When Fentanyl Finds an Outlier: Talking With Teenagers About the Danger
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When Fentanyl Finds an Outlier:
Talking With Teenagers About the
Danger
Scott D. Cook-Sather, MD, FCPP,a,b Elynor Urban, BSN,a Vincent A. Romano, Michael A. Romano
In the United States from 2013 to Central to our story, opioid response
2019, the nonmethadone synthetic phenotypes of respiratory depression
opioid–involved death rate increased and airway compromise are
1040%, from 1.0 to 11.4 per 100 000 multifactorial, uncommon in children,
(age adjusted), with 51.5% of all 2019 and most certainly underreported.10
drug overdose deaths linked to Fentanyl may be especially dangerous
synthetic opioids such as fentanyl.1 because of its potency, rate of onset,
Opioid-involved poisoning deaths and other ligand-specific factors.11
overall contributed a loss of 0.21 years Although low-dose intraoperative
in life expectancy from 2000 to 20152 fentanyl has been associated with
and undoubtedly contributed to the 2- lower odds of postoperative
to 3.5-fold increase in excess mortality respiratory complications than a high
in American teenagers and young dose or none altogether,12 as little as
adults from 2000 to 2017.3 Emerging 0.5 mg/kg intravenous fentanyl has
a
data during the coronavirus disease been associated with respiratory The Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania; and bDepartment of Anesthesiology and
2019 pandemic suggest further arrest.13 Secondary drug exposure Critical Care, Perelman School of Medicine, University of
worsening of the opioid crisis.4 and comorbidities such as obstructive Pennsylvania, Philadelphia, Pennsylvania
sleep apnea may exaggerate
Dr Cook-Sather conceptualized and organized this
Medical uses of opioids have come respiratory sensitivity to collaborative writing project and made final manuscript
under increased scrutiny among fentanyl.10,13,14 Novel quantitative revisions; Ms Urban, Ms Romano, and Mr Romano each
drafted her or his initial statement and helped with the
physicians; anesthesiologists in trait loci have been associated with revision process; and all authors approved the final
particular have sought to minimize morphine-induced respiratory manuscript as submitted and agree to be accountable
for all aspects of the work.
their administration.5 Nonetheless, depression in mice,15 but
DOI: https://doi.org/10.1542/peds.2021-051368
opioids in limited amount and over pharmacogenetic understanding of
Accepted for publication June 16, 2021
limited duration have benefitted fentanyl-induced respiratory
countless patients. Fentanyl Address correspondence to Scott D. Cook-Sather, MD, FCPP,
depression and overdose death in Department of Anesthesiology and Critical Care Medicine,
requirements are variable and humans is limited.16,17 The Children’s Hospital of Philadelphia, 3401 Civic Center
depend on procedure and individual Blvd, Philadelphia, PA 19104. E-mail: sather@chop.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
patient sensitivity, the latter a With this article, we offer 4 1098-4275).
consequence of interacting recollections of the experience of a Copyright © 2021 by the American Academy of Pediatrics
environmental and genetic factors 17-year-old male patient who had no
FINANCIAL DISCLOSURE: The authors have indicated
that set different pain thresholds and history of drug use or obstructive they have no financial relationships relevant to this
alter fentanyl pharmacokinetics and sleep apnea but who displayed article to disclose.
pharmacodynamics. The variability in heightened sensitivity to fentanyl FUNDING: No external funding.
fentanyl pharmacokinetics is well after a routine medical procedure. POTENTIAL CONFLICT OF INTEREST: The authors have no
potential conflicts of interest to disclose.
established,6,7 but genetic These overlapping perspectives
associations gauging fentanyl strive to convey the lived experience
response sensitivity are only in of opioid-induced respiratory To cite: Cook-Sather SD, Urban E, Romano VA, et al.
