Sufentanil and Alternative Facts

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It’s bad enough that mainstream media and politicians continue to spread false information regarding the opioid epidemic, with key blame placed on the shoulders of Big Pharma, and without consideration to other important influences.  For example, managed care and third-party payers prefer the most abusable immediate release opioids over safer alternatives like buprenorphine (buccal, branded as Belbuca and transdermal, branded as Butrans), tapentadol, and of course the abuse deterrent formulations of which there are several, all in an effort to maximize profit and without regard to safety.  Also, opioid prescribing and overall daily doses have drastically declined since 2015, yet politicians, peer reviewed literature and mainstream media continue to begin their rhetoric verbally and in writing, with data “from 1999 to present” and without consideration to contemporary data dating 2015 to present. And aside from this, managed care dictates what non-medication therapies a patient can receive, and how many visits, if any, such as physical therapy, cognitive behavior therapy, chiropractor, to name a few. But, the focus of this post is not about politics or managed care greed, as there is plenty of that on my previous posts.

Today I focus on an article posted by Anesthesiology News from 9/7/2019 entitled “Study Maps IV Morphine Equivalence of Sublingual Sufentanil”.  The article was intended to provide an update on two sublingual sufentanil tablet (ssT) products, Zalviso and Dsuvia (both manufactured by AcelRx Pharmaceuticals), the latter of which was approved for use in the US last November for acute pain with very strict access guidelines and availability only within acute care settings such as operating rooms and emergency rooms. Zalviso is a similar product available in Europe but not yet in the US; it is a unique device that can be used post-operatively in the form of patient controlled analgesia, a popular pain management technique generally employing morphine or hydromorphone so that patients have control over their as needed pain medication doses post-operatively.

The Anesthesiology News article written by Ethan Covey included a few statements from presumed experts. Dr. Eric Michael of the State University of New York (SUNY) Upstate Medical Center was one of the interviewees. I’m going to give him some leeway, because according to the article he is a fellow, which indicates less life experience as a physician. Also, his training according to the article is in interventional pain management, which focuses on various techniques (e.g. facet joint injections, nerve blocks,  neuroaugmentation,  vertebroplasty, kyphoplasty, nucleoplasty, endoscopic discectomy, implantable drug delivery systems), but that does not ensure expertise in complex and advanced pain pharmacotherapeutics.

The author, Mr. Covey, gets a flunking grade for not checking the facts! The statement quoted from Dr. Michael in the article is “…while the sublingual formulation may help improve the efficiency of pain management in the emergency room or outpatient surgical center, the ease of administration will make it a popular drug of abuse if it makes its way to the black market. … IV fentanyl is also not available for outpatient use, and somehow it seems to have made its way onto the streets. How can they be so sure the same won’t happen with sublingual sufentanil?” This statement is so inaccurate, I’m sitting here pulling my hair out.

Here are the facts…

  • IV fentanyl HAS NOT “made its way onto the streets” as suggested by Dr. Michael. IV prescription fentanyl almost, or perhaps NEVER makes it to the streets, and there is plenty of data to support that.
  • Pharmaceutical fentanyl that does make it to the streets is relatively rare, and when that happens, it is NOT fentanyl from the IV formulation we see in hospitals, as Dr. Michael suggests. Instead, it is from various dosage forms that ARE prescribed for outpatient use outside the hospital such has transdermal fentanyl, or various sublingual forms like Actiq and others which are collectively known as TIRFs (transmucosal immediate release fentanyls). Still this is relatively rare compared to other abusable prescription opioids.
  • Dr. Michael is correct that “…the sublingual formulation may help improve the efficiency of pain management in the emergency room or outpatient surgical center”.
  • Illicit, non-pharmaceutical grade BOOTLEG FENTANYL DERIVATIVES ARE on the streets.  These are not FDA approved products and they are imported from other counties, most notably China. This is nicely outlined by Bettinger and colleagues in Fentanyl; Separating Fact from Fiction.

If Dr. Michael and Mr. Covey want to make a fair comparison for the likelihood of sufentanil sublingual tablet diversion, they should compare it to other pharmacologically and therapeutically similar products that are ONLY AVAILABLE within institutions and that are NOT available by outpatient prescription.  Those drugs are NOT fentanyl; they are alfentanil and remifentanil.  I am not aware of any single instance where either of these two drugs have been diverted or are commonplace on the streets.

