he's like 5'5 or something, I'm sure the BMI is still out the roof.

3:48 PM  
Blogger Jillene said...

I don't know this...but wouldn't mixing fentanyl gel or liquid with cocaine or heroin be a problem. It would be wet and would require some other prep. I have heard of cutting with oxycontin and seroquel but not fentanyl. I've only seen patients come in to the ER after eating the gel. Wow...what a horrible life it must be to be addicted to illicit substances?

6:43 PM  
Blogger Fat Doctor said...

Me likes Fentanyl. A lot. Mmmm.

7:04 PM  
Blogger Megan said...

No lie. As a medical student, I saw a 200lb 5 year old.

8:27 PM  
Blogger La Lubu said...

My daughter's father was busted with fentanyl; he had ordered it from some foreign country over the internet. Pre-filled syringes.

I'm surprised it's not a bigger drug problem than heroin, just being a mouse-click away.

The reason information like this should be spread far-and-wide by the police isn't to insure the safety of the street-drug market, but to give cues to family members. I mean, there's a popular image of the drug fiend as being out in the street at all hours, and that if a person isn't hanging out on the corner, around known drug-users or areas popular for drug-selling----well, that person couldn't possibly be on drugs, could he?

Sure he could. He could be staying up through the night, getting high on prescription drugs ordered over the internet. Then, in the morning, he could dress as if he's going to work. He leaves at the same time, so you naturally assume he's going to work.

You go to work. You spend the day there. He drives to the gas station for a pack of cigarettes, then sleeps off his high.

Addicts have different methods for disguising/hiding their high; disseminating information about the "next big drug thing" helps others spot the warning signs. If you aren't attuned to the drug world, you won't necessarily recognize the warning signs.

8:30 PM  
Anonymous Emma said...

I suppose 112 pounds is slightly better than 160, but, my stars.

10:00 PM  
Anonymous Anonymous said...

I have a question about fentanyl.
what are you thoughts about it's use in obstetric epidurals ? and do you think that it has an effect on neonatal health? short term or long term?
and can you direct me to some long term studies on intrapartum epidural exposure ?

9:18 PM  
Blogger That Girl said...

As amusing as it may be - people have a point when they say the police have a duty to advertise bad drugs as quickly as possible.
I get the cases you docs dont get (unless youre a morgue doc).
When you do a bad drug in the street in front of your dealer then try to drive home - you die and your car crashes into other people, who also die and are injured.
The 2 weeks that some bad heroin went around I picked up countless dead bodies off the road.
So it's really a public safety issue vs a drug user safety issue.
Not that I dont think drug users have a right to be safe also - personally, i think it should be legal and controlled - if your a heroin addict, fine, but get a ride with someone else. It would make the world a less dangerous place for everyone.

11:09 AM  
Blogger neonataldoc said...

Thanks, all. Nobody wants to talk about lethal injection? Fat doctor, please, try to set a good example! That girl, I know you have a legitimate point, but when someone dies from a drug overdose the police are not the first ones who should be blamed.

Anonymous, you ask some broad questions! I don't have a reference at the top of my head. I doubt that fentanyl in epidurals does any significant long term damage to babies.

8:12 PM  
Anonymous Anonymous said...

Speaking of lethal injections... What really disturbs me is that a friend told me that in Texas (I think) EMTs give the injection, as doctors say it runs against the Hippocratic Oath. What's disturbing is that these EMTs are so willing to kill someone they don't know - it makes me wonder if they really feel a pressing need to save people they don't know.

12:15 PM  
Anonymous Anonymous said...

P.S. My almost six year old triplets are and weigh 42 to 44 pounds, including the one who is well above average height, making her a little lean. I can't even imagine 112, 160 or 200 pounds on them. I myself am quite overweight, so I hope things will be better for them.

12:18 PM  
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hi,I visited this online pharmacy two days ago and found out that the prices for Pain Relief drugs: Butalbital-APAP,Fioricet,Motrin,Tramadol,Ultracet,Ultram are so low, Can you tell me how they managed to do this ?

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