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Publication Type: Safety Notice
Single or Multiple Incident: Multiple
Date: 10/16/2020 12:00:00 AM
Country: Australia
This safety notice discusses the opioid toxicity associated with the presence of acetylfentanyl or fentanyl in illicit drug use. Acetylfentanyl and fentanyl may be misrepresented as or be adulterants in illicit cocaine or ketamine. Acetylfentanyl has a similar potency to fentanyl, both may cause serious harm and death. People who do not use opioids regularly (‘opioid naïve’) may be unintentionally exposed and are at high risk of overdose. Even people who regularly use opioids are at risk due to the relatively high potency of fentanyl and acetylfentanyl. Several recommendations to identify and manage opioid toxicity associated with acetylfentanyl and fentanyl are presented.

Additional Details

Medication/Gas/Fluid:
opioids, fentanyl, acetylfentanyl, cocaine, ketamine, naloxone
Medication/IV List:
narcotics/opiates, IV, transdermal, and oral

Communication
  1. Be aware that most Urine Drug Screens do not detect synthetic opioids such as fentanyl.
  2. Notify the NSW Poisons Information Centre for all suspected opioid overdoses where the patient reported taking a stimulant or ketamine or required high doses of naloxone. Ensure that urine and blood samples are collected and retained. The notification will be passed on to the NSW Ministry of Health.
Rules / Policies / Procedures
  1. Have a high index of suspicion for illicit fentanyl and fentanyl analogues in suspected opioid overdose. This includes people who deny opioid use or report use of other non-opioid illicit drugs including ketamine or stimulants such as cocaine, but who present clinically with signs of an opioid overdose.
  2. Airway management, oxygenation, and ventilation support take precedence over naloxone.
  3. Cases may require titrated doses of naloxone with a higher total dose of 800 micrograms or more. Balance this against the risk of precipitated withdrawal in an opioid-dependent person.
  4. The duration of effects from acetylfentanyl and fentanyl are longer than for heroin. Cases may require repeated doses of naloxone or a continuous infusion. Contact the Poisons Information Centre (PIC) or local toxicology service for advice or notify the PIC prior to discharge.
  5. Consider supplying take-home naloxone on discharge.

Acetylfentanyl and fentanyl in non-opioid illicit drugs