When Fentanyl Finds an Outlier: Talking With
initial discovery stages and are depression and its life-threatening
Teenagers About the Danger. Pediatrics.
focused largely on analgesic potential outside of medical 2021;148(4):e2021051368
phenotypes.8,9 supervision. Clinicians must be
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PEDIATRICS Volume 148, number 4, October 2021:e2021051368 FAMILY PARTNERSHIPSvigilant in identifying opioid effects, that you are an outlier on the bell recovered and got ready to go home.
outliers, namely, those who may be curve distribution of responders. When Dr Scott gave his straightforward
at high risk for abuse, addiction, account of what occurred, I thought
respiratory compromise, and death, I wanted to be certain that you about the implications for you and all
taking every opportunity to educate understood the significant dangers young people leaving home. You said,
and prevent such events. of fentanyl because the drug as it is “That was the best ‘don’t do drugs’
available outside of hospital settings lecture” you ever heard, and I agreed
FROM DR SCOTT TO VINCENT is not pharmaceutical grade nor is it with you, because the talk was
carefully measured or administered connected to your own experience, not
As a healthy high school senior, you
by experts with safety protocols in just an abstract lecture.
came to our ambulatory surgery
place. It is illicitly manufactured
center for a short procedure. As
versions of unknown purity, I have my own experience to draw on,
your anesthesiologist, I listened as
potency, and quantity, offered in so I know. I chose to tell you that my
you told me and the operating room
unsafe settings, often along with son suffers from the disease of
nurses about your plans for college
other sedative substances that can addiction, although not to opioids,
next year. Calmly breathing the
work in dangerous synergy. because I wanted you to understand
anesthesia gases, you slid easily into
Overdose death is a tragic end and that the sensitivity lesson you learned
unconsciousness. The procedure
can happen to anyone, so everyone about yourself applies to all substances
was uneventful until, with the
must be on guard and avoid opioid of abuse. My son has now been clean
procedural stimulus gone, your
misuse. An outlier could easily die and sober for 15 years. I was candid
breathing became slow and shallow,
after a curious first try. with you about his experience with
and then obstructed. I opened your
addiction because it is prevalent in too
airway with a jaw thrust and
I explained to you that someday we many homes and in too many
supported your breathing using my
will offer comprehensive genetic neighborhoods. It does not
anesthesia mask and bag. Your
tests before surgeries and discriminate. By sharing my family
oxygenation, which had begun to
procedures like yours to develop story, and in being a part of your story, I
drift downward, immediately
precision anesthesia regimens for hoped that you and others might find
returned to normal. We brought you
optimal patient safety and comfort. reason to turn away from drugs.
to the postanesthesia care unit
During your procedure, without
(PACU), where you remained safe,
such testing, I watched in real time FROM VINCENT TO ANYONE READING
but for a full 10 minutes, nurse Ellie
and I continued intermittent jaw
as your fentanyl sensitivity revealed THIS
itself. I glimpsed your future
thrust, mask ventilation, and During the drive to the surgery center
vulnerability. I said that I hoped our
supplemental oxygen administration. with my dad, I was calm. My parents
conversation became an effective
Then, as expected, you stirred and had told me what to expect. I looked
“vaccine” for you amid the opioid forward to stopping at my favorite
breathed easily on your own.
epidemic, that other public health restaurant afterward to get
As I left to care for my next patient, I crisis currently overshadowed by something to eat. We checked in and
asked nurse Ellie to keep you in the coronavirus disease 2019. then went to the preoperative room
PACU until I could return. When I did so where a nurse asked us questions and
30 minutes later, you had recovered and FROM NURSE ELLIE TO VINCENT told us what to expect. I didn’t need
were smiling. You offered that you did As your PACU nurse, I was the first any calming medication. Dr Scott
not have a sore throat or nausea, which face you saw when you woke up. Dr arrived and explained the anesthesia.
