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In addition to seeing traumatic injury and neurological dysfunction we also work with patients that need orthopedic care. One of the most common surgeries that we see, at least post-operatively, is a spinal fusion.
If any one has had contact with this, or any, type of spinal surgery then you know it is a very invasive, complicated and painful surgery. For some reason the orthopedic surgeons usually choose to do spinal fusions on adolescents. This is good for the patient for several reasons, but usually translates into difficult care because of how these patients react to the surgery.
Pain Service - the folks that administer and track the use of pain medicines, usually the hard-core narcotic stuff - used to just place a single epidural, basically a needle is placed in the spinal nerves were pain medication is administered, this often resulted in a lot of pain for both the patient and the care staff.
Recently, however, they have started placing two epidurals and that has resulted in much lower pain levels which eases anxiety and increases the patients ability to recover. http://www.or-live.com/distributors/NLM/rnh.cfm?id=321 - this link is to a real surgery video for a spinal-fusion on an adolescent. It was interesting and informative to watch, but it is not for everyone for obvious reasons.

After thinking about this situation I decided to look into what it is that is being administered to the patient through the epidural line. Often the medication of choice is known as Fentanyl. Often Fentanyl is paired with another analgesic known as Bipuvacaine, but we can only focus on one drug due to my time and length restrictions. With these ideas in mind, this weeks 'DotW' feature is going to be about Fentanyl.
Let us begin, as always, with the organic molecule:


Fentanyl has gotten a lot of press lately due to the fact that several deaths have resulted from overdose in the past little while.

Fentanyl is an analgesic of high potency, approximately 300 times that of morphine...The first CsA (case of abuse) of fentanyl came to the attention of law enforcement in late 1979 but was not identified until 1981. In the next three years a procession of new fentanyl CsA's appeared in the illicit drug market. The abuse of fentanyl CsA's peaked in 1985 and has since decreased dramatically, a phenomena which was the result of DEA successfully terminating the operation of the responsible laboratories. However, the ripple effect is still being felt as international and national meetings have been held to discuss the problems presented by CsA's.
(http://designer-drug.com/synth/index.html)

Fentanyl is used illegally for a feeling of intense happiness that is provided by narcotics such as fentanyl. However this feeling is often followed by some of the negative side effects listed below. Another reason that fentanyl is bad to use illegally is because it is highly addictive. Since it is taken most often using a shot, when used illegally some of the transmitted diseases such as AIDS and hepatitis can be transmitted as well.

Fentanyl falls under the category of narcotic analgesics, this means basically that it is a pain reliever that relieves pain without the patient losing consciousness. Another narcotic analgesics include morphine and oxycontin. Fentanyl is used in two major ways: by taking orally or by using a patch.
(http://web1.caryacademy.org/chemistry/rushin/StudentProjects/CompoundWebSites/2004/fentanyl/Uses.htm)

Shortly after its discovery in 1960, another form of fentanyl was discovered that is widely used today and that is fentanyl citrate. Fentanyl citrate allows for patients to have fast pain relief, up to 80 times that of morphine, by simply sucking on a "lollipop". This lollipop however is supposed to be bitter.
(http://web1.caryacademy.org/chemistry/rushin/StudentProjects/CompoundWebSites/2004/fentanyl/History.htm)

It is also possible to snort or smoke Fentanyl for the desired effect. Fentanyl is a dangerous drug in the wrong hands because it is similar to the drug heroine in its uses and in its addictiveness.

The way in which I see Fentanyl administered is through an epidural line in the patient. It is often combined with another medication known as Bipuvacaine. When it is administered in this way it looks like a thick almost syrupy liquid. The Fentanyl is in small plastic bags - think of a small IV bag - and then placed in a device known as a PCA or Patient Controlled Analgesic. These are the pumps that allow the patient to press a button for a demand dose of pain control.
When only one epidural was placed the number of times the button was pressed was relatively high - there is a lockout function on these pumps so that the patient does not accidentally overdose on the pain med by pressing the button too many times. Now, with the advent of the double epidural I have seen little to no usage of the pain button, pain seems to be under control.