Once again, we have an article that provides false information which could contribute to further rhetoric by politicians and media muckrakers. I hope this will provide clarity on the alternative facts as published by Anesthesiology News.

Comments, as always are welcome!

8 thoughts on “Sufentanil and Alternative Facts

  1. I have peripheral nueropathy first in right ft/ leg traveled up leg hit kidneys/ bladder the left ft/leg now in hands & arms I hurt terribly all over day 24/7 & wet myself all the time never knowing when I will pee& cannot afford the pads, pull ups ect; I pee so much & still have really bad dry mouth from all meds I have to take ! Nothing helps all this pain just get three 7.5 percocet in 24 hrs only tell take them just right after taking them Dr. Doesn’t care just wants to do shots,,things I’ve had that never worked before taking numerous things like that. .HELP ME PLEASE I CAN’T STAND THE PAIN ANY MORE IT JUST KEEPS TRAVILING TO OTHER PLACES !!

  2. As a former #CPP it makes me sick to see the lies continue, patient suffering and suicide due to intractable pain. As for all those procedures that interventional pain mgt drs have come up with all I hear about is the nightmares after these injections and no one addressed CPP’s That have whole body pain. No one is ever cutting me or injecting me again. Since being forced off opioids I’ve developed pain hypersensitivity, I black out as I did from the second orthotics injection. I fell in the office, rammed the injected knee into his cabinets and then my back and head hit the cabinets. Between the pain still in my knee and now in my head the Dr did nothing. He left his nurses with me and didn’t send me to the ER after hitting my head and I have ITP. He did absolutely nothing and insisted the orthotics was for pain. I’ve had enough. .

  3. Good job calling them out. If you pull your hair out in response to asinine comments, you’ll soon look like me! 😉

    1. At least it’s only your hair.
      My Doc retired. He prescribed oxycontin for my RSD for 27 years. I had good pain control.
      I got a newbie Dr who force tapered me saying I should take Tylenol because she STUDIED that oxycontin doesn’t help pain. STUDY ME
      Nothing else changed.
      My Reflex Sympathetic Dystrophy is from 3 leg ulcers due to surgery complications.
      My health has been declining since w/out any meds.
      17 months ago I was healthy.
      I’ve literally been sitting except for bathroom and from bed to couch.
      Lupus flares
      Pancholitis – 2x hospitalized
      Fluid in legs
      Ulcers not looking so good; getting deeper & darker / flaking.
      Anyway, thanks a lot.
      There’s a lot of hair pulling…
      My dog is going bald

      1. How can we, as CPP’s better help legislators, the Opiod Hysteria hungry media & the general public realize 1st & foremost This Other Side of The Opiod Crisis? When in fact what’s Actually causing the overdoses
        diversions, etc are from:
        1) A Combination of substances found in one’s body during a proper autopsy,( which many had to be redone in order to be recalculated correctly)
        2) Along with The Once attainable Dr-PT relationships all of a sudden around the end of 2016 began being taken away, pts were now having to undergo rapid force TAPERING or ultimately face DISCONTINUATION altogether! This even after the Director’s announcements from the CDC himself ( Robert Redfield to be exact) regarding there being misapplications in the 2016 guidelines!
        3) Many unsavory characters finding ways of making profits due to those law abiding citizens/pts now having & being discharged from their pain management practices all while their once trusted physchians hands are tied as they claim, turn8ng to the streets for something
        4) Worst case scenario being how when dependant, Not addicted,( which the public is Yet to comprehend) end up buying from the streets- get it laced w/ fentynal from China & overdosing this way unknowingly before,
        5) Stigma still attached to being Dependant, being labeled as “with Drug Seeking Behavior” by Dr.’s as is we know any better after many years of what’s called Step Theraphy by health ins. before even considering opiates for relieving our pain cor which last we Che med Are ALL FDA Approved for several decades w/ enough labels, cautionary measures in place and now the PDMP’s as well!
        Bottom line, as embarrassing as it might seem; Us CPP’s would have to be complete idiots to break the dam rules set forth in our pain contracts w/ anyone still willing to treat us w/ the needed useful Opiod pain medication that’s beneficial for a quality of life outside of just being bedridden watching life pass us by.

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