are risks I had mentioned preoperatively Scott had brought you to the PACU
and that you remembered. I explained and was assisting your breathing. Going into the operating room, I felt
that you had received several sedative When he handed off your care to me, fine. The anesthesia mask was on my
and anesthetic medications, including a we ensured that I could keep your face and the last thing I remember was
small dose of intravenous fentanyl, 0.5 airway open. Before he left, your a question about which sports I play. I
mg/kg, which contributed to your need airway tone had returned and you slept through everything. Next thing I
for additional respiratory support. were breathing well without our help. knew, I woke up with nurse Ellie
Lingering nitrous oxide, sevoflurane, and alongside my bed and my dad walking
propofol may have contributed, but the As you awakened and became more into the room. Slowly, I became more
main culprit was fentanyl. Your reaction talkative, I learned that you would soon alert and heard what they were saying.
suggested that you are unusually head off to college. Your dad was sitting Nurse Ellie said I am sensitive to
sensitive to its respiratory depressive by your side, watching carefully as you anesthesia. When Dr Scott returned
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2 COOK-SATHER et aland explained what happened, I was Dr Scott told us he would have felt your newly understood opioid
shaken. He told me that my airway remiss if he did not discuss the sensitivity, have an undeniable
partially collapsed after the procedure morning’s events in detail. He grasp of your vulnerability.
and he had to hold up my jaw so I could explained that you received, among Together, we need to share our
breathe. I learned the anesthesia other anesthetic drugs, a small dose cautionary tale and keep finding
included a small dose of fentanyl. Dr of fentanyl. You were extremely ways to talk to teenagers, outliers or
Scott explained that if such a small dose sensitive to it. Your breathing rate not, about the dangers of fentanyl
of this opioid could slow my breathing slowed and your airway began to and opioids overall.
dramatically and collapse my airway, have issues. This was not a major
what would something like heroin do concern while you were being In 2020, there were 1214 overdose
to me? I learned that whereas many closely monitored and treated by deaths in the City of Philadelphia,
people are not harmed by small doses professionals in a medical setting, he just 3 fewer fatalities than the most
of opioids, I am different. If I have just a explained. The issue, however, is if such cases recorded in any previous
little of these drugs, I could die. you were not in such a setting. I year.18 Fentanyl was present in
Knowing this frightened me, especially knew what Dr Scott was getting at: 84%.
because I will go away to college soon. if you even try an opioid one time,
If I ever experiment with drugs on your risk of death is real. I could tell ACKNOWLEDGMENTS
purpose or accidentally, I could have a that you were surprised. I was We thank Alison M. Cook-Sather,
major problem. Without saying it word probably more in shock. PhD, and Ellen C. Jantzen, MD,
for word, Dr Scott warned me to stay FAAP, for their critical readings and
away from all opioids and never to I’ll tell you why. Over my last few suggestions on drafts of this article.
experiment with them because I could years with the Pennsylvania State
die quickly. I felt afraid hearing this, but Police, I’ve mainly investigated
I began to think about everything I human trafficking cases. The victims,
often young women, are targeted ABBREVIATION
could do to stay safe. It was important
because of their histories of PACU: postanesthesia care unit
for me to hear this right after I survived
an encounter with fentanyl. Without a addiction to opioids, like fentanyl
doubt, that was the best “say no to and heroin. Many have told us that
traffickers would supply them with REFERENCES
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4 COOK-SATHER et alWhen Fentanyl Finds an Outlier: Talking With Teenagers About the Danger
Scott D. Cook-Sather, Elynor Urban, Vincent A. Romano and Michael A. Romano
Pediatrics originally published online September 14, 2021;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2021/09/13/peds.2
021-051368
References This article cites 17 articles, 1 of which you can access for free at:
http://pediatrics.aappublications.org/content/early/2021/09/13/peds.2
021-051368#BIBL
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Downloaded from www.aappublications.org/news by guest on September 17, 2021When Fentanyl Finds an Outlier: Talking With Teenagers About the Danger
Scott D. Cook-Sather, Elynor Urban, Vincent A. Romano and Michael A. Romano
Pediatrics originally published online September 14, 2021;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2021/09/13/peds.2021-051368
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2